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33 Pelvic Floor Conditions: Fecal Incontinence
H.Sphincter Replacement
If an overt sphincter injury is found, whether from
traumatic accident, foreign body or other etiology,
attempts at more conservative measures, such as
SNS should be employed rst. If these measures
fail, surgical reconstruction of the sphincter may
be required. The prognosis in such cases with
sphincter repair alone are poor, but the function
and physical nature of the cerclage that the sphincter complex creates is a necessary part recreating
continence in this group of patients. As indicated
above, early post-obstetric injury represents one
of the few etiologies that may result in good longterm function with sphincter repair alone.
Sphincter Replacement Options
• Graciloplasty ± Dynamic Neuromodulation
(not available in the USA at the time of
publication)
• Gluteoplasty
• Articial Bowel Sphincter (not available in
the USA at the time of publication)
• Magnetic Anal Sphincter (not available in the
USA at the time of publication)
261
Fig. 33.7 Graciloplasty: This technique involves harvesting and transposing the gracilis muscle as a proximally pedicled ap. The muscle is tunneled around the
sphincter complex and sutured in place. (With permission
from Baeten C, Breukink S. Dynamic graciloplasty. In:
Wexner SD, Fleshman D (eds). Master Techniques in
Surgery. Colon and Rectal Surgery. Anorectal Operations.
Wolters Kluwer, Philadelphia, 2012)
Graciloplasty
In the patient with an unreconstructable sphincter disruption, sphincteroplasty may be impossible. In such cases, dynamic or stimulated
graciloplasty has shown signicant improvement in quality of life and incontinence symptoms. The gracilis muscle is harvested, tunneled
around the sphincter, and sutured in place. In the
unstimulated approach, patients learn to voluntarily contract this muscle to improve continence. In the dynamic version of graciloplasty,
neuromodulation stimulates the fast-twitch skeletal muscle of the gracilis neo-sphincter to convert to slow twitch muscle bers improving
functional outcome of the reconstruction.
Unfortunately, there are very few centers with
expertise in this technique, and referral to centers of excellence is required (Figs. 33.7 and
33.8).
Fig. 33.8 Graciloplasty. In the superior stimulated version, neuromodulation is employed to convert the fast
twitch skeletal muscle to slow twitch, resulting in relatively tonic contraction. (With permission from Baeten C,
Breukink S. Dynamic graciloplasty. In: Wexner SD,
Fleshman D (eds). Master Techniques in Surgery. Colon
and Rectal Surgery. Anorectal Operations. Wolters
Kluwer, Philadelphia, 2012)
Gluteoplasty
Using the gluteal muscles in a similar fashion to
the gracilis muscle in the graciloplasty, functional skeletal muscle is wrapped around the
sphincter complex. Contraction of the new
262
M. T. M. O’Donnell and J. I. S. Bleier
sphincter complex is achieved during ambulation. There has been marginal success with this
surgery.
Articial Bowel Sphincter (ABS)/
Magnetic Anal Sphincter (MAS)
Healthy patients with severe FI despite trial of
other modalities and sufcient healthy soft tissue
surrounding their anal canal can be considered
for sphincter replacement. Compared to the surgical sphincter reconstruction, replacement of the
sphincter through articial implantable devices
may be more appropriate in the otherwise healthy
patient who has failed medical management,
SNS, and undergoes EAUS to demonstrate an
unreconstructable sphincter. Contraindications
include history of pelvic irradiation, IBD, diabetes, and immunosuppression.
The ABS is an inatable cuff tunneled and
xed around the anal canal through perineal incisions. The cuff is kept full during resting state to
retain continence and when the patient needs to
evacuate, he or she can actively pump uid from
the cuff to the reservoir implanted in the space of
Retzius through a pump within the labia majora
or scrotum. The cuff then passively rells with
uid after evacuation over 8–10min.
This modality has been plagued with unreli-
able success and unacceptably high rates of complications—both related to patient morbidity and
device failure. Although highly effective in certain cases, it is no longer currently available in
the United States.
The magnetic anal sphincter (MAS) is a device
consisting of small magnets on a exible string.
