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190
A.C. Lowry and J.L. Irani
experience. EMG recruitment is done on patients with
obstructive defecation unless full-thickness rectal prolapse is
present. In all other patients, non-relaxation would be
addressed fi rst even if an indication for surgery was present.
In addition, EMG recruitment helps to confi rm or refute the
diagnosis of anismus. We perform manometry on these
patients but largely for research purposes rather than as aid
for clinical decision-making. Balloon expulsion testing is
rarely done. It is helpful however when the diagnosis is
uncertain or if the patient is diverted.
Etiology and Treatment Options
Key Concept : Treatment decisions depend upon the etiology
of obstructive defecation .
If a full-thickness rectal prolapse is diagnosed, surgical
correction is performed; any persistent evacuation diffi culties are addressed postoperatively. Please see Chap. 11 where
Drs. Wexner and Hayden address the options for repair. If
non-relaxation of the puborectalis muscle is identifi ed on
testing, particularly if seen on two tests, that issue is
addressed fi rst even if a rectocele, internal intussusception,
or enterocele is also identifi ed. If a rectocele is the only
abnormality identifi ed, it is addressed; the same is true for
enterocele and sigmoidocele in some circumstances.
Non-relaxing Puborectalis
Key Concept : Non - relaxation of the puborectalis muscle may
be an isolated fi nding or seen in combination with other
abnormalities . Initial treatment is medical management
including dietary recommendations and possible recommendation of fi ber supplements or osmotic laxatives combined
with biofeedback therapy .
Non-relaxation of the puborectalis may be diagnosed on
EMG recruitment, defecography, balloon expulsion tests,
and ultrasound. There is controversy about the diagnostic
criteria and even the existence of this fi nding [ 9 , 12 ]. The
false-positive rate is poorly documented but false positives
do occur, likely secondary to a poor understanding of instructions or embarrassment [ 9 ]. In our institution, 15 % of
patients were able to demonstrate appropriate puborectalis
function during their fi rst biofeedback appointment, suggesting a false-positive diagnosis (unpublished data).
Our preferred initial treatment of non-relaxation of the
puborectalis is biofeedback therapy. Regardless of the technique utilized, the goals of biofeedback therapy are to correct the lack of appropriate coordination of the abdominal
muscles and sphincter mechanism and to enhance rectal sensory perception. Published methods include manometrybased biofeedback, EMG biofeedback, balloon defecation,
and home device training. Surface EMG electrodes may be
used on the abdominal and gluteal muscles. Protocols vary
but typically include four to six training sessions.
Improvement of symptoms varies between 44 and 100 % in
several uncontrolled trials [ 29 ]. The wide range is likely due
to the vague defi nition of endpoints, variable duration of
follow-up, and inconsistent patient selection. What is clear is
that results are better in patients who complete the fullprescribed course of treatment [ 30 ]. There have been several
randomized controlled trials [ 31 – 36 ] where biofeedback was
compared to medical management, polyethylene glycol,
diazepam/placebo, balloon defecation treatment, and sham
feedback therapy. In all of these studies, biofeedback was
found to be superior to the other treatment options. An additional 1-year long-term follow-up study reported that biofeedback was superior to medical management [ 34 ]. Another
recent study showed benefi t in patients with anismus with
and without IBS [ 37 ]. Overall, in addition to the positive out-
comes, biofeedback is inexpensive and safe without reported
adverse events.
Failure of Initial Management/Surgical Options
Key Concept : If symptoms do not resolve with biofeedback
therapy , reported alternative treatments include botulinum
neurotoxin injection and surgical division of the puborectalis
muscle . Botulinum neurotoxin appears to be safe , while surgical division of the puborectalis muscle is no longer recommended because of reported complications .
