Obstructed Defaecation Syndrome

What is obstructed defaecation? Obstructed defaecation simply means having difficulty emptying the bowel. What causes obstructed defaecation?

There are two causes of obstructed defaecation, functional causes and physical causes. Sometimes the two can coexist:

• Functional- in this situation the pelvic floor fails to relax or even tightens when a patient tries to open their bowel.
• Physical causes- these are caused by weakness in the pelvic floor rectoceles, enteroceles and internal prolapse (intussusception). These cause either a physical blockage to evacuation, or result in a pocket forming which traps some bowel content meaning evacuation is incomplete.

Symptoms

What symptoms do obstructed defaecation cause? The symptoms experienced include some or all of the following:

• Needing to strain
• Never feeling empty
• Frequent visits to the lavatory
• Fruitless visits to the lavatory
• Using a finger to help evacuation

As emptying may not be complete some patients describe leakage of a small amount of stool after they have been to the lavatory. How is obstructed defaecation investigated? Before confirming the diagnosis and finding a cause for obstructed defaecation, patients will require some form of endoscopic examination of the bowel either by flexible sigmoidoscopy or colonoscopy to ensure that it is otherwise healthy.

The most useful test to determine the cause of obstructed defaecation is a video proctogram. This gives information not only about structural problems but also whether or not the pelvic floor works properly. A transit study is often performed to establish Most patients will also have tests of their sphincter muscle function (anorectal physiology) and an endoanal ultrasound scan to look for any damage to the muscle.

How is obstructed defaecation treated?

Keeping the stools soft, avoiding straining and the use of glycerine suppositories will help many patients. Where the problem is due to function then biofeedback / physiotherapy is usually recommended to enable patients to regain co-ordination of their pelvic floor. If a physical cause for the symptoms is found surgical correction may be recommended. Such procedures might include rectocele repair, or ventral mesh rectopexy for patients with enterocele or internal prolapse

Exercises

Exercises When not on the toilet:

• Pelvic floor relaxation breathing technique: lie down with your knees bent and feet flat on the floor. Breathe in fully, hold your breath and consciously relax your abdomen outwards and downwards. Then sigh the breath out, imagining your pelvis getting wider as you do so. Repeat 5 times
• Child’s pose with open knees: kneel down with wide knees (so that your tummy can drop in between your knees) and put your forehead on the ground and your arms above your head. Relax fully, feeling the stretch in your pelvic muscles. Remain in this position for five minutes if you can.
• Side twist/thoracic expansion: lie down on your side with your knees bent and arms stretched out in front of you. Then bring one arm over to the other side and roll onto your back, keeping your knees in the same position. Hold the stretch for two minutes, then roll over onto the opposite side and repeat on the opposite side.
• Try perineal massage: wash your hands and keep your nails short. Using a lotion or lubricant suitable for intimate areas, gently massage your perineum (the area between your scrotum and anus if you’re a man, or your vagina and anus if you’re a woman). This will help the muscles in that area to relax.

When sitting on the toilet:

• Keep your knees higher than your hips when sitting on the toilet, by putting a small footstool underneath your feet. This makes the anal canal straighter and therefore it is easier to open your bowels.
• Try the “wonder woman” pose: sit with your feet apart and hands on your hips. Push your tummy out until you feel it pushing against your fingertips. This will automatically relax your pelvic floor muscles.

Surgical Options

Other Procedure Performed

• Internal delormes procedure
• Transperineal repair of rectocele
• Transvaginal rectocele repair

The decision of the procedure is decided by a multidisciplinary team of colorectal surgeon, physiologist, specialist nurse, gynecologist and psychiatrist