Obstructive defecation syndrome

this is for my future students

1. Obstructed Defecation Syndrome Dr. Nabarun Biswas (FCPS Surgery) Registrar Mymensingh Medical College Hospital

2. What is ODS ? “ Difficulty in evacuation, which may or may not be associated with constipation“ “ Difficulty in evacuation or emptying the rectum which may occur even with frequent visits to the toilet and even with passing soft motions”

3. What is Constipation? “ Constipation is a symptom, not a disease characterized by infrequent bowel movements, usually less than 3 stools per week or hard to pass”.

4. Common causes of constipation Diet Medications Medical conditions slow movement of stool within the colon, irritable bowel syndrome, and pelvic floor disorders  associated diseases: hypothyroidism, diabetes, Parkinson's, celiac disease, non-celiac gluten sensitivity, colon cancer, diverticulitis, and IBD Psychological Congenital

5. Features of Constipation that correlates with ODS

6. Pathophysiology of ODS 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”

7. Why Obstructed Defecation occurs? One review stated that the most common causes of disruption to the defecation cycle are associated with pregnancy and childbirth, gynaecological descent or neurogenic disturbances of the brain-bowel axis. Patients with obstructed defecation appear to have impaired pelvic floor function

8. Specific causes of Obstructed Defecation Anismus and pelvic floor dysfunction Rectocele Rectal invagination/ intussusception Internal anal sphincter hypertonia Anal stenosis Fecal impaction Rectal or anal cancer Descending perineum syndrome

9. Correlation with ODS Obstructed defecation is one of the cause of- Chronic constipation Incomplete evacuation of bowel Chronic large bowel obstruction and Tenesmus

10. Classification Outlet obstruction can be classified into 4 groups Functional outlet obstruction Mechanical outlet obstruction Dissipation of force vector Impaired rectal sensitivity

11. 1. Functional outlet obstruction Inefficient inhibition of the internal anal sphincter Short-segment Hirschsprung's disease Chagas disease Hereditary internal sphincter myopathy Inefficient relaxation of the striated pelvic floor muscles Anismus (pelvic floor dys-synergia) Multiple sclerosis Spinal cord lesions

12. 2. Mechanical outlet obstruction Internal intussusception Enterocele 3. Dissipation of force vector > Rectocele > Descending perineum > Rectal prolapse 4. Impaired rectal sensitivity Megarectum Rectal hyposensitivity

13. Signs and symptoms incomplete or unsuccessful attempts to evacuate prolonged episodes on the toilet rectal pain posturing digitations or perineal massage to aid defecation enema dependency

14. Key features of obstructed defecation An inability to voluntarily evacuate rectal contents Normal colonic transit time

15. Five Questionnaire to diagnose & grading ODS Excessive straining? Incomplete rectal evacuation? Use of enemas and/or laxatives? Vaginal-anal- perineal digitations (needing to press in the back wall of the vagina or on the perineum to aid defecation) Abdominal discomfort and/or pain?

16. Diagnostic Approach for ODS

17. Dr Longo’s ODS Score

18. Interpretations Each point is scored according to frequency of the symptom. Questions 1-6: 0 =never, 1 = less than once weekly, 2 = 1–6 times weekly, 3 = every day; question 7:0 = less than 5 min, 1 = 6 – 10 min, 2 = 11–20 min, 3 = more than 20 min; question 8: 0 = no alteration of lifestyle, 1 = mild alteration, 2 = moderate alteration, and 3= significant alteration of lifestyle. The total score is in the range of 0 (best) to 24.

19. 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

20. Management Specific to the cause: Conservative: Dietary fiber Plenty of water Laxatives Rectal enema/ irrigation Biofeedback for anismus Psychotherapy Avoid chocolate and constipating foods

21. Management Surgical treatment: Manual technique Stapled technique

22. Manual technique to perform a kind of “surgical” irrigation; to perform either a resection or a plication or a pexy in case of internal mucosal prolapse; to reinforce the rectovaginal septum and/or, again, resect the redundant mucosa, in case of significant rectocele ; and to perform miotomy in case ODS is due to a muscular disorder.

23. Stapled technique STARR procedure

24. 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 overlapping dog ears at 3 and 9 o‘clock positions.

25. Let’s see a video

26. Conclusion ODS is a problem that is frequently encountered in the elderly females, and the management should be tailor-made to each clinical scenario.

27. THANK YOU ALL