If obstructive defecation symptoms persist in patients
whose only abnormality is non-relaxation of the puborectalis
muscle, then botulinum neurotoxin injection may be considered. In reported studies two bilateral injections of botulinum neurotoxin into the puborectalis and external sphincter
muscles are performed with total amounts varying from 60
to 100 units [ 38 – 44 ]. The injections are done under either
digital or ultrasound guidance and with either local or general anesthesia. Improvement in symptoms varies from 33 to
79 % [ 38 , 40 – 45 ]. In the studies with postoperative evalua-
tion, the sphincter pressures and anorectal angle decreased.
The improvement typically lasts only 3 months, so repeat
injections are often required. Careful selection of patients is
important. In one study, examination under anesthesia of
nonresponders revealed signifi cant abnormalities (rectal prolapse, fi ssure, internal anal sphincter myopathy) in 97 % of
patients [ 38 ]. When those patients were excluded, the
response to botulinum toxin was 96 %. In that same study,
gender and presenting symptoms were the only factors predictive of success, with men and patients presenting with
obstructive defecation symptoms alone more likely to
respond. A randomized study compared biofeedback to botulinum neurotoxin injection in treatment of anismus [
39 ].
12 O bst ruct ive Def ecatio n
191
Initial improvement was signifi cantly better in the injection
group, but there was no difference in long-term success or
patient satisfaction. None of the studies reported serious
complications, though temporary incontinence of fl atus is
reported in several studies. Our feelings are that while the
primary disadvantage of botulinum neurotoxin injection is
the potential need for repeat treatment, it appears to be safe
and a reasonable option in the treatment of these patients.
On the other hand, surgical division of the puborectalis
muscle, a previously reported option has been largely abandoned because of the high rate of incontinence [
46 – 48 ].
However, one recent study compared biofeedback, botulinum neurotoxin injection, and surgical division of the
puborectalis muscle [ 49 ]. Patients undergoing surgical treat-
ment had the best long-term improvement, with 70 %
improvement at 1 year vs. biofeedback (30 %) or botulinum
toxin injection (35 %). Incontinence was reported in 13 %.
Outpatient anal dilatation is described as another option.
Thirteen patients performed daily insertion of anal dilatators
for 30 min for 3 months [ 50 ]. At 6 months from the end of
treatment, all patients reported improvement. For patients
who prefer or do not respond to other treatments, the remaining surgical option is diversion.
Our Recommendations
In our practice, patients with non-relaxation of the puborectalis muscle, either as an isolated or combined abnormality,
are referred for biofeedback. For those patients with isolated
non-relaxation that persists after biofeedback, botulinum
neurotoxin injection is offered. We do not recommend division of the puborectalis muscle because of the risk of irreversible incontinence. Diversion is rarely indicated but may
be offered when the impact on the symptoms severely impair
patient’s quality of life.
Rectoceles
Key Concept : Rectoceles are common fi ndings in parous
women ; caution must be exercised in attributing symptoms to
them .
The prevalence of rectoceles is poorly documented, as
many women are asymptomatic, with reported rates varying from 18 to 40 % in limited studies (Fig. 12.8 ) [ 17 , 51 ].
Confounding this, rectoceles are seen on defecography in
81 % of asymptomatic women [ 17 ]. Because rectoceles are
quite common, you should be cautious about attributing
symptoms to that fi nding alone. In addition, a recent review
demonstrated variable association of the degree of posterior compartment prolapse and symptoms of obstructive
defecation [
52 ].
Fig. 12.8 Rectocele ( Courtesy of M . Shane McNevin , MD )
Surgical Indications
Key Concept : Surgery is indicated for persistent obstructive
defecation symptoms and / or a symptomatic vaginal bulge .
Women with obstructive defecation secondary to a rectocele typically complain of a sense of incomplete evacuation
with a sensation of stool trapped in a visible vaginal bulge or
rectal pocket. Perineal or posterior vaginal wall pressure facilitates evacuation and may serve as an indication that rectocele
repair will alleviate the symptoms. While some surgeons use
rectocele size over 3 cm as a criterion for surgery [ 53 ], others
have found that this does not correlate well with the extent of
symptoms [ 54 ]. Some authors believe that retention of dye in
the rectocele is an indication of the clinical signifi cance of the
rectocele, while others maintain that this fi nding does not
relate to the relief of symptoms postoperatively [ 55 – 57 ].