This is implanted around the anal sphincter, tunneled optimally just below the puborectalis muscle. The number of magnets is selected by the
surgeon to provide complete occlusion of the anal
canal as they are attracted to each other at rest.
During defecation, Valsalva pressure forces the
magnets apart, allowing the stool bolus to be evacuated. Unfortunately the MAS is not available in
the USA at the time of publication.
J.Ostomy
Patients with fecal incontinence refractory to all
other interventions may be offered stoma formation as it can ameliorate perianal hygiene difculties and provide more manageable control of
fecal material. Patients who are wheelchairbound or paraplegic may desire this option
because the location of the stoma is easier to take
care of independently. An end sigmoid colostomy
should be considered in most patients, except
those with slow colonic transit time. Patients with
chronic constipation or slow colonic transit time
are likely better served by creation of an ileostomy. Satisfaction rates in patients with FI who
receive an ostomy are high.
∗Other Therapies
The following therapies have shown some promise as less invasive methods for improving fecal
incontinence, but require further long-term study.
These should be considered in patients who are
not interested in SNS or desire non-surgical
options.
Injectables
Surgical repair of internal anal sphincter defects
has not been shown to be effective in isolation,
and thus injection of biocompatible material
into the intersphincteric or submucosal plane
has been used for the treatment of minor fecal
incontinence. The therapeutic goal is aimed at
increasing the bulk of tissue in the anal canal,
resulting in more effective physical occlusion.
A number of materials have been used including autologous fat, collagen, non-animal stabilized dextranomer in hyaluronic acid (NASHA
Dx- Solesta
NC), and carbon- coated beads (Durasphere
EXP®, Coloplast Corp., Minneapolis, MN).
Ultrasound-guided delivery of the bulking
agents has been shown to be more effective
than digitally-guided injection. Durable ef-
®
; Salix Pharmaceuticals, Raleigh,
33 Pelvic Floor Conditions: Fecal Incontinence
263
cacy has been demonstrated with Solesta at 24
and 36months with over half of patients experiencing a greater than 50% reduction in the
number of FI episodes. However, long- term
studies are needed.
RF Remodeling
The Secca® procedure involves the delivery of
radiofrequency energy as an alternating current
to generate thermal energy within the anal canal
to induce collagen ber remodeling within the
sphincter complex. The initial therapy was based
on the theory that scarication causes a relative
physiologic obstruction, thus improving control,
however, interestingly, newer studies involving
histologic assessment of tissue after RF therapy
has revealed that the previously damaged sphincter muscle actually becomes more normal appearing after remodeling rather than simply forming
scar.
Conclusion
In summary, a detailed history can often reveal
the etiology of fecal incontinence in patients and
all therapy should be individualized based upon
the cause when possible. The majority of patients
will improve with non-surgical management of
diet modication, ber supplementation and
anti- diarrheal, slowing medications. The remainder of patients may benet from one or more of
the surgical interventions described, which
should be tailored to the etiology of the FI and
the wishes and comorbidities of the patient.
Sacral nerve stimulation has emerged as a reliable treatment for a number of cause of FI and
should be incorporated in the armamentarium of
the Colorectal surgeon. Knowledge regarding all
of the techniques available is important in this
often underdiagnosed and difcult to treat
problem.
Acknowledgements Disclosures: J Bleier has served as a
proctor for Medtronic. The authors have no other relevant
afliations or nancial involvement with any organization
or entity with a nancial interest in or nancial conict
with the subject matter or materials discussed in the manuscript apart from those disclosed.
Suggested Reading
Brown HW, Wexner SD, Segall MM, Brezoczky KL,
Lukacz ES. Accidental bowel leakage in the mature
women’s health study: prevalence and predictors. Int J
Clin Pract. 2012;66:1101–8.
Madoff RD, Parker SC, Varma MG, Lowry AC. Faecal
incontinence in adults. Lancet. 2004;364:621–32.
Paquette IM, Bordeianou L.Evaluation and treatment of
FI.In: Steele S, Hull T, Hyman N, Maykel J, Read T,
Whitlow C, editors. The ASCRS manual of colon and
rectal surgery. Cham: Springer; 2019. p.1091–105.
