Obstructed Defecation Research Articles

Comparison of pre and post-operative ODS (Obstructed Defecation Syndrome) score in patient with ODS undergoing Stapled Transanal Rectal Resection (STARR)

Background: There are a variety of surgical approaches for correction of ODS, most of these have high recurrence and complication rates. Stapled transanal rectal resection (STARR) was introduced in 2003 by Antonio Longo as a minimally invasive transanal operation for ODS associated with rectocele and or rectal intussusception.
 Objective: This study was designed to assess the efficacy of Stapled Transanal Rectal Resection (STARR) as a surgical treatment of Obstructed Defecation Syndrome(ODS).
 Methodology: This is a quasi experimental study that was carried out at Colorectal surgery unit of surgery department in Bangabandhu Sheikh Mujib Medical University. The sample size was 17. The admitted patient of Obstructed Defecation Syndrome with Rectocele and or Rectal intussusception was selected according to inclusion and exclusion criteria. The patient was evaluated by history, clinical examination, proctoscopy, colonoscopy and defecography. Preoperative Longo’s ODS score was determined for each patient and it was compared with postoperative ODS score. Regular follow up was done for each patient at one, three and six months after each operation.
 Results: Significant improvement of ODS score was observed in 82.35% patients. Only 02 (11.8%) patients didn’t respond to STARR procedure and their postoperative score was 13-15 may be due to coexistence of pelvic floor dysynergy. Postoperative defecatory urgency developed only in 02(11.76%) patients. No patient developed significant postoperative complication like hemorrhage or rectovaginal fistula.
 Conclusion: STARR is a simple, less invasive and effective procedure for the treatment of ODS due to rectocele and/or rectal intussusception without major morbidity but pelvic floor dyssynergy should be excluded preoperatively because it’s presence makes the surgical intervention fruitless.
 Journal of Surgical Sciences (2019) Vol. 23(2): 67-70

MR defecography in obstructed Defecation syndrome

Abstract Background ODS is an emerging clinical problem, especially for adult female patients (80%–90%). The pathophysiology of ODS remains to be clearly defined. This is because anatomic defects, such as internal rectal prolapse and rectocele, may be associated with functional alterations, such as paradoxical puborectalis contraction and spastic external sphincter contraction. Aim of the Work Obstructed defecation syndrome (ODS) is a type of constipation characterized by fragmented stools, need for straining at defecation, sense of incomplete evacuation, tenesmus, urgency and pelvic heaviness. This study is aimed to assess and compare and matching the role of Dynamic magnetic resonance imaging (MRI defecography) with the cilincal diagnosis in such patients. Pateints and Methods This retrospective, case-control study was conducted on twenty patients suffering from obstructive defecation syndrome that have been diagnosed clinically. The patients age is ranged between 16 and 69 years old. Results Statistically MRI study showed significant anatomical defects (p < 0.05) as the followings: Most of patients had Rectocele (65%), Disenergic Pelvic Syndrome (DPS) because of pelvic floor descents in (55%) of patients. Intossusception(45%),Cystocele (30%), interocele(25%), Anismus(15%) and uterine prolapsed (15%) Conclusion MRI has good value to detect abnormalities pertinent to posterior compartment in pelvis. Results of MR imaging showed positive agreement with clinical diagnosis of ODS in65% of patients. MRI showed 90% sensitivity, specificity, positive and negative predictive values as well as accuracy. MRI assessment of the posterior pelvic compartment can be indicated to detect the anatomical defects and lead to more successfully patient management and subsequently decreases the rate of postoperative recurrence.