Key Concept : A number of surgical options are available for
rectocele repair ; there is no clear evidence of superiority of
one approach .
Rectoceles occur because of disruption or diffuse thinning
of the fascial tissue between the rectum and the vagina. They
are essentially a hernia. In other areas of the body, mesh is
frequently utilized now to reduce recurrence rates. Similarly,
because of recurrence rates with traditional native tissue
repairs of rectoceles, repairs utilizing mesh were developed.
Some of those repairs, with the use of synthetic mesh, for
example, have been complicated by persistent pain, mesh erosion, and infection. Another approach, stapled transanal
resection of the rectum (STARR procedure) involves resection of redundant tissue in the rectum without repair of the
fascia using linear staplers. While certain patients benefi t, the
procedure does not resolve symptoms in all women with rectoceles, and there is a generalized paucity of data describing
the results in patients with rectoceles alone.
Ventral rectopexy with mesh anchored to the perineal
body is also currently being evaluated with the goal of
192
A.C. Lowry and J.L. Irani
repairing the fascial defect with reduced complication rates
because of the abdominal approach. Unfortunately, no single
approach has yet been shown to be superior to the others. An
issue with the literature regarding rectocele is that the defi nition of anatomically successful repair is not standardized.
Furthermore, in most cases, the different approaches vary in
success rates with regard to the outcome measured (i.e.,
recurrence, function, complications).
Transvaginal surgical choices include posterior colporrhaphy, site-specifi c rectocele repair, and mesh implantation.
Posterior colporrhaphy involves midline plication of tissue
in the rectovaginal septum often with perineoplasty. After
dissection of the vaginal epithelium from the rectovaginal
septum, the fascia, and in some hands the levator ani muscles, is plicated in the midline. The fi bromuscular tissue
adjacent to the perineal skin is also plicated to complete the
perineoplasty. Generally, the anatomic abnormality is successfully repaired, but dyspareunia is common and the functional results variable [
58 – 64 ]. Recurrence of symptoms
appears to increase with the length of follow-up [ 65 ].
Site-specifi c repairs consist of identifi cation and repair of
the fascial defect in the rectovaginal septum [ 66 – 71 ]. A fur-
ther modifi cation added a perineal repair [ 72 ]. These repairs
also result in acceptable anatomic correction with less sexual
consequences, but the recurrence rates appear to be higher.
A randomized trial of posterior colporrhaphy compared to
site- specifi c repair with and without graft augmentation demonstrated slightly better anatomic success in the posterior colporrhaphy patients with no difference in functional outcome
or dyspareunia [ 58 ]. Another comparative study confi rmed
those fi ndings [ 73 ]. Overall, relief of defecation symptoms
varies from 46 to 72 % [ 72 – 74 ].
Disappointing recurrence rates motivated the search for
alternative repairs [ 65 , 75 , 76 ]. The third vaginal approach
option is mesh implantation, which can occur either through
use of a mesh-kit technique or as a supplement to any of the
other procedures. Synthetic permanent, synthetic absorbable, and biologic meshes have been used. A number of comparative studies of synthetic mesh demonstrated comparative
anatomic results to native tissue repair [ 77 – 81 ]. Four ran-
domized controlled trials comparing transvaginal permanent
synthetic mesh to traditional native tissue repair have been
published; two of the studies involved the use of mesh kits
[ 82 – 85 ]. One reported fewer recurrences with the use of
mesh, while the other three reported no differences. The rate
of mesh extrusion ranged from 5.6 to 16.9 %. Interestingly,
the study with the positive results also revealed a much
higher rate of new prolapse in an untreated compartment
than with traditional repair [ 86 ]. Complications related to the
mesh including mesh extraction, mesh retraction, pelvic
pain, and sexual dysfunction were reported. Recent concerns
about vaginal erosions of the mesh and mesh contractions
resulting in chronic pain and vaginal shortening resulted in
an update warning from the FDA in 2011 counseling
surgeons about the risks and need for informed consent [ 87 ].