Paquette IM, Varma MG, Kaiser AM, Steele SR, Rafferty
JF. The American Society of Colon and Rectal
Surgeons’ clinical practice guideline for the treatment
of fecal incontinence. Practice parameters. Dis Colon
Rectum. 2015;58(7):623–36.
Tjandra JJ, Dykes SL, Kumar RR, etal. Practice parame-
ters for the treatment of fecal incontinence. Dis Colon
Rectum. 2007;50:1497–507.
Wald A.Clinical practice. Fecal incontinence in adults. N
Engl J Med. 2007;356:1648–55.
Wexner SD, Bleier JI.Current surgical strategies to treat
fecal incontinence. Expert Rev Gastroenterol Hepatol.
2015;9(12):1577–89.
Wexner SD, Fleshman JD, editors. Master techniques in
surgery. Colon and rectal surgery: anorectal operations. Philadelphia, PA: Wolters-Kluwer; 2012.
Pelvic Floor Conditions: Diarrhea
RebeccaRhee andAnnaSerur
34
Refer to Algorithm in Fig. 34.1
A. Pelvic oor dysfunction refers to a broad
group of disorders that are caused by abnormalities in the muscles and joints of the pelvic
oor (Table 34.1). Patients can present with
defecatory problems with either inability to
empty or to store the stool, pelvic pain or pressure and occasionally gross organ protrusion.
Fecal incontinence, although not life threatening, can lead to signicant disability and psychological trauma. It is more prevalent in the
elderly and in hospitalized individuals. The
prevalence of fecal incontinence in the noninstitutionalized patients in the United States
is estimated to be 8.3%, and consists of liquid
stool in 6.2%, solid stool in 1.6%, and mucus
in 3.1%. It occurs at least weekly in 2.7%,
with 0.9% of patients experiencing it daily.
Loose or watery stools are an independent risk
factor in both men and women.
B. Fecal incontinence is dened as accidental
passage of stool or mucus from the rectum
without patient’s knowledge, or without vol-
R. Rhee
Division ofColorectal Surgery,
Maimonides Medical Center, Brooklyn, NY, USA
A. Serur (*)
Department ofColorectal Surgery,
Maimonides Medical Center, Brooklyn, NY, USA
e-mail: aserur@maimonidesmed.org
untary contraction, or both. Diarrhea is a
very common cause of fecal incontinence.
When a patient develops diarrhea, the colonic
transit time is increased and the anorectal
sensation may be diminished leading to quick
evacuation. Fecal incontinence with diarrhea
may occur even in patients with intact sphincters and no neurologic dysfunction. Anal
sphincter pressure has to be much higher in
order to hold the liquid stool and allow for
controlled evacuation.
C. Evaluation of patients with fecal inconti-
nence and diarrhea include a thorough history and physical exam, including obstetric
history, other co-morbid conditions, history
of injury to the sphincters, neurologic insults
as well as the duration of symptoms, history
of travel, dietary habits. A physician evaluating a patient with fecal incontinence may
request the patient to keep a stool diary. A
sample may be found on a website www.
bowelcontrol.nih.gov. Another tool to evalu-
ate patients with fecal incontinence and diarrhea is the validated Bristol Scale (Fig.34.2).
The validated Bristol Stool scale consists of
seven descriptions of stool characteristics
and helps to objectively determine the
patient’s stool consistency. It is friendly to
use and includes pictures of each stool type.
D. The rst step in the evaluation of diarrhea is
to rule out an infectious cause. Stool cultures
should be tested for ova and parasites, CMV
© Springer Nature Switzerland AG 2020
S. R. Steele etal. (eds.), Clinical Decision Making in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-65942-8_34
265
266
R. Rhee and A . Serur
Fig. 34.1 Diarrhea evaluation algorithm. IBD inammatory bowel disease
Table 34.1 Causes of pelvic oor dysfunction
Fecal incontinence
Constipation
Rectocele
Paradoxical puborectalis contraction
Pelvic pain syndromes:
Levator syndrome
Coccydynia
Proctalgia fugax
Pudendal neuralgia
and bacterial infections. Additionally, fecal
leukocytes can indicate an infectious or
inammatory condition. C. difcile may be
separately tested for one of the available
stool studies (e.g., toxin, PCR).