75: Surgical correction of obstructed defecation syndrome

75: Surgical correction of obstructed defecation syndrome

Commentary on “The role of conventional pelvic floor reconstructive surgeries in obstructed defecation symptoms change: CARE and OPTIMAL trials sub-analysis of 2-year follow-up data”

Commentary on “The role of conventional pelvic floor reconstructive surgeries in obstructed defecation symptoms change: CARE and OPTIMAL trials sub-analysis of 2-year follow-up data”

Primary mesorectal carcinoid tumour, a case report and review of literature

: Carcinoid tumours of unknown origin (CUO) are rare and account for only 10% of carcinoid tumours (1). Utilisation of 68-gallium Dotatate positron emission computerised tomography (PET-CT) offers increased sensitivity and characterization of CUO, compared to traditional Octreotide scans (2). Development of this may allow investigation into the mesentery as a potential primary site. A 55-year-old woman was referred with a 4-month history of proctalgia and obstructive defecation. Digital rectal examination (DRE) revealed a posterior retro-rectal mass. Computerised tomography (CT), biopsy and octreotide scan along with elevated serum chromogranin A levels confirmed a carcinoid mass in the mesorectum, distinct from the bowel wall. Laparoscopic ultra-low anterior resection with ileostomy formation was performed. Eighteen months post-operatively, surveillance CT thorax, abdomen and pelvis (TAP) highlighted an enlarged lymph node in the right external iliac chain, which was positive on gallium PET-CT. Following multidisciplinary (MDT) discussion, a laparoscopic right obturator lymph node resection was undertaken after which post-operative histology confirmed metastatic well-differentiated neuroendocrine tumour. Management of CUO is challenging and as such should be individualized with an MDT-based approach. The mesenteric organ should be considered as a potential primary site in the setting of mesenteric carcinoid when no other primary focus is identifiable. Future guidelines should reflect this.

A DESCRIPTIVE STUDY OF MR DEFECOGRAPHY FOR EVALUATION OF OBSTRUCTED DEFECATION SYNDROME

Objective:-This study aims to ascertain the role of MR Defecography in the evaluation of obstructed defecation syndrome (ODS) with objective to describe spectrum of MR Defecography findings in obstructed defecation syndrome (ODS) and describe a number of reference lines and measurement points used to diagnose and grade pelvic floor disorders and Document the MRI appearance of disorders associated with ano-rectal dysfunction. MR Defecography demonstrated the profile of obstructed defecation syndrome on the basis of MR defecography and demonstrate its utility in simultaneous & objective evaluation of all three pelvic compartments. This diagnostic modalities provide a detailed pelvic floor anatomy and functional evaluation, as well as their respective abnormalities, making a precise diagnosis and provides valuable information on treatment planning & decrease chance of postoperative recurrence.
 Subjects and Methods: It was Cross-sectional and prospective (quantitative) hospital based descriptive type of observational study carried out at a tertiary hospital SMS hospital, jaipur. Chosen the patients diagnosed with ODS as per Rome criteria (III) whose colonoscopy or rectosigmoidoscopy, had been done to rule out other findings from Feb 2018 to September 2019.MR defecography (static and dynamic) with 3 T (PHILIPS INGENIA) MRI system having tunnel configuration. After written and informed consent, patient was positioned supine in MR machine gantry . Static imaging performed in the axial T1WI high resolution, axial, coronal and sagittal T2WI high resolution images at rest for anatomical evaluation. Following this,after ultrasound gel instilled in the patient’s rectum and intravaginaly ,dynamic imaging were taken in the midsagittal plane through the anal canal using a T2 weighted sequence. This sequence was ran for almost 2 min, while the patient performs various maneuvers (Kegel (squeeze), valsalva menuvere (strain), and defecation). MR defecography structurally and functionally evaluated in all 3 pelvic floor compartments and associated defects noted and grading of specific findings like organ specific prolapse, pelvic floor relaxiation and descent were measured.
 Results: In our study most common findings were pelvic floor descent and anorectal junction descent in 92.68% cases each followed by rectocele in 82.93% cases. Among the females, vaginal/uterine prolapse were observed in 65.31% cases. Least common findings were paradoxical contraction (8.54%) and sigmoidocele (0%). Significant difference was observed in MRI functional parameters in resting state and during defecation/maximal strain position, utilising HMO system for pelvic floor relaxation and descent, as significant difference (p <0.001S) was observed in all parameters including H line, M line, bladder base descent, cervical/vaginal and anorectal junction descent during resting state and during defecation/maximal strain position. Out of 82 conservative biofeedback therapy was given to 79.27 % patients, surgical management was done in (7.32%) and combination of both therapies was given in 13.41% of cases. Out of 82 patients 68.29% showed benefit from management and showed improvement on follow and 31.71% patients were not improved on follow up.
 Conclusion: As complete survey of the entire pelvis is necessary before surgical repair Magnetic resonance imaging permits evaluation of all three pelvic compartments and as we demonstrated in our study more than one compartment are frequently affected in obstructed defecation syndrome. Static MR Imaging can be also useful to identify the defects responsible for pelvic organ prolapse and stress urinary incontinence, and so help perform site specific repair in surgery, to avoid the high recurrence rates.Findings reported at dynamic MR imaging of the pelvic floor are valuable for selecting candidates for surgical treatment and for indicating the most appropriate surgical approach as detection rate of pathologies increased during defecation / maximal straning as concluded by our study.