Your patients should be informed that surgical intervention
may be necessary to correct the mesh extrusion and pain secondary to the mesh, should it occur. At the present there
appears to be additional risk and insuffi cient benefi t for recommending the use of synthetic mesh [ 88 ].
Those fi ndings and recommendations led to use of other
materials. One randomized controlled trial comparing synthetic absorbable mesh to native tissue found no difference
in recurrence rates [ 89 ]. Unfortunately, the authors did not
report bowel or sexual functional outcomes. There is some
evidence that the complication rate is lower with biologic
mesh than with other mesh. However, two studies comparing
its use to native tissue found either no benefi t [ 85 ] or a higher
recurrence rate [ 58 ].
Transperineal repairs of rectoceles involve a perineal incision with subsequent dissection of the rectovaginal septum
separating the posterior vaginal wall from the external sphincter distally and rectal wall proximally. The dissection proceeds cephalad to the posterior fornix. Imbrication of the
fascial tissue, along with a site-specifi c repair or insertion of
mesh, completes the repair [ 90 – 93 ]. A levatorplasty may also
be added. A randomized controlled trial compared transanal
repair, transperineal repair alone, and transperineal repair
with levatorplasty [ 94 ]. Defecography revealed a reduction in
the size of the rectocele in all groups, but functional scores
improved only in the two transperineal groups. The combination of a transperineal approach with levatorplasty yielded the
most improvement in functional outcome.
Transanal repair of rectocele involves the elevation of rectal mucosal fl aps for the length of the rectocele [ 53 , 95 , 96 ].
The tissue in the rectovaginal septum is then imbricated; anterior levatorplasty and internal sphincter muscle plication may
be added. The mucosal fl aps are then re-approximated. Several
investigators report high rates of symptomatic improvement
after transanal repair [ 53 , 95 – 101 ]. Typically, low rates of dys-
pareunia are demonstrated. However, a randomized controlled
trial comparing vaginal to rectal repairs found a higher recurrence rate (7 % vs. 40 %) and more frequent incontinence of
fl atus after the transanal repair [ 102 ]. As noted above, the trial
comparing transanal and perineal approaches demonstrated
better functional results with the transperineal approach [ 94 ].
Yet, a recent Cochrane review found lower recurrence rates
with a vaginal approach compared to transanal repairs, highlighting the differences among the various approaches for
each of the outcomes assessed [ 103 ].
Regardless of the type of repair, most studies demonstrate
improvement in obstructive defecation symptoms including
splinting [
85 , 94 , 104 ]. On the downside, those same studies
also reveal a persistence of some symptoms in about 50 % of
patients. This data, in addition to the frequency of the anatomic fi nding in asymptomatic women, emphasizes the
12 O bst ruct ive Def ecatio n
193
importance of careful selection and informed consent for
these patients. This is especially pertinent when considering
that conservative management, including dietary, medication, and lifestyle changes and possibly a pessary, results in
improvement in ~50 % of patients [
105 ].
Our Recommendations
Recognizing there is not an optimal repair, our preferred
approach is a site-specifi c repair if the defect can be identifi ed and the surrounding tissue seems adequate. If the defect
cannot be identifi ed clearly, then a native tissue imbrication
with the possible addition of biologic mesh (per surgeon
preference) is utilized. Restoration of the perineal body is
included. At the present time, we are avoiding the use of synthetic mesh.
Internal Intussusception
Key Concept : If internal intussusception is the only abnormality identifi ed , medical management is the fi rst - line
treatment .
Internal intussusception (i.e., rectoanal intussusception,
internal rectal prolapse, occult rectal prolapse) is fullthickness, circumferential prolapse of the rectum during
evacuation that does not protrude through the anus [ 106 , 107 ].
