[22] Secondary constipation is caused by many other different factors such as diet, drugs, behavioral, endocrine, metabolic, neurological, and other disorders.
[20] Other authors use the term ODS to refer to defecatory dysfunction in the absence of any pathological findings (that is, a purely functional disorder).
[20] Wherever possible, this article generally follows the definitions and terminology of the 2018 consensus statement,[note 2] wherein ODS is defined as "a subset of functional constipation in which patients report symptoms of incomplete rectal emptying with or without an actual reduction in the number of bowel movements per week.
However, the following entries are present, as well as separate codes for most of the individual organic lesions listed in this article: The term "obstructed defecation syndrome" does not appear in the Rome IV classification.
[32] These are defined as "Inadequate propulsive forces as measured with manometry with or without inappropriate contraction of the anal sphincter and/or pelvic floor muscles",[32] and "Inappropriate contraction of the pelvic floor as measured with anal surface EMG or manometry with adequate propulsive forces during attempted defecation" respectively.
Possible complications of rectal digitation are injury of the lining of the rectum,[21] such as ulcerations with bleeding and discomfort, and anal fibrosis leading to a stricture.
[12][2] The pelvic floor (pelvic diaphragm) can be divided into 4 compartments: Anterior or urinary (bladder, bladder neck, and urethra), Middle or genital (vagina and uterus in women, prostate in men), Posterior (anus, anal canal, sigmoid, and rectum), and Peritoneal (endopelvic fascia and perineal membrane).
[43] A significant pathophysiological factor in obstructed defecation is dysfunction of anorectal and colon motility,[44] and impaired pelvic floor function.
[23] 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.
[44] They also have a mechanical support function since they adhere to the surface of enteric ganglia and nerves with filaments of glial fibrillary acid protein.
[44] These cells synchronize various elements of the enteric nervous system, and their loss may significantly impact colonic motility.
[51] A cul-de-sac hernia (peritoneocele) is a herniation (protrusion) of peritoneal folds into the rectovaginal septum (the tissue between the rectum and the vagina) which does not contain any other abdominal organs.
Symptoms are variable, depending on the severity and the location of the herniation, and may include incomplete evacuation of the rectum, heavy sensation in the pelvis, and constipation.
[21] Enterocoele may develop because of weakening pelvic floor, multiple pregnancies, hysterectomy, and long term chronic straining.
Typically such patients complain of defecation urgency and frequent bowel movements, but only small fecal pellets are passed leaving a sensation of incomplete evacuation.
During surgery anatomic defects in the sigmoid colon are sometimes observed in patients with ODS, such as acute bends which are stuck laterally (to one side of) or in front of the rectum.
[39] Extensive anorectal sensory and motor physiological testing may help to identify subgroups of patients in whom surgery may be more successful.
[12] For example, some have suggested that anismus is an over-diagnosed condition, since the standard investigations or digital rectal examination and anorectal manometry were shown to cause paradoxical sphincter contraction in healthy controls, who did not have constipation or incontinence.
[57] Due to the invasive and perhaps uncomfortable nature of these investigations, the pelvic floor musculature is thought to behave differently than under normal circumstances.
[1] Non relaxation or paradoxical contraction of the puborectalis muscle at the anorectal junction can be felt when the patient performs a Valsalva manoeuvre or evacuation.
The members of the panel were all engaged in research and treatment of ODS, and were considered expert in the field of pelvic floor functional disorders.
[59] For patients with rectal intussusception and a large rectocele or enterocele the experts all preferred laparoscopic (transabdominal) ventral rectopexy with non resorbable mesh, regardless of the function of the sphincter.
[34] In general, it is hard to assess the effectiveness of biofeedback because variation in exactly how it carried out, and also published research usually lacks control groups and validated outcome measures.
[15] For patients who do not undergo biofeedback, simple pelvic floor and abdominal muscle relaxation exercises may also be useful to make evacuation easier.
[58] The original STARR procedure uses 2 specially designed surgical staplers, which are inserted via the anus and enable excision of the full thickness of the excess bowel wall in the lower rectum.
[15] In one large report on over 2000 patients who underwent STARR found that there was improvement in obstructed defecation symptoms and quality of life 12 months after the procedure.
[21] One report found that almost all patients with ODS who underwent the STARR procedure had an "hourglass" stricture and reduced size and length of the rectal ampulla visible on defecography after 4-6 months.
[62][non-primary source needed] It is also used for rectoceles,[63] solitary rectal ulcer syndrome,[64] and can be combined with procedures for vaginal prolapse, for example sacrocolpopexy.
[65] The procedure is able to correct multiple anatomical defects associated with vaginal and rectal prolapse, as well as improving function in terms of continence and defecation.
[24] Some of the reasons for this female predilection are thought to be related to trauma from childbirth through vaginal delivery, menopausal tissue changes and hysterectomy.