Clinical outcomes of stapled transanal rectal resection (STARR) for obstructed defecation syndrome: Is STARR really a star on long-term follow-up?

Background: Obstructive defecation syndrome (ODS) is a common and poorly understood cause of constipation. Stapled transanal rectal resection (STARR) is one of the surgical options for ODS. Objectives: This study evaluates short-term and long-term functional outcomes following STARR for ODS patients and predictive factors determining the outcome of the surgery. Design: Retrospective analysis of prospectively collected data. Setting: This study was conducted in the colorectal unit of a tertiary hospital in Mumbai, India. Patients and Methods: Patients who underwent STARR surgery for ODS from January 2009 to January 2013 were evaluated. Patients were periodically followed up for 5 years. Main Outcome Measures: Longo scores and patient satisfaction were periodically evaluated in the 5-year follow-up. Sample Size: 204 patients. Results: 204 patients (M:F = 133:71, mean age 54.2 years) were evaluated. The mean preoperative Longo score was 23.2 ± 4.1. The mean operative time was 40 min and the median hospital stay was 2.1 days. On follow-up at 3 months symptoms improved in 92% patients, at 12 months symptoms persisted or recurred in 15% patients. Mean Longo scores at 12 months, 3 years, and 5 years follow-up was 7.14, 10.25, and 16.41 respectively. Patient satisfaction rate showed a declining trend in relation to time. ODS recurrence was observed in 41 (20%) patients and 78 (38%) patients at the end of 3 years and 5 years, respectively. Conclusions: STARR for ODS is a safe surgical procedure with minimal complications and good short-term functional results but fails in maintaining long-term efficacy of its results. Proper patient selection is extremely important for good functional outcomes. Limitations: Single-center study of retrospective nature with limited sample size. Conflict of Interest: None.

Mucopexy-Recto Anal Lifting (MuRAL) in managing obstructed defecation syndrome associated with prolapsed hemorrhoids and rectocele: preliminary results.

PurposeTreatment of rectocele associated with prolapsed hemorrhoids is a debated topic. Transanal stapling achieved good midterm results in patients with symptoms of obstructed defecation, nevertheless a number of severe complications have been reported. The aim of this study was to evaluate the safety and efficacy of a new endorectal manual technique in patients with obstructed defecation due to the combination of muco-hemorrhoidal prolapse and rectocele.MethodsPatients enrolled after preoperative obstructed defecation syndrome (ODS) score, defecography and anoscopy were submitted to the novel Mucopexy-Recto Anal Lifting (MuRAL) combined with a modified Block procedure, and followed up by independent observers with digital exploration 3 weeks postoperatively, and digital exploration plus anoscopy at 3, 6, and 12 months. Operative time, hospital stay, numerating rating scale (NRS), ODS, satisfaction scores, and recurrence rate were recorded.ResultsMean operative time was 35.7 minutes. Fifty-six patients completed 1-year follow-up: 7.1% had acute urinary retention, NRS score was < 3 from the third postoperative day, mean time of daily activity resumption was 12 days, none had persistent fecal urgency, 82% declared excellent/good satisfaction score, significant improvement of 6- and 12-month ODS score, no recurrence of rectocele, and 7.1% recurrence of prolapsed hemorrhoids were observed.ConclusionMuRAL associated with modified Block technique gave no severe complications and resulted in a safe and effective approach to symptomatic rectocele associated with muco-rectal prolapse. Further randomized studies, larger series, and longer follow-up are needed.