Defecography is the best way to diagnose internal intussusception. Importantly, it is unclear whether internal intussusception is pathologic or is a normal variation, as rectal
intussusception is seen in 50 % of asymptomatic patients on
defecography during defecation [ 17 ]. Interestingly, there is
no difference in the speed or effectiveness of evacuation
between asymptomatic volunteers with and without rectal
intussusception. Likewise, symptomatic patients with intussusception did not have signifi cantly different evacuation
parameters compared to either asymptomatic group [
Furthermore, some authors believe it is a consequence of
obstructed defecation rather than a cause of it [
quency with which obstructed defecation is associated with
internal intussusception is unknown [ 110 ].
Rectal intussusception may cause symptoms of obstruction by blocking the rectal ampulla during defecation; this
may cause a persistent urge to defecate as well as pain in the
anal canal [ 111 ].
The treatment of internal intussusception is controversial.
Initial management is always conservative. Therefore, we
and most authors recommend conservative treatment consisting of fi ber supplementation, refraining from straining,
and biofeedback [ 3 , 109 , 112 – 114 ]. Over 50 % of patients
with rectal intussusception experience complete or partial
resolution of constipation symptoms with biofeedback [
109 ]. The fre-
108 ].
110 ].
Surgical Treatment
Key Concept : Caution must be exercised before the recommendation of surgical intervention as the outcomes after
traditional surgical correction were disappointing . While
more recent results from two new procedures are more
encouraging , the role of surgery for this diagnosis is unclear .
Surgery for internal intussusception should be approached
with caution. Adequate repair, as evidenced by elimination
of the intussusception on defecography, may not equal
symptom relief for the patient, and likewise, despite persistence of an anatomic problem (i.e., surgical failure), patients
may feel symptomatic relief [ 109 , 111 ]. Furthermore, the
risk of internal prolapse progressing to total rectal prolapse
is low [ 113 , 115 ].
Various surgical techniques have been employed to treat
internal intussusception associated with obstructed defecation including traditional rectopexy, ventral rectopexy, and
stapled transanal resection of the rectum (STARR). In a survey of constipated patients who underwent laparoscopic
resection rectopexy after biofeedback failed, 53 % reported
improvement in bowel frequency [ 116 ]. In another small
study, the majority of patients who underwent resection rectopexy reported an improvement in constipation symptoms
[ 117 ]. However, others have found rectopexy to be an inef-
fective treatment for obstructed defecation that may even
worsen constipation or tenesmus [ 118 , 119 ]. Because the
functional outcomes of traditional rectopexy (± resection)
are unacceptably poor and patients with internal intussusception are unlikely to see improvements in their obstructive
defecation with this procedure, a very frank discussion with
the patient must precede surgical intervention [ 120 ].
Until recently, we, along with most surgeons, avoided
surgery for internal intussusception because of the high likelihood of persistent symptoms. A small percentage of patients
underwent stoma formation because their symptoms were so
troublesome and prior repairs had been ineffective. Recently,
however, outcomes from two procedures have been more
encouraging. Laparoscopic ventral rectopexy, performed by
dissecting exclusively anterior to the rectum, preserving the
lateral stalks, and using polypropylene mesh for rectal fi xation, has been used for internal intussusception with good
results. At 3 months postoperative, 86 % of patients reported
improvement in their obstructed defecation, and there were
no mesh-related complications [ 120 ]. Others have found
similar results [ 119 ]. Yet, many surgeons fear placing a per-
manent mesh directly on the bowel due to the potential for
erosion or infection. At 6-month follow-up from laparoscopic ventral rectopexy using biologic mesh (Permacol) in
patients with internal rectal prolapse and constipation, 82 %
reported cured or improved constipation. There were no
mesh-related complications [ 121 ]. While still in its infancy,
ventral rectopexy has promising initial results.
194
A.C. Lowry and J.L. Irani
As previously described, stapled transanal resection of
the rectum (STARR) has emerged as another possible technique to treat obstructed defecation secondary to multiple
causes, including internal intussusception. Notably, the presence of a coexisting enterocele, however, is a relative contraindication to the STARR procedure [ 122 ]. One hundred
nineteen women suffering from obstructed defecation with
associated rectocele and rectal intussusception were randomized to biofeedback or STARR; there was a signifi cant
improvement in symptoms in the STARR group compared to
the biofeedback group after 1-year follow-up (81 % vs.
