Obstructed Defecation Syndrome:

Diagnosis & Surgical Treatment

By Dr Ashwin Porwal
Consultant Procto-Surgeon Apollo Jehangir Hospital Poona Hospital & Inamdar Hospital

Obstructed Defecation Syndrome (ODS)

Constipation due to difficulty in passing stools once it has reached rectum as a result of Recto rectal Intussusceptions (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
ODS is a complex and multifactorial condition which is often referred to as an Iceberg Syndrome

Prevalence of Constipation
Constipation 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

NICE guidelines for STARR Surgery for ODS

1)Failure of conservative treatment for ODS

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

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 intussusceptions 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

Definition

A rectocele is an out pouching of the anterior rectal wall and posterior vaginal wall into the lumen of the vagina
high rectoceles due to stretching or disruption of the upper third of the vaginal wall and uterosacral ligaments mid level rectoceles most 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 multifarious 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 of chronic

constipation and are symptomatic for ODS is as high as 60% in my 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

Diagnostic Approach for ODS

Before patient sees surgeon
Patient sees the surgeon Patient Interview Clinical Examination
Colonoscopy to rule out tumors + IBD Conservative treatment with laxatives /enemas / diet failed

Patient history Dr Longos Score (ODS Score) assessment Incontinence / Urogenital assessment to rule out other complications Quality of life / Patient motivation assessment

Perinea Examination Proctoscopy resting / straining Urogenital Examination

Clinical Evaluation

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

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 digitations

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 Digitations for 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

Dr Longos ODS Score

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

Case: Internal Rectal Prolapse & Rectocele (Conventional Defecography)

Intussusception & Rectocele (1)

Intussusception & Rectocele (2)

Intussusception & Rectocele (3)

Intussusception & Rectocele (4)

MR Defecography

MRI Defecography Videos

ODS Cause Substantiated by Defecography Findings

Rectal Intussusception Internal Rectal Prolapse
closure of the anus by prolapse of the rectum into the anal canal

Rectocele
accumulation of stool in ventral protrusion of the rectal anterior wall

Patient Inclusion Criteria for STARR Surgery

Symptomatic Dr Longos Score more than 15
Evacuation by prolonged or repeated straining Frequent calls to defecate prior to or following evacuation Use of digital means to effect evacuation Laxative and or Enema use required to defecate Sense of incomplete evacuation Excessive time spent on the toilet Pelvic Pressure, Rectal discomfort, and Perinea pain

Radiological & Clinical Findings

Recto rectal Intussusceptions Reconcile

Failure with medical management for 3-6 Months: By Means of Diet & Pelvic floor physiotherapy

Patient Exclusion Criteria for Surgery

General Exclusion Criteria
Active anorectal infection Concurrent severe anorectal pathology Proctitis (Inflammatory Bowel Disease (IBD), Radiation) Enterocele at rest (low, stable) Chronic Diarrhea

Relative Exclusion Criteria

Previous transanal surgery (Rectal anastomosis) Presence of foreign material adjacent to the rectum (mesh) Concurrent psychiatric disorder

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 oclock positions. Similar approach at the posterior wall with stitches at 4, 6 and 8 oclock positions. Suturing of the overlaping dog ears at 3 and 9 oclock positions.

STARR Videos

Complications
rectovaginal fistula bleeding (needing intervention) stenosis constant pain suture-insufficiency (0,3%) (3,7%) (1,1%) (4,0%) (0,3%)

urgency

(9,4%)

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

Treating ODS - A Patient Case Study!

History Taking Diagnosis STARR Surgery
After Care & Follow up

Complain: Chronic Constipation since 3 years

Patient Profile: 26 year old nulliparous female Patient History: Chronic constipation for over 3 years Symptoms: Need to go to the toilet 3-4 times in a day, Excessive straining, Extended time in toilet (15 min. minimum), Digitations, Fragmented defecation, Hard stool, Feeling of stool obstructed within the rectum No relief with diet and pelvic floor physic for 6 months Diagnosis: P/R examination Anterior Rectocele Dr Longos ODS Score 24 MR Defecography findings Moderate anterior Rectocele with severe descent of the Rectum Advise STARR Surgery

Patient Case Study continued...

History History Taking Taking Diagnosis STARR STARR Surgery Surgery
After Care Follow & Follow up up

Surgery Stapled Transanal Rectal Resection (STARR) 3hrs after surgery the patient complained of mild pain in the anal region, Was advised to discontinue NBM and take regular Maharashtrian dinner. 12hrs after surgery bearable pain, passed motion with slight discomfort and observed a few drops of blood during defecation. Discharged 24 hrs after hospitalization and subsequently the patient resumed work after 4 days.
Follow up 2 Weeks: Less difficulty to pass motion, No h/o straining, No h/o digitation, Patient was on laxative but it helped her, Satisfactory defecation at least 70% of the time. 1 Month: Motion was fine, evacuation was complete with lesser dose of laxatives.

Patient Case Study continued...

History Taking Diagnosis STARR Surgery
After Care & Follow up

Follow up 3 Months: Patient was not on laxative but motion was sooth and without straining
Findings of MR Defecography repeated after 3 months Normal with absence of Rectocle or any obstruction Patient was advised to stop all medication and also advised to take a high fiber diet with plenty of water

My experience of 1st 100 STARRs

Patient inclusion criteria
Symptomatic with Dr Longos ODS score above 15 Rectocele > 3cm & Recto rectal Intussusceptions

Patient distribution
Male 43 , Female 57 Age 37 < 40 yrs, 63 > 40 yrs Nulliparous Female 33% Rectocele Males: 67 % Females: 90% Recto rectal Intussusceptions Males: 87% Females: 53%

Follow up Schedule
2 weeks, 1 Month, 3 Months, 6 Months & 1 Year

Findings
Average Dr Longos ODS score pre operatively = 26 Average Dr Longos ODS score 12 months post operatively =8

ODS Score for 1st 100 STARR Cases

Symptoms
Defecation frequency Straining Intensity Extension of time in defecation Sensation of incomplete evacuation Recto/perineal pain/discomfort Activity reduction per week Laxatives Enemas Digitation Mean Dr Longos ODS Score

Mean Pre-op Score

1 1 2 3 2 4 5 3 5 26

Mean 12 Months Post-op Score

0 0 1 1 1 2 3 0 0 8

Thank You!