Obstructed defecation syndrome: a diagnostic and therapeutic challenge.

Obstructed defecation syndrome produces constipation with anal blockage and a feeling of incomplete evacuation, due to either anatomic and functional causes. This is a complex and multifactorial entity due to diverse etiological factors that may coexist in many patients. Therefore, a diagnostic approach requires structural and functional assessment. The concordance between findings of diagnostic tests is suboptimal, thus an individualized analysis is mandatory in each patient. Therapeutic strategies require the best understanding of anatomic and functional aspects. Consequently, this entity is a diagnostic and therapeutic challenge.

Role of three-dimensional ultrasound in females with obstructed defecation (in comparison with defecography)

BackgroundGrowing attention of pelvic floor disorders has led to development of new imaging techniques, with increasing importance of ultrasonography. The 3DUS technique is considered an accessible tool for imaging of the posterior pelvic compartment. The purpose of this study is to highlight the role of 3D ultrasound in evaluation of obstructed defecation in females and comparing the findings with defecography.ResultsStudy included 30 females classified into two groups: (1) 20 patients (case group complaining of obstructed defecation); (2) ten females (control group-normal nulliparous females). All of them were subjected to defecography and 3D ultrasound during resting, squeezing, and straining. Detection rate of rectocele and intussusception with 3D ultrasound was lower than defecography. By US, significant statistical difference between patients and controls in all measurements of levator hiatus, IS, ES, and PRS thickness during straining (P value < 0.001). During straining, cut-off value of 20.75 cm2 for hiatal area gives sensitivity of 100% and specificity of 95% and using ARA, cut-off value of 105° gives sensitivity of 98% and specificity of 90% for differentiation between patients and controls.ConclusionUltrasound can be considered a complementary test to defecography in investigation of patients with obstructed defecation. Ultrasound can diagnose levator muscle attenuation and avulsion, thickness of IS, ES, PRS, and distensibility of hiatal area.

The role of conventional pelvic floor reconstructive surgeries in obstructed defecation symptoms change: CARE and OPTIMAL trials sub-analysis of 2-year follow-up data.

The current study was aimed at addressing two questions: first, is any conventional vaginal prolapse repair effective in curing obstructed defecation symptoms, and second, is there evidence to suggest that a sacrocolpopexy will increase the risk of worsening or new-onset obstructed defecation symptoms? This is a sub-analysis of two major clinical trials performed by the Pelvic Floor Disorders Network: the Colpopexy and Urinary Reduction Efforts (CARE) trial and the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) trial. Two-year follow-up data were included. Demographics, pelvic organ prolapse quantification examination, and symptoms were compared between first, two surgical arms in the OPTIMAL study and second, CARE and OPTIMAL datasets using Chi-squared test for categorical variables and Student's t test or Mann-Whitney U test for continuous variables. A total of 353 subjects form the OPTIMAL study and 279 subjects from the CARE study met the inclusion criteria. Regardless of trial, obstructed defecation symptoms were present in more than half of the patients at the initial visit before the surgical intervention, and interestingly, about one third of the patients were symptomatic at the 24-month follow-up in all surgical groups. The conventional vaginal prolapse surgeries, with or without posterior vaginal wall repair, improved obstructed defecation symptoms by 50%, but about 35% of patients were suffering from at least one of the aspects of obstructed defecation at the 24-month follow-up. It is also important to note that about a quarter of the patients experienced persisting or worsening of their obstructed defecation symptoms in the absence of anatomical failure.

Impact of TRREMS on symptoms of obstructed defecation due to rectocele: predictive factors and outcomes.

