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.

Download full-text


Available from: Theodoros Troupis, Nov 11, 2014
  • Source
    • "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. "
    [Show abstract] [Hide abstract]
    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.
    Full-text · Article · Aug 2012 · Journal of the Korean Society of Coloproctology
  • Source
    • "Some well-known etiology of constipation includes endocrine and metabolic diseases (e.g., diabetes mellitus), neurological diseases (e.g., spinal cord injury) ) (Bassotti et al., 1998 ), cancer, those undergoing surgery, and cancer treatment. Other common causes of constipation are rectoanal problems such as anal strictures, iatrogenic conditions such as constipation because of drugs or previous surgery, and dietary factors such as a low residue diet (Abyad & Mourad, 1996; Andromanakos, Skandalakis, Troupis, & Filippou, 2006; Annells & Koch, 2002; Bharucha, Locke, Seide, & Zinsmeister, 2007; Böhmer, Taminiau, Klinkenberg-Knoll, & Meuwissen, 2001; Bosshard, Dreher, Schnegg, & Bula, 2004; Guo et al., 2004; Knowles, Scott, Williams, & Lunniss, 2000; ABSTRACT The aim of this study is to translate into the Turkish language, and test the reliability and validity, of the Turkish version of the Constipation Risk Assessment Scale (CRAS). This study consisted of 245 adult in-patients who were hospitalized in the medical and surgical clinics of Celal Bayar University Hospital in January through May 2007. "
    [Show abstract] [Hide abstract]
    ABSTRACT: The aim of this study is to translate into the Turkish language, and test the reliability and validity, of the Turkish version of the Constipation Risk Assessment Scale (CRAS). This study consisted of 245 adult in-patients who were hospitalized in the medical and surgical clinics of Celal Bayar University Hospital in January through May 2007. The patients were categorized into two groups (constipated and not constipated) according to Rome II criteria. All participants were assessed with the CRAS. The CRAS was retested on 32 patients selected randomly from among the initial constipated group (n =152). The statistical analysis consisted of reliability and validity analyses. Test-retest comparison and internal consistency were used to assess the reliability of the instrument. Divergence and known groups approaches were used to test for construct validity. Correlation analysis using the Pearson's coefficient was conducted to assess the test-retest. For testing of the criteria and known groups, Student's t test and Mann-Whitney U test were used. Cronbach's = value for the constipated respondents was r = 61.9. According to the effect size comparisons, the most effective variable on the CRAS score was perception of constipation risk requirement. The overall score and subsection score correlations were also found acceptable (r = 0.47-0.57).
    Full-text · Article · May 2011 · Gastroenterology nursing: the official journal of the Society of Gastroenterology Nurses and Associates
  • Source
    • "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). "
    [Show abstract] [Hide abstract]
    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.
    Full-text · Article · Jan 2008
Show more