Constipation of anorectal outlet obstruction: Pathophysiology, evaluation and management

Tzaneio General Hospital of Piraeus, Le Pirée, Attica, Greece
Journal of Gastroenterology and Hepatology (Impact Factor: 3.5). 05/2006; 21(4):638-46. DOI: 10.1111/j.1440-1746.2006.04333.x
Source: PubMed


Constipation is a subjective symptom of various pathological conditions. Incidence of constipation fluctuates from 2 to 30% in the general population. Approximately 50% of constipated patients referred to tertiary care centers have obstructed defecation constipation. Constipation of obstructed defecation may be due to mechanical causes or functional disorders of the anorectal region. Mechanical causes are related to morphological abnormalities of the anorectum (megarectum, rectal prolapse, rectocele, enterocele, neoplasms, stenosis). Functional disorders are associated with neurological disorders and dysfunction of the pelvic floor muscles or anorectal muscles (anismus, descending perineum syndrome, Hirschsprung's disease). However, this type of constipation should be differentiated by colonic slow transit constipation which, if coexists, should be managed to a second time. Assessment of patients with severe constipation includes a good history, physical examination and specialized investigations (colonic transit time, anorectal manometry, rectal balloon expulsion test, defecography, electromyography), which contribute to the diagnosis and the differential diagnosis of the cause of the obstructed defecation. Thereby, constipated patients can be given appropriate treatment for their problem, which may be conservative (bulk agents, high-fiber diet or laxatives), biofeedback training or surgery.