The aim of this study was to evaluate the impact of the transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS) on the treatment of obstructed defecation due to rectocele and to identify the predictive factors for unsuccessful results. Consecutive patients with obstructed defecation symptoms (ODS) associated with rectocele who had the TRREMS procedure were included. Each patient was assessed by echodefecography, manometry, and colonic transit time as well as the Cleveland Clinic constipation score (CCS) before therapy and at follow-up after 6months. Reduction in the CCS score was calculated as a ratio. Factors correlated with a decrease in the CCS were analyzed in a univariate analysis. A total of 81 patients were included. Nineteen patients had postoperative complications that were not severe: 7 (8.6%) had tenesmus, 6 (7.4%) stenosis (4 treated with digital dilatation and 2 with endoscopic stricturectomy), 4 (4.9%) residual mucosal prolapse treated with rubber band ligation, 1 (1.2%) early bleeding, and 1(1.2%) thrombosis. Seventy-nine (97.5%) patients had a significant clinical response with significant reduction of the CCS constipation score from median 13 (range 17-10) to 4 (range, 8-2) (p = 0.0001); only 2 patients (2.5%) had an unsatisfactory response, complaining of straining and vaginal digitation during the evacuatory effort. Patients with anismus previously treated with biofeedback had a lower reduction ratio of the CCS score compared with patients without anismus (61.2 ± 2.8% versus 70.9% ± 1.5, p = 0.0006). There were no significant differences in the reduction of the CCS according to age, parity, type of delivery, previous hysterectomy, post-menopausal status, rectal mucosal prolapse and/or associated rectal intussusception, grade of rectocele and presence of complications. The TRREMS procedure significantly improved evacuation disorders in this study. Appropriate selection of patients is key for the success of this approach. Anismus even if previously treated with biofeedback, was the main predictive factor of unsuccessful treatment.

Effects of bilateral transcutaneous tibial nerve stimulation on constipation severity in geriatric patients: A prospective clinical study

Constipation is the most common digestive complaint in the general population, and one of the most frequently encountered health problems in the geriatric population. In the present study, we aimed to determine whether bilateral transcutaneous tibial nerve stimulation affects constipation severity in geriatric patients with refractory chronic constipation. Bilateral transcutaneous tibial nerve stimulation was carried out three times per week for 30 min in geriatric patients aged >65 years with less than three defecations per week. The patients were evaluated, and constipation severity was compared before the treatment, at the end of the 6-week treatment and 12 weeks after the end of the treatment. Assessment carried out using the Constipation Severity Instrument showed that the scores for subscales; that is, obstructive defecation, colonic inertia and pain, improved significantly by the end of the treatment compared with the scores obtained before the treatment. Furthermore, the improvement in pain continued for 12 weeks after the treatment, and although there was a slight decrease in the scores for the other subscales, they significantly improved compared with the scores obtained before the treatment. During the 12-week follow-up period, bilateral transcutaneous tibial nerve stimulation significantly improved constipation severity in geriatric patients with refractory chronic constipation. We believe that this easy-to-use and low-cost method can be applied to eligible geriatric patients who cannot be treated through dietary adjustments and/or medical interventions. Geriatr Gerontol Int 2020; 20: 101-105.

Assessment of anal sphincter distensibility following the STARR procedure: a pilot study

Aim: The STARR (Stapled Trans-Anal Rectal Resection) procedure consists of a surgical correction of symptomatic rectocele refractory to medical treatment, involving anal dilatation. The aim of the study was to determine the impact of the STARR procedure on anal distensibility using EndoFLIP® device.Methods: All female patients with a minimal rectocele of 3 cm and with symptoms of obstructed defecation syndrome (ODS) refractory to medical treatment were included prospectively. Patients with previous anal incontinence were not included. Wexner, ODS and Kess scores were recorded. Endoanal ultrasounds and EndoFLIP® measurements were performed pre-surgery and 3 months following the STARR procedure. The distensibility index (DI) at 40 mL of inflation at rest was the primary study endpoint.Results: Seven patients (median age: 52.5, range: 44–62) were included between 2014 and 2017. The DI after surgery was the same as the pre-surgery DI. No patient developed symptoms of faecal incontinence or urge to defecate in the three months following the STARR procedure. All patients reported an improvement in their ODS and Kess scores three months after the STARR procedure. No anal sphincter defects were detected by endoanal ultrasound.Conclusion: Anal dilatation did not appear to alter anal distensibility in patients with a normal anal function before the STARR procedure.

