Defecatory Dysfunction and the Pelvic Floor

Abstract

Defecatory dysfunction is infrequently considered a gynaecological problem. However, obstructed defecation (OD) more commonly affects women than men and is associated with pelvic floor dysfunction. Therefore, we set out to write a review from a urogynaecologists’ prospective focusing on OD as it relates to the pelvic floor. Literature on this topic remains sparse and the studies tend to have a low sample size. It is clear that OD is associated with pelvic floor dysfunction including urinary incontinence and structural dysfunction; however, it is less clear which is the primary pathology. Management of OD needs to be considered in treatment of pelvic floor dysfunctions. OD effects 14% of the general population. Ninety percent of the patients with OD will have a rectocele, enterocele or even intussusception. The pathophysiology is multifactorial and still not fully comprehended. Aetiology of constipation is classified as primary or secondary. The former includes slow transit or normal constipation and defecation disorders. The latter includes constipation caused by medications, diet and medical conditions. The Rome IV criteria are used to define functional constipation globally. Defecation disorders of the pelvic floor are categorised as structural disorders, pudendal neuropathy and dyssynergic defecation. First-line management includes treating the primary causes, dietary modification and laxatives. We stress the importance of posture whilst defecating is of utmost importance. A full squatting position with a slight forward tilt results in the broadening of the anorectal angle thereby facilitating emptying. Biofeedback therapy is still considered first-line treatment for dyssynergic defecation. Finally, surgical management of advanced stage prolapse is often unavoidable but is not a cure of OD. The increasing use of translabial ultrasound as a diagnostic modality will hopefully help facilitate research in this area.