Obstructed defecation

Other names| rectal outlet obstruction, evacuatory dysfunction, obstructed defecation syndrome, outlet constipation, pelvic outlet obstruction[1]

Obstructed defecation, is "difficulty in evacuation or emptying the rectum [which] may occur even with frequent visits to the toilet and even with passing soft motions".[2] The conditions that can create the symptom are sometimes grouped together as defecation disorders. The symptom tenesmus is a closely related topic. Another source defines evacuatory dysfunction as "a constellation of symptoms such as prolonged repeated straining at bowel movements, sensation of incomplete evacuation, and the need for digital manipulation".[1]

Some describe an "obstructed defecation syndrome", defining it loosely as "difficulty in evacuation, which may or may not be associated with constipation"[2]

Others inappropriately equate obstructed defecation with anismus.[3] Although anismus is a type of obstructed defecation, obstructed defecation has many other possible causes other than anismus.

## Contents

* 1 Signs and symptoms
* 2 Causes
* 2.1 Incomplete evacuation
* 3 Diagnosis
* 3.1 Classification
* 4 Treatment
* 5 See also
* 6 References

## 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

Fecal incontinence to gas, liquid, solid stool, or mucus in the presence of obstructed defecation symptoms may indicate occult rectal prolapse (i.e. rectal intussusception), internal/external anal sphincter dysfunction, or descending perineum syndrome.[1]

## Causes

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.[4] Patients with obstructed defecation appear to have impaired pelvic floor function.[5]

Specific causes include:

* Anismus[4] and pelvic floor dysfunction[6]
* Rectocele[6][4]
* "Rectal invagination" (likely refers to rectal intussusception)[4]
* Internal anal sphincter hypertonia[3]
* Anal stenosis[6]
* Fecal impaction[6]
* Rectal or anal cancer[6]
* Descending perineum syndrome[6]

### Incomplete evacuation

Obstructed defecation may be a cause of incomplete evacuation of stool.[7] Normal emptying of rectal contents is 90-100%. <90% evacuation could be defined as incomplete evacuation. Incomplete evacuation is also one of the factors implicated in the cause of fecal leakage.

## Diagnosis

The two key features of obstructed defecation are:

1. An inability to voluntarily evacuate rectal contents[6]
2. Normal colonic transit time[6]

A 5 item questionnaire was validated for diagnosis and grading of obstructed defecation syndrome.[7] The parameters were:

1. Excessive straining
2. Incomplete rectal evacuation
3. Use of enemas and/or laxatives
4. Vaginal-anal-perineal digitations (needing to press in the back wall of the vagina or on the perineum to aid defecation)
5. Abdominal discomfort and/or pain

### Classification

Obstructed defecation is one of the causes of chronic constipation.[5] Obstructed defecation could be considered to be a type of bowel obstruction, where it may be classified under large bowel obstruction. Obstructed defecation frequently gives rise to a symptom called tenesmus. Constipation, bowel obstruction and tenesmus are therefore all closely related topics.

Outlet obstruction can be classified into 4 groups.[8]

* 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 dyssynergia)
* Multiple sclerosis
* Spinal cord lesions

* Mechanical outlet obstruction

* Internal intussusception
* Enterocele

* Dissipation of force vector

* Rectocele
* Descending perineum
* Rectal prolapse

* Impaired rectal sensitivity

* Megarectum
* Rectal hyposensitivity

## Treatment

Obstructed defecation has many causes, so the management in any individual case is specific to the cause of the symptom. For rectal internal intususception treatment is surgical, either STARR or rectopexy. For rectocele STARR or mesh implantation. For anismus/ pelvic floor dessynergia: biofeedback exercise.

## See also

* Tenesmus
* Constipation
* Defecography

## References

1. ↑ 1.0 1.1 1.2 Wexner, edited by Andrew P. Zbar, Steven D. (2010). Coloproctology. New York: Springer. ISBN 978-1-84882-755-4.
2. ↑ 2.0 2.1 Marzouk, Deya. "Obstructed Defaecation Web". http://www.obstructed-defaecation.com/Welcome.html. Retrieved 9 September 2012.
3. ↑ 3.0 3.1 Lubowski, DZ; King, DW (February 1995). "Obstructed defecation: current status of pathophysiology and management.". The Australian and New Zealand journal of surgery 65 (2): 87–92. doi:10.1111/j.1445-2197.1995.tb07267.x. PMID 7857236.
4. ↑ 4.0 4.1 4.2 4.3 Kairaluoma, MV (2009). "[Functional obstructed defecation syndrome].". Duodecim; laaketieteellinen aikakauskirja 125 (2): 221–5. PMID 19341037.
5. ↑ 5.0 5.1 Sun, WM (Jul–Aug 1993). "Obstructed defecation.". Journal of Gastroenterology and Hepatology 8 (4): 383–9. doi:10.1111/j.1440-1746.1993.tb01532.x. PMID 8374096.
6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Welton, Mark Lane. "Obstructed Defecation". Armenian Medical Network, Inc. http://www.health.am/ab/more/obstructed-defecation/. Retrieved 9 September 2012.
7. ↑ 7.0 7.1 Renzi, A; Brillantino, A; Di Sarno, G; d'Aniello, F (May 17, 2012). "Five-Item Score for Obstructed Defecation Syndrome: Study of Validation.". Surgical innovation 20 (2): 119–25. doi:10.1177/1553350612446354. PMID 22599920.
8. ↑ Wexner, edited by Andrew P. Zbar, Steven D. (2010). Coloproctology. New York: Springer. pp. 140. ISBN 978-1-84882-755-4.

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