Surgical Correction of Obstructed Defecation Syndrome

Video Objective Obstructed defecation syndrome (ODS) is a form of colonic constipation in which stool cannot effectively be evacuated from the rectum. ODS is usually caused by a combination of behavioral, functional, and anatomic factors. While many women with ODS can experience improvement with aggressive medical management, the anatomic contribution what we term a “posterior” enterocele to defecation obstruction can be significant. Setting We present a video description of anterior rectopexy at the time of sacrocolpopexy with obliteration of the rectovaginal space to address posterior compartment prolapse as a cause of outlet constipation. Interventions To date, we have completed 12 procedures with resolution of ODS in all subjects. With 6-12 months of post-operative follow up, there have been no operative complications and no recurrent posterior enterocele. One subject had recurrent rectal mucosal prolapse. Prospective data collection is still ongoing. Conclusion The modification to sacrocolpopexy presented in this video seeks to address ODS by obliterating the rectovaginal space. Traditional sacrocolpopexy does not effectively address this defect and small bowel continues to herniate behind the posterior vaginal mesh.

Transanal hybrid colon resection: techniques and outcomes for benign colorectal diseases.

Transanal hybrid rectal and colon resection have been introduced in recent years at dedicated surgical centers. The anus is used as a natural orifice for large size access. The use of transanal hybrid colectomy techniques is still in its infancy with outcomes and unique complications being identified. The purpose of this work is the evaluation of outcomes for transanal hybrid colon resections (ta-CR), including intra operative and postoperative complications, results, and advantages. A prospectively maintained database was analyzed. Inclusion criteria were any patient who underwent ta-CR for rectal prolapse, slow transit, obstructive defaecation, and chronic sigmoid diverticulitis. Patients were excluded from ta-CR if BMI > 30, major previous abdominal surgery, or presence of a large inflammatory mass in diverticulitis. Transanal access was used for all operative steps requiring access of more than 5mm, such as staplers, large graspers, and specimen retrieval. Data acquisition and analysis was performed for operative time, complications, and postoperative quality of life. From 2012 to 2017, 82 patients underwent ta-CR [33 males, 49 females, median age 58 (24-80)]. Transanal-subtotal colectomy and ta-CR for constipation was performed in 12 patients; ta-CR and rectopexy in 31, and ta-CR for diverticulitis was performed in 39 patients. Conversion to traditional approach was required in 3 cases (3.6%). Intraoperative complication included 1 rectal tear requiring intervention. Post-op complications included 3 leaks requiring laparoscopic and 1 open revision, the latter developed wound infection and an incisional hernia. Gastrointestinal Quality of Life Index (GIQLI) improved significantly from preoperative 89 to postoperative 119 (p < 0.001). No patients with ta-CR without open revision developed a hernia post-op with median 18months follow-up. ta-CR is a safe and effective NOTES Hybrid technique for colorectal procedures in selected patients with benign colon disorders. GIQLI shows improvement and this technique can have the potential in preventing wound and hernia complications.

Laparoscopic pelvic organ suspension with mesh: a modified technique and primary results

BackgroundPelvic organ prolapse recurrence rate is an important issue which impacts the patient's quality of life and results in a new surgical procedure. We use a new technique of laparoscopic pelvic organ suspension (rectal suspension) for pelvic organ prolapse treatment in our center. We evaluated the results of this technique, three months after surgery and at the time of study reporting. MethodsAll patients with pelvic organ prolapse for whom laparoscopic pelvic organ prolapse had been done were evaluated. Data were collected from the patient's charts and their short term follow up 3 months after the surgery and their last follow up visit. Demographic, history, physical examination, Wexner's fecal incontinence score and Altomare's Obstructed Defecation Syndrome score, post-operation complications and patient's satisfaction were analyzed, retrospectively. ResultsAll patients were female with a mean age of 57±11.43 years (range 32–86 years). Mean BMI was 26.1±3.73. Nine patients had rectal bleeding (31%), 18 had prolonged or difficult defecation (62%), 16 had rectal prolapse (55.2%), 11 had gas incontinence (37.9%), 9 had liquid stool incontinence (31%), 5 had stool incontinence (17.2%), 9 had vaginal prolapse (31%), 23 had constipation (79.3%), 9 complaint of pelvic pain (31%), 9 had urge or stress urinary incontinence (31%) and 13 had dyspareunia (44.8%