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Available from: Theodoros Troupis, Nov 11, 2014
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    • "From such a perspective, an analysis of the causes of the descending perineum syndrome is important. Causes in women are known to be associated with the number of vaginal deliveries, cases of obstructed labor, and anorectal surgery [8, 9] while rectoceles and intussusceptions are also known to induce excessive straining, causing constipation and resulting in a descent of the perineum. In addition, Pucciani et al. [10] showed that a total abdominal hysterectomy was also associated with perineal descent in women. "
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    ABSTRACT: Treatment of descending perineal syndrome is focused on personal etiology and on improving symptoms. However, the etiology of increased perineal descent (PD) is unclear. Therefore, the aim of the present study was to evaluate factors associated with increased resting and dynamic PD in women. From January 2004 to August 2010, defecographic findings in 201 female patients were reviewed retrospectively. Patient's age, surgical history, manometric results and defecographic findings were compared with resting and dynamic PD. Age (P < 0.01), number of vaginal deliveries (P < 0.01) and resting anorectal angle (P < 0.01) were correlated with increased resting PD. Also, findings of rectoceles (P < 0.05) and intussusceptions (P < 0.05) were significantly correlated with increased resting PD. On the other hand, increased dynamic PD was correlated with age (P < 0.05), resting anal pressure (P < 0.01) and sigmoidoceles (P < 0.05). No significant correlation existed between non-relaxing puborectalis, history of pelvic surgery and increased PD. Also, no significant differences in PD according to the symptoms were observed. Increased number of vaginal deliveries and increased resting rectoanal angle are associated with increased resting PD whereas increased resting anal pressure is correlated with increased dynamic PD. Older age correlates with both resting and dynamic PD. Defecographic findings, such as rectoceles and intussusceptions, are associated with resting PD, and sigmoidoceles correlated with dynamic PD. These results can serve as foundational research for understanding the pathophysiology and causes of increasing PD in women better and for finding a fundamental method of treatment.
    Journal of the Korean Society of Coloproctology 08/2012; 28(4):195-200. DOI:10.3393/jksc.2012.28.4.195
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    • "Failure of relaxation of the puborectalis and the external anal sphincter muscles, or paradoxical contraction of these muscles during straining to defecate is called anismus (Preston & Lennard-Jones 1985). The basic mechanism behind persistent constipation is the failure of the anorectal angle to straighten and the anal canal to shorten as a result of sustained contraction of the puborectalis muscle (Andromanakos et al. 2006). "
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    ABSTRACT: The aim of this study was to evaluate a rehabilitative programme including biofeedback training for the treatment of chronic constipation. A prospective series of patients with constipation, as defined by the Rome II diagnostic criteria, were assessed by a clinician, a dietitian and a physiotherapist. Anorectal physi- ology investigations and defecography were performed prior to and after the programme. The treatment involved consultation by the dietitian, postural re-education and pelvic floor re-education regarding the proper pattern of defecation. The subjects were followed up in alternate weeks for the first 3 months and then monthly for another 3 months. Twenty patients have been recruited into the programme since 2005. Ten subjects have completed the course of treatment and three have defaulted; the remaining seven were still undergoing treatment at the time of writing. On completion of the programme, there was a significant improvement in fibre intake (pre-treatment=12.9191.06 g; post-treatment= 20.2661.064 g; P=0.001), average straining effort (pre-treatment=6.360.391; post-treatment=3.720.391; P=0.001) and average straining time (pre- treatment=17.612.172 min; post-treatment=6.002.172 min; P=0.004). The subjects reported a >50% improvement in their symptoms. A rehabilitative programme for constipation can significantly ameliorate the problem of constipa- tion. The method of anorectal manometry was employed to assess the paradoxical response of the anorectum during attempted defecation.
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    ABSTRACT: Outlet obstruction syndrome (OOS) is related to anatomic alterations, such as rectocele, enterocele and distal intussusception which may be associated with functional disorders, such as paradoxical puborectalis contraction. Patients unresponsive to conservative treatment are eligible for surgical correction of the specific anatomic defect. Recently, new techniques of stapler-assisted trans-anal surgery have been proposed as an alternative to traditional trans-anal operations. This prospective study was undertaken with the aim of assessing the efficacy and postoperative morbidity of two trans-anal stapled techniques (stapled trans-anal prolapsectomy or stapled trans-anal rectal resection, STARR) which were selectively performed in patients with OOS, based on the specific clinical, manometric and defecographic findings. From January 2004 to December 2006, 31 female patients (median age = 58.2 years: range = 27-77 years) underwent surgery at the Division of General Surgery, Colo-Rectal Disease Unit of San Martino Hospital in Genoa. Patients had preoperative colonoscopy, anorectal manometry, defeco- graphy, and a complete standardized questionnaire was completed preoperatively and at every six-month follow-up visit aimed at assessing the obstructed defecation score (ODS), the degree of symptoms (Gravity Disease Score = GDS), as well as the quality of life (PAC-QoL), and the satisfaction index by means of a visual analogue scale (VAS: 0-10). A complete re-assessment was performed after one year, including anorectal manometry and defecography. Six patients underwent stapled trans-anal prolapsectomy and 25 underwent STARR (double-STARR in seven, and single anterior STARR in 18 patients). All patients had a regular postoperative course. They had follow-up visits for a median period of 12 months (range: 4-27 months); 23 patients completed clinical and instrumental follow-up at one year, with a significant improve- ment of post-operative scores of outlet obstruction; moreover, 3 of them (13%) judged their final clinical outcome as excellent, and 18 (80%) as good or moderate. As regards anorectal manometry, pre- and postoperative resting and squeeze pressures were not different thus excluding any postoperative damage to the anal sphincter; conversely, an improvement of rectal sensation was observed in 15 patients (79%) as suggested by the decrease of rectal sensitivity threshold volumes (P = 0.01) and maximum tolerable volume (P < 0.01); moreover, in 7 out of 19 patients (36.8%) the balloon expulsion test became positive. With regard to postoperative defecography, normal findings were observed in 11 patients (61,2%) with a significant reduction of rectocele (P < 0.001); persistent abnormal findings were observed in 7 patients (38,8%). The accurate preoperative assessment and the selective trans-anal correction of rectocele and/or intussusception determined a significant improvement of outlet obstruction scores coupled with a normalization of defecographic and manometric findings, which was most relevant in patients under- going STARR, without any serious postoperative complication.
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