33 %, respectively). Fifteen percent of STARR patients
experienced an adverse event (local infection, anorectal
pain, incontinence, bleeding, urinary infection, or depression) [
123 ]. Similarly, 85 % of 14 patients with intussuscep-
tion (± rectocele) reviewed retrospectively who underwent
the STARR procedure had signifi cant improvement in stool
evacuation at 68-month follow-up; however, three required
reoperation [ 124 ]. Although 81 % of 326 patients who under-
went STARR were highly satisfi ed and would recommend it
or have it again, 72 % reported fecal urgency at 8 weeks
(which declined over time) and 10 % reported recurrent
symptoms postoperatively [ 125 ]. In another small study, 24
patients underwent pre- and postoperative MR defecography; an intussusception was observed in 20 patients, 18 of
whom also had an anterior rectocele. Following the STARR
procedure, 79 % of patients reported that the main symptoms
disappeared (excessive straining, need for digital assistance
during defecation, or incomplete evacuation), and MR
revealed a correction of intussusception in 75 %. Furthermore,
these patients had a signifi cantly improved Cleveland
Constipation Score compared to those without radiographic
evidence of correction of intussusception [ 108 ]. In a retro-
spective review of 123 patients with obstructive defecation
and rectocele and/or intussusception, 65 % had subjective
improvement after STARR; however, 28 % had recurrent
intussusception, 24 % required reoperation, and the postoperative complication rate was high, including one death following reoperation for necrotic rectum and uterus [ 126 ].
Although good results can often be enjoyed following the
STARR procedure, several possible complications have been
reported including urinary retention, severe pain, infection,
fecal incontinence, stenosis, rectovaginal fi stula, peritonitis,
fecal urgency, bleeding, hematoma, and necrotizing fasciitis
[ 122 , 124 , 126 – 128 ].
Our Recommendations
We currently treat internal intussusception primarily with
conservative management. For patients with signifi cant
persistent symptoms, we are now trying ventral rectopexy
after careful informed consent about the relative lack of
published data. We have avoided the STARR procedure
after balancing the risk of complications with the likelihood
of improvement.
Enterocele
Key Concept : Enterocele is usually present with other pelvic
fl oor fi ndings , making the exact symptoms attributable to
enterocele indecipherable .
Enterocele is a peritoneum-lined sac usually containing
small bowel that herniates into the rectogenital septum
[ 114 , 129 ]. Characteristic symptoms of enterocele may be as
follows: diffi culty emptying, post-evacuation discomfort,
and pelvic pain or heaviness [ 130 ]. Symptoms may be exac-
erbated by standing, may worsen as the day goes by, and are
relieved by laying down [ 130 ]. Nevertheless, it is controver-
sial whether or not enterocele causes diffi culty evacuating
and obstructed defecation [ 130 , 131 ]. When comparing 77
women with enteroceles to 233 women without enteroceles,
there were no signifi cant differences in symptoms related to
bowel function, such as infrequent bowel movements, straining, manual evacuation, and fecal incontinence [ 132 ].
With opacifi cation of the bowel (using oral and rectal
contrast), enterocele can be seen on defecography, when
present [ 114 , 130 ]. Enterocele is often not the sole fi nding
on pelvic fl oor studies. In 104 patients with an enterocele,
76 % had concomitant fi ndings such as perineal descent,
rectocele, and rectal intussusception [ 130 ]. Since it is
unclear what specifi c symptoms are caused by enterocele,
initial management should be nonsurgical. We advise these
patients to increase fi ber and water intake, avoid straining,
and initiate biofeedback [ 133 ]. Surgical repair may be more
effective at relieving pelvic pain rather than obstructed defecation [ 130 ]. In 20 patients who underwent obliteration of
the pelvic inlet with nonabsorbable mesh, symptoms of
obstructed defecation persisted in all 15 patients with evacuation diffi culties preoperatively [ 131 ].
