Obstructed defecation (OD)is a broad term of the pathophysiologic condition describing the inability to evacuate contents from the

rectum leading to difficulty with defecation that impairs the quality of life. Represents a widespread clinical problem that occurs in about 7% of the adult population

The stimulus to defecation is distention of the rectum relaxation of the internal sphincter contraction of the external sphincter sampling response the squatting position the angulation between the rectum and the anal canal is straightened out Valsalva maneuver, coordinated with pelvic floor relaxation Inhibition of the external sphincter permits passage of the fecal bolus

Normal defecation

The process of defecation requires relaxation of the puborectalis and external

anal sphincters, straightening of the rectoanal angle, and an increase in intraluminal pressure usually induced by a Valsalva maneuver to increase intraabdominal pressure. Obstructed defecation may result if either of these functions is impaired

Obstructed defecation syndrome is characterized by: Difficult evacuation Excessive straining during defecation Sensation of incomplete evacuation Prolonged time to defecate External assistance to aid defecation

Perineal support Odd posture Insertion of fingers into the vagina and/or anal canal Enema

Anal pain

Presence of two or more of the following symptoms: -Straining during at least 25% of defecations -Lumpy or hard stools in at least 25% of defecations -Sensation of incomplete evacuations for at least 25% of defecations -Sensation of anorectal obstruction/blockage for at least 25% of defecations -Manual manoeuvres to facilitate at least 25% of defecations (such as digital evacuation, support of the pelvic floor) -Fewer than three bowel movements a week Loose stools are rarely present without the use of laxatives *Criteria have to have been met for the previous three months, with the onset of symptoms six months prior to diagnosis

Mechanical causes. Functional disorders.

Rectoanal intussusception Pelvic organ prolapse Rectocele Sigmoidocele Enterocele

Anismus descending perineum syndrome Solitary rectal ulcer syndrome

internal or occult rectal prolapse and internal procidentia, is defined as the circumferential, full thickness infolding of the mid-rectum during the effort of straining to evacuate. This infolding extends into the anal canal, without reaching the external anal orificeIt is classified as: First degree when the protrusion is invisible Second degree when it is visible on straining, Third degree when visible externally

It is caused by: diastasis of the levators deep Douglas pouch Redundant rectosigmoid loss of rectal horizontal position (due to loose attachment to the sacrum)

Rectoanal intussusceptiois

Rectoanal intussusceptiois

A herniation of the rectal wall through a defect in the rectovaginal septum in the direction of the vagina. Possible causes are Erect bipedal posture Vaginal childbirth, Chronic increase in abdominal pressure Congenital or inherited weakness in the pelvic support system

Rectocele

Rectocele

It is classified as:

First degree 2-4 cm Second degree 4-6 cm Third degree more than 6 cm

The surgical indications for rectocele repair are controversial, but most surgeons advocate operative repair when a symptomatic rectocele is large (> 3 cm), or if it fails to empty sufficiently on defecography

Prolapse of the small bowel into the rectogenital space The etiological classification of enterocele Primary

Multiparity Advanced age General lack of elasticity Obesity Increased abdominal pressure after gynecological surgical procedures, especially hysterectomy.

Secondary

Another classification Congenital (unusual deep Pouch of Douglas), Pulsion-mediated (caused by chronic increase of abdominal pressure) Traction (associated with a loss of support of the pelvic floor)

difficult defecation caused by a functional disorder: Anismus Pelvic fl oor dyssynergia Descending perineum syndrome reflect the phenotypic spectrum of rectal evacuation disorders

Anismus pelvic floor dyssynergia

increased anal resting tone failure of relaxation or paradoxical contraction of the puborectalis and/or external anal sphincter during defecation The is a sequel of long-standing, excessive straining, which weakens the pelvic floor causing excessive perineal descent Chronic straining with ischemic ulceration

descending perineum syndrome

Solitary rectal ulcer syndrome

Diagnostic Criteria* for Functional Defecation Disorders 1. The patient must satisfy diagnostic criteria for functional constipation** 2. During repeated attempts to defecate must have at least 2 of the following:

a. Evidence of impaired evacuation, based on balloon expulsion test or imaging b. Inappropriate contraction of the pelvic floor muscles (ie, anal sphincter or puborectalis) or less than 20% relaxation of basal resting sphincter pressure by manometry, imaging, or EMG c. Inadequate propulsive forces assessed by manometry or imaging

1.

2. 3.

4.

How often do you use an enema or suppository to move your bowels? How often do you have difficulty evacuating? How often do you need to put a finger in the vagina or rectum to move your bowels? How often do you need to return to the toilet after having a bowel movement?
How often do you feel that you have not emptied your bowels during a movement?

5.

Answer Never Less than weekly 1-6 times a week Daily

Score 0 1 2 3

How often do you have to strain or push to have a bowel movement? How often do you change your lifestyle/habits because of difficulties with bowel movements? Answer Never Sometimes Often Always Score 0 1 2 3

How much time do you need to spend on the toilet to have a bowel movement? Answer Score Less than 5 minutes 0 6-10 minutes 1 11-20 minutes 2 More than 20 minutes 3

1.
2. 3. 4. 5. 6. 7.

Clinical assessment Sigmoidoscopy Standard proctography Videoproctography Dynamic MRI. Anorectal manometry EMG Studies

Biofeedback techniques for treating anismus: Sensory training Electromyographic feedback Manometric feedback

Most studies on biofeedback training report good short term efficacy, mirrored by an improved psychological state and quality of life, whereas the long term follow up studies showed a fading effect over time.

Surgical treatment of rectocele:

Posterior colporrhaphy Transanal repair Defect-directed repair Posterior fascial replacement Abdominal approaches.

Surgical treatment of rectal prolapse : Abdominal Procedures : Anterior Resection Rectal Fixation with Foreign material Suture Rectopexy with Sigmoid Resection Suture Rectopexy Alone Laparoscopic procedures

Surgical treatment of rectal prolapse : PERINEAL PROCEDURES: Perineal Rectosigmoidectomy Delorme's Procedure