E. Fecal incontinence with diarrhea may be
caused by a rectal mass or a large rectal
polyp. It is essential that the patients with FI
have either a full colonoscopy or a sigmoidoscopy if a full colonoscopy was performed
within a year.
F. There is a battery of tests used to evaluate
patients with fecal incontinence. Anal
manometry, PTNML, and anal electromyography are very helpful in trying to determine
treatment for a particular patient. Anal
manometry is used to evaluate the resting and
squeeze pressures of the sphincter muscles as
well as rectal compliance and rectal capacity.
There are poor established parameters for
normal pressures. According to the Cleveland
Clinic Florida-Fecal Incontinence Scale
(CCF-FIS), normal resting pressures are
40–70 mm Hg (55–95 cm water). Normal
squeeze pressures are 100–180mm Hg (136–
244cm water). Women generally have lower
resting and squeeze pressures than men.
There is no correlation between low pressures and surgical outcomes. However, pressures can be used for comparisons before and
after therapy. Pudendal nerve terminal motor
latency (PTNML) is another test used for
evaluation of patients with fecal incontinence. It assesses the neuromuscular integrity of the pelvic oor by measuring the
length of time required for a xed electrical
stimulus to conduct along the pudendal nerve
and cause muscle contraction. Normal
latency is considered to be 2ms (SD, 0.2ms).
Latency is prolonged in patients with damage
to the neuromuscular unit. The PTNML
appears to be the most signicant predictor
of functional outcome after sphincteroplasty.
In patients with a neurologic condition or
insult, anal electromyography can quantitate
the sphincter dysfunction. It can assess the
extent of damage secondary to the neurologic
condition and help in identifying other conditions responsible for fecal incontinence.
Needle electrodes are inserted directly into
the sphincter muscle and the patient is asked
clear cut edges
clear cut edges
pieces
34 Pelvic Floor Conditions: Diarrhea
267
Separate, hard
lumps
Soft blobs with
Fig. 34.2 Bristol Stool Scale. The seven types of stool
are (1) Type 1: Separate hard lumps, like nuts (hard to
pass), (2) Type 2: Sausage-shaped, but lumpy, (3) Type 3:
Like a sausage but with cracks on its surface, (4) Type 4:
Sausage-like
but lumpy
Soft blobs with
to contract the muscle as when holding a
stool and then relax it.
G. Endoanal ultrasound is a great tool to assess
the external and internal sphincter muscle. It
gives a real-time, 3-D picture and has a very
high specicity and sensitivity, 98–100% for
the external sphincter and 95.5% for the
internal sphincter. Three regions are examined: the most distal anal canal where only
the external sphincter muscle is present, the
mid anal canal visualizing both internal and
external sphincter and the proximal anal
canal-the level of the pubococcygeus muscle.
The normal thickness of the external sphincter muscle is ~8.3 mm (95% condence
interval [CI], 7.6–9mm). Mean internal anal
sphincter thickness is described as 6.5 mm
(95% CI, 5.8–7.2 mm). Tjandra and colleagues found EAUS to be more accurate
than EMG in evaluating sphincter defects
and more comfortable for the patient.
H. Defecography or MRI defecography is used
to evaluate rectal emptying as well as ability
to be able to hold the stool. While not a traditional component of a diarrhea evaluation, It
may be helpful in diagnosis of rectal prolapse,
Like a sausage,
but with cracks
on surface
Like a sausage or snake, smooth and soft, (5) Type 5:
Soft blobs with clear cut edges (passed easily), (6) Type
6: Fluffy pieces with ragged edges, a mushy stool, and
(7) Type 7: Watery, no solid pieces, entirely liquid
Like a sausage or
snake, smooth and
soft
Watery, no solid
rectocele, cystocele and internal prolapse—
conditions that can lead to symptoms of diarrhea. Most patients with incontinence have a
hard time tolerating this procedure. A pelvic
mass can cause an extrinsic compression on
the rectum, causing urgency and incontinence. Pelvic MRI is an excellent tool in
diagnosing this problem.
Refer to Algorithm in Fig.34.3
I. Treating the cause of diarrhea, increasing the
consistency of the stool and slowing down
the transit time may lead to improvement in
patient’s fecal incontinence. Treatment of
fecal incontinence with diarrhea ranges from
dietary modication to anti-diarrheal medicine to surgical options. Medical management should be exhausted prior to
recommending surgical alternatives.
J. Dietary modication is the rst step in treat-
ment of diarrhea. Patients should avoid foods
such as dairy products, caffeine, spicy foods,
and should increase intake of ber-rich
foods, including fruits, vegetables, nuts and
268
Fig. 34.3 Diarrhea management algorithm
R. Rhee and A . Serur
whole grains. A diet should include soluble
and insoluble ber and adequate amount of
uids.
K. Patients should be instructed to take a ber
supplement such as Metamucil, Fibercon,
Beneber, etc. As each of these vary in their
taste, consistency, and amount of ber per
scoop/pill/wafer, it is important to ensure
patients are instructed in goals for intake.
L. Constipating medicines such as Loperamide
or diphenoxylate with atropine are the next
step in treating incontinence with chronic
diarrhea. Both of these medications can be
given up to 4 times a day, 30 min before
meals, and once before sleep. Cholestyramine
and Tincture of Opium can be added to the
regimen if Loperamide and diphenoxylate
with atropine fails to solidify the stool.
Ondansetron has been shown to be effective
in Irritable Bowel Syndrome with diarrhea.
In a randomized, double-blind, placebocontrolled trial of 120 patients with Rome III
criteria for diarrhea-predominant irritable
bowel syndrome, 4mg dose led to improved
stool consistency, decreased number of days
with urgency, improved urgency scores, and
decreased frequency of defecation.
Amitriptyline is another drug that improves
diarrhea and decreases rectal urgency.
M. Skin barriers and creams should be used to
decrease secondary morbidity of diarrhea.
Balneol lotion and Calmoseptine ointment
are very effective in creating a protective barrier and avoiding irritation and skin break
down. Patients should be counseled about
avoidance of wipes and prolonged use of steroid creams.
N. Developing a regular bowel routine is
referred to as bowel training. Bowel training
is a difcult task for patients who have diarrhea and takes weeks to months to develop
but is possible. It works very well in patients
with constipation and overow incontinence.
Daily enemas or rectal washout can be done
daily or twice a day in order to facilitate
bowel training.
O. Pelvic oor exercises and biofeedback ther-
apy uses audiovisual cues to change patient’s
bowel habits. It requires a motivated patient
and a motivated therapist. Very few studies
have been done to support its efcacy. Many
different techniques have been described
leading to inconsistent treatment, and the
evidence for long-term effect is poor.
P. Anal plug is another modality that can be
used to improve patients’ quality of life but
not to eliminate the problem. A Cochrane
review of four studies with 136 patients
noticed improvement in patients with minor
leakage. However, approximately one-third
of patients did not tolerate the plug, discontinuing its use.
Q. SECCA procedure was introduced in 2002. It
involves application of temperature-
34 Pelvic Floor Conditions: Diarrhea
269
controlled radiofrequency energy to the anal
canal. The mechanism of its action is not
clear but it does improve the sphincter
function and anorectal sensitivity. A review
of 10 studies with 200 patients demonstrated
its efcacy in mild to moderate incontinence
with improvement in CCF/Wexner incontinence and quality of life scores.
R. Non-absorbable bulking agents injectable
(Solesta) is composed of sodium hyaluronate
and dextranomer. It was approved by the
FDA for the treatment of fecal incontinence
in 2011. It is injected into the submucosa of
the upper anal canal bulking it up. The compound also promotes broblast and collagen
growth. In a multicenter study, 62.7% of
patients experienced more than 50% reduction in both solid and liquid stool incontinence episodes. NASHA/Dx was found to be
effective and safe over a 24-month period.