Surgical Treatment
Enterocele repair can be undertaken from a transvaginal
or transabdominal approach. Both yield excellent anatomic results; however, evaluating functional outcomes
is more diffi cult, given that the majority of enteroceles
are seen in women with other pelvic fl oor pathology
[ 133 ]. Transvaginal repair is traditionally performed
in patients with uterovaginal prolapse (Fig.
Looking at abdominal approaches, there are defi nitively
pros and cons when evaluating the outcomes. Abdominal
12.9a, b ).
12 O bst ruct ive Def ecatio n
Fig. 12.9 ( a , b ) Vaginal vault
prolapse with enterocele and
mesh repair
195
a
b
colporectosacropexy with nonabsorbable mesh anatomically
corrected the enterocele in 58 of 59 study patients; however, the number of patients with obstructed defecation
was not different before and 27 months after surgery [ 134 ].
Obliteration of the pelvic inlet with U-shaped nonabsorbable mesh adequately corrected the enterocele in 91 % of
patients; however, obstructed defecation persisted in 75 %
of patients who presented with this problem before the
procedure [
indication to the STARR procedure [
135 ]. Some authors feel enterocele is a contra-
122 , 128 , 136 ], while
others have shown no difference in functional outcome and
postoperative complications in patients with and without
enterocele undergoing STARR for obstructed defecation
syndrome [ 137 ]. Although studies are few, a combined
laparoscopic and STARR procedure may ultimately prove
benefi cial to patients with enterocele [ 138 , 139 ].
Our Recommendations
Based on the available data, it is unlikely that repairing an
enterocele alone will benefi t a patient complaining of
obstructed defecation. Most repairs are performed in patients
with additional indications for surgery such as rectal prolapse and rectal intussusception [
134 , 140 ]. For patients with
196
A.C. Lowry and J.L. Irani
Fig. 12.10 Sigmoidocele seen on defecography ( Courtesy of Steven
D . Wexner , MD )
mild symptoms and relatively limited enterocele, medical
management with an adequate bowel regimen is recommended. If concomitant anismus is identifi ed, then a trial of
biofeedback may be warranted.
Sigmoidocele
Solitary Rectal Ulcer Syndrome (SRUS)
Key Concept : SRUS is a rare entity with characteristic histologic fi ndings that should be treated with behavior modifi cation ,
fi ber , and biofeedback . Ventral rectopexy may offer improvement in symptoms , although experience is limited thus far .
Solitary rectal ulcer syndrome is associated with evacuation abnormalities. Vague associated symptoms include the
following: rectal bleeding, passage of mucus, rectal pain,
excessive straining, and tenesmus [ 114 ]. Once the diagnosis
is confi rmed by biopsy and histological analysis and malignancy is ruled out, SRUS is traditionally treated conservatively with fi ber supplementation, avoidance of straining,
and biofeedback. Topical applications, such as steroids or
sulfasalazine, have not proven effective [ 114 ].
Ulceration, if present, is typically anterior and low in the
rectum making resection a diffi cult proposition, especially
since the syndrome is strongly associated with chronic
straining. Targeting therapy towards this abnormality (i.e.,
avoidance straining) is generally effective and avoids a large
operation [ 114 , 143 ]. We generally counsel the patients
regarding dietary management, regular attempts to defecate,
avoidance of prolonged time on the toilet, and appropriate
toiling posturing. If non-relaxation is present on testing, biofeedback is also recommended.
Ventral rectopexy is emerging as a possible surgical
option should conservative measures fail. Forty-eight
patients who underwent laparoscopic ventral mesh rectopexy for SRUS after initial biofeedback were evaluated:
100 % had epithelial ulcer healing, and 68 % had improved
ODS symptoms [ 144 ].
Key Concept : Patients with large sigmoidoceles may benefi t
from surgical correction , although data is sparse .
