obstructed defecation syndrome: diagnosis & surgical treatment

Obstructed Defecation Syndrome: Diagnosis & Surgical Treatment

By

Dr Ashwin PorwalConsultant Procto-Surgeon

Apollo Jehangir Hospital

Poona Hospital &

Inamdar Hospital

12/3/2014Copyright@ 2014 Healing Hands Clinic

www.healinghandsclinic.co.in1

Obstructed Defecation Syndrome (ODS)

Constipation due to difficulty in passing stools once it has reached rectum as a result of RectorectalIntussusception (Internal Rectal Prolapse) or Rectocele

ODS has been shown to be the result of an abnormal function of the muscles involved in defecation or an anatomical abnormality of the pelvic organs



Prevalence of ConstipationConstipation prevalence in the general population is

estimated at around 5-15% .

reports suggesting significantly higher levels in the elderly, especially above the age of 65.

reports of females being affected more then males, male to female ratio of 1: 2.2.

ODS is estimated to be prevalent in 7% of the adult population and is judged to be the cause of one third of all cases of constipation



1)Failure of conservative treatment for ODS

2)Underlying structural abnormality like Rectocele & Recto-Rectal Intussuception on MRI Defecography

NICE guidelines for STARR surgery for ODS

Efficacy of STARR in ODS

In multiple studies reviewed by NICE , It was observed that there was significant improvement in pre operative constipation symptoms at a mean follow up of 2 years.Post op Defecography also demonstrated correction of rectocele and intussuception in one study .Quality of life following STARR was assessed in few studies , excellent or good outcome was reported by 70-80% of the patients.



Rectocele in females – A Rectovaginal Defect

• A rectocele is an out pouching of the anterior rectal wall and posterior vaginal wall into the lumen of the vagina

Definition

• high rectoceles due to stretching or disruption of the upper third of the vaginal wall and uterosacral ligaments

• mid level rectocelesmost common and are associated with loss of pelvic floor support

• low-level rectoceles can be caused by obstetric trauma

Gradation



Rectocele: Prevalence

Prevalence in young nulliparous women : 12%

• Source: Australia & NZ Journal of Obst & Gynec.2005 Oct;45(5):391-4

Prevalence in multiparous women

with uterus : 18.6 % without uterus : 18.3%

• Source: American Journal of Obst & Gynec

Prevalence of Rectocele in male patients who have a history ofchronic constipation and are symptomatic for ODS is as high as 60% inmy routine clinical observation



Rectocele & ODS

Symptoms of Rectocele include:

– Pain or pressure in the vagina

– Pain during sexual intercourse

– Pain or pressure in the rectum

– Feeling of tissue bulging out of vagina

– Constipation: ODS (Obstructed Defecation Syndrome)

• Difficult passage of stool

• Needing to apply pressure on vagina to pass stool

• Feelings of incomplete stool passage



• Colonoscopy to rule out tumours + IBD

• Conservative treatment with laxatives /enemas / diet failed

Before patient sees

surgeon

• Patient history

• Dr Longo’s Score (ODS Score) assessment

• Incontinence / Urogenital assessment to rule out other complications

• Quality of life / Patient motivation assessment

Patient sees the surgeon

– Patient Interview

• Perineal Examination

• Proctoscopy resting / straining

• Urogenital Examination

Clinical Examination

• Conventional Defecography / MRI Defecography

• Anal-manometry and Endo-anal ultrasound – only if incontinence or suspicion of sphincter damage – otherwise not mandatory

• Colon transit – suspicion of slow bowel movement

Clinical Evaluation

Diagnostic Approach for ODS



Patients of ODS: Symptoms and Signs

• Pain at defecation• Haemorrhoidal prolapse (!) • Extended time at the toilet• Perineal pain / discomfort when standing• Use of laxatives or enemas• Fecal Incontinence• Extreme straining to defecate• Feeling of incomplete evacuation• Fragmented defecation• Vaginal, Perineal or Rectal digitation



History Taking for Constipation

Obstructive

• Excessive Straining

• Poor response to Laxatives over a period of time

• Either 2-3 visits/day or 2-3 visits in a week to toilet

• Inadequate Defecation

• Feeling of stools obstructed in Rectum

• Rectal and or Vaginal Digitationfor Evacuation

Functional / IBS

• Straining + -

• No feeling of stools obstructed in rectum

• Usually responds to laxatives

• Inadequate Defecation +

• Multiple visits to toilet +

• Usually no history of digitation



Defecography

• Salient phases of Conventional / MRI Defecography Image captured

– During rest with filled anal bulb

– During maximum contraction of anal sphincter and pelvic floor muscles

– During straining without evacuation

– During evacuation

– During rest when evacuation is completed



Surgical Treatment for ODS –Stapled Transanal Rectal Resection(STARR)



Treatment for ODS

STARR (Stapled Transanal Rectal Resection)

• Transanal resection of the lower rectum

• Full thickness resection of the anterior rectum wall by stapler after longitudinal stitches at 10, 12 and 2 o‘clock positions. Similar approach at the posterior wall with stitches at 4, 6 and 8 o‘clock positions.

• Suturing of the overlaping dog ears at 3 and 9 o‘clock positions.



Conclusion

STARR is a safe and effective procedure to treat ODS (Obstructd Defecation Syndrome)

The surgery needs only 24hrs of hospitalisation & patient can resume his routine work from 3rd day

The key to success is patient selection

Problem could be the cost involved



Thank You!



obstructed defecation syndrome: diagnosis & surgical treatment

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