S. Depending on the etiology of incontinence,
surgery can be the primary modality or the
treatment of last resort. Neuromodulation,
overlapping sphincteroplasty, articial bowel
sphincter and diversion with ileostomy/colostomy are existing options for patients.
Fecal Incontinence is a chronic life-long
disease that can be a result of congenital or
acquired conditions. The goal of treatment is
to improve patient’s quality of life and not
necessarily cure the disease. The most frequent type of Fecal Incontinence is the loss
of liquid stool. Chronic diarrhea is a factor
that can be modied by patients with fecal
incontinence leading to better control and
thus better quality of life.
Suggested Reading
Alavi K, Chan S, Wise P, Bordeianou L, et al. Fecal
incontinence: etiology, diagnosis, and management. J
Gastrointest Surg. 2015;19(10):1910–21.
Deuekom M, Dobben AC. Plugs for containing fae-
cal incontinence. Cochrane Database Syst Rev.
2012;4:CD005086.
Ditah I, Devaki P, Luma HN, et al. Clin Gastroenterol
Hepatol. 2014;12(4):636–43.
Duelund-Jakobsen J, Worsoe J, Lundby L, et al.
Management of patients with faecal incontinence.
Therap Adv Gastroenterol. 2016;9(1):86–97.
Frascio M, Mandolno F, Imperatore M, Wexner SD,
etal. The SECCA procedure for faecal incontinence: a
review. Colorectal Dis. 2014;16(3):167–72.
Gantke B, Schafer A, Enck P, Lubke HJ. Sonographic,
manometric, and myographic evaluation of the anal
sphincters morphology and function. Dis Colon
Rectum. 1993;36(11):1037–41.
Jorge JM, Wexner SD. Etiology and management of fecal
incontinence. Dis Colon Rectum. 1993;36(1):77–97.
La Torre F, de la Portilla F. Long-term efcacy of dex-
tranomer in stabilized hyaluronic acid (NASHA/Dx)
for treatment of faecal incontinence. Colorectal Dis.
2013;15(5):569–74.
Ng KS, Sivakumaran Y, Nassar N, Gladman MA.
Fecal Incontinence: Community Prevalence and
Associated Factors–A Systematic Review. Dis
Colon Rectum. 2015;58(12):1194–209. https://doi.
org/10.1097/DCR.0000000000000514. Review.
Whitehead WE, Borrud L, Goode PS, etal. Fecal inconti-
nence in the US Adults: epidemiology and risk factors.
Gastroenterology. 2009;137(2):512–7.
Chronic Constipation
PaulaI.Denoya andSyedK.Abbas
35
Introduction
Constipation is one of the more prevalent gastrointestinal complaints in the general population.
One out of six adults suffers with this condition
in varying degrees. According to the Rome IV
criteria, constipation is dened as the presence of
two or more of the following symptoms that
occur in more than 25% of defecations: straining
during defecation, sensation of stool in the rectal
vault after defecation, sensation of obstruction or
blockage, passage of lumpy and/or hard stools,
need for manual maneuvers to facilitate defecation (such as digital evacuation and perineal support during defecation), and less than three
spontaneous bowel movements per week. These
symptoms must be present for at least three
months with onset of symptoms at least six
months prior to diagnosis. In patients with irritable bowel syndrome, the criteria for constipation
have not been clearly dened. Patients do not
meet the criteria of constipation if they exhibit
symptoms of irritable bowel syndrome, such as
abdominal pain that is relieved with defecation,
unpredictable stool frequency, and variable stool
forms with defecation (varies between diarrhea
and hardened stool). Furthermore, patients with
P. I. Denoya (*) · S. K. Abbas
Department ofSurgery, Stony Brook University
Hospital, Stony Brook, NY, USA
e-mail: paula.denoya@stonybrookmedicine.edu
constipation rarely have loose stools without the
use of laxatives.
The most common causes of constipation are
insufcient uid or ber intake and poor bowel
habits. When examining the other causes, constipation can be categorized into primary and secondary causes. Primary causes of constipation
are divided into normal transit constipation
(NTC), slow transit constipation (STC), and defecatory disorders.
In NTC, patients will report symptoms of constipation while having normal passage of stool
through the colon. The symptoms in NTC tend to
be associated with psychosocial stress.
In STC, patients have normal colonic transit at
rest, but have decreased or absent colonic motility after meals or blunted responses to laxatives
and cholinergic medications. It is suspected that
there is a possible dysfunction in the enteric
nerve plexus or the interstitial cells of Cajal.
Defecatory disorders are characterized by
abnormalities in the pelvic oor muscles.
Dyssynergia is the impaired relaxation or inappropriate contraction of the puborectalis and external
anal sphincter muscles during defecation. When
these muscles contract, the anorectal angle is narrowed, increasing the anal canal pressures and preventing effective defecation. Abnormally elevated
resting pressures in the anal canal due to anal
sphincter muscle spasms denes anismus, which
can also cause constipation. Structural abnormalities, such as megacolon and megarectum, can fall
© Springer Nature Switzerland AG 2020
S. R. Steele etal. (eds.), Clinical Decision Making in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-65942-8_35
271
272
P. I. Denoya and S. K. Abbas
under defecatory disorders. The dilation and distension of the colon or rectum can be attributed to
neurologic dysfunction or chronic fecal retention
and impaction (Table35.1).
There are a wide variety of secondary causes of
constipation. The most common manifestations of
secondary constipation are multifactorial and
involve multiple organ systems, including neurologic, psychiatric, metabolic, endocrine, autoimmune, and congenital. Furthermore, mechanical
obstructions from benign and malignant pathologies can present as constipation, such as rectoceles, rectal prolapse, intussusception, colonic
lesions like adenocarcinoma and polyps, and colon
or anorectal strictures. Medications that cause constipation as a side effect are analgesics, anticholinergics, neurally active drugs, cation-containing
agents, and diuretics.
Refer toAlgorithm inFig. 35.1
Diagnosis
A. History
When obtaining the history from a constipated
patient, it is important to dene the nature and
the duration of constipation. Some of the most
common complaints in constipated patients
include abdominal bloating, pain with defecation, rectal bleeding, overow diarrhea or
incontinence, and lower back pain. Patients
that have difculty with rectal evacuation may
complain of a sense of incomplete evacuation,
manual extraction of stool, tenesmus, and
enema retention. Other important aspects of
the history should be explored, such as the
patient’s normal pattern of defecation, onset
and duration of abnormal pattern, perceived
hardness of stools, straining to defecate, and
the amount of time spent during defecation.
Obtaining a validated constipation score is
useful both to help direct therapy and to monitor post therapeutic outcomes. The Cleveland
Clinic Florida-Fecal Incontinence Score
(CCF-FIS) is the most widely employed score.
Table 35.1 Etiology of constipation
Primary causes of constipation
Normal transit constipation
Slow transit constipation
Defecatory dysfunction
Dyssynergia
Megacolon/megarectum
Secondary causes of constipation
Neurologic disorders Medications
Peripheral disorders Analgesics
Autonomic
neuropathy
Hirschsprung disease Anticholinergics
Chagas disease Antihistamines
Intestinal
pseudoobstruction
Sacral nerve
damage
Central disorders Antipsychotics
Multiple sclerosis Cation-containing
Spinal cord injury Iron supplements
Parkinson disease Aluminum
Endocrine disorders Barium
Diabetes mellitus Neurally-active drugs
Hypothyroidism Opiates
Hyperparathyroidism Antihypertensives
Panhypopituitarism Ganglionic blockers
Metabolic disorders Vinca alkaloids
Hypokalemia Calcium channel
Hypercalcemia 5HT3 antagonists
Uremia Diuretics
Porphyria
Myogenic disorders
Myotonic dystrophy
Dermatomyositis
Scleroderma
Amyloidosis
Structural abnormalities
Colorectal cancer
Extraintestinal mass
Postinammatory,
ischemic, or surgical
stenosis
Anal ssure
Anal stricture
Rectal prolapse
Rectocele
Intussusception
NSAIDs
Antispasmodics
Antidepressants
agents
(antacids, sucralfate)
blockers