Sigmoidocele is similar to enterocele; however, the
peritoneal sac contains sigmoid colon that herniates into
the rectogenital septum [ 141 ]. There is a paucity of stud-
ies on this entity. In 1994, Jorge et al. [ 142 ] noted 24 sig-
moidoceles out of 463 (5 %) cinedefecographies
performed for constipation, incontinence, and chronic
idiopathic rectal pain. Sigmoidocele was classifi ed based
on the degree of descent of the lowest portion of the sigmoid: 1st degree = above the pubococcygeal line, 2nd
degree = below the pubococcygeal line but above the
ischiococcygeal line, and 3rd degree = below the ischiococcygeal line (Fig. 12.10 ). Six patients with either 2nd-
or 3rd-degree sigmoidocele underwent colectomy with or
without rectopexy, and all reported improvement in constipation. The authors conclude that there is correlation
among the mean level of sigmoidocele, percentage of
redundancy, and clinical symptoms [
there have been no further published data evaluating sigmoidocele in relation to obstructed defecation; thus, we
cannot provide evidence-based recommendations on its
treatment.
142 ]. Nevertheless,
Our Recommendations
Once malignancy is ruled out, we target the potential causes
of SRUS such as straining and prolapse (internal) through
the use of a bowel regimen and potentially biofeedback.
Although uncommon, if external rectal prolapse is present,
it is repaired. Ventral rectopexy may become a reasonable
surgical intervention for patients with persistent symptomatic ulceration although insuffi cient data exists at present to
recommend it. Surgical resection has been utilized, but the
operations are often technically challenging and frequently
symptoms persistent. Occasional patients require diversion.
The optimal timing for surgery and most effective surgical
procedure are not known at this time.
Persistent Symptoms
It should be clear from the discussion that some patients will
have persistent symptoms. They should be evaluated for missed
diagnoses, failed surgical correction of the identifi ed problem,
12 O bst ruct ive Def ecatio n
197
a
c
b
d
Fig. 12.11 Sacral nerve stimulation. ( a ) Accessing the correct sacral level. ( b ) Lead in place. ( c ) Fluoroscopy to confi rm lead placement. ( d )
Completed in place with fi nal wound closure
and new abnormalities that arose after surgical intervention.
Attention is then directed to a recognized etiology for the symptoms. If that evaluation is not rewarding, then conservative management including dietary, lifestyle, and medication management
should be recommended. Biofeedback may be helpful. A new
option, sacral nerve stimulation is being investigated.
100 % [ 145 ]. Although it is diffi cult to interpret the current
results, SNS offers a test period prior to permanent implantation, thus reducing the expense for patients who fail to
respond. Risks from the procedure are often minimal and
include infection and pain. Therefore, given the paucity of
effective surgical treatments for obstructive defecation syndrome, SNS may emerge as a promising intervention to offer
patients who fail conservative therapy and do not have other
Sacral Nerve Stimulation
specifi c anatomic causes (Fig. 12.11a–d ).
Key Concept : Sacral nerve stimulation ( SNS ) is not currently
US FDA approved for constipation but may be an option in the
Summary Pearls
future .
Most studies evaluating SNS for constipation are uncontrolled, retrospective case series that combine patients with
slow-transit constipation and evacuatory dysfunction and
have short durations of follow-up. Nevertheless, success
rates (mostly defi ned as increase in defecatory frequency) in
patients who went on to permanent implant range from 42 to
Symptoms of obstructive defecation are relatively common
and may be the result of a number of different etiologies.
Your history and physical examination will not only help
determine the cause but also guide your subsequent evaluation. Remember fi rst and foremost that conservative management benefi ts a signifi cant percentage of patients, and this
198
A.C. Lowry and J.L. Irani
should be balanced against any attempt at surgical intervention. Operative therapy can be effective in select individuals,
but persistent symptoms are a frequent occurrence. Therefore,
frank discussion with your patient regarding the expected
outcomes and potential complications is imperative. A careful evaluation is critical for the ones with persistent symptoms in order to appropriately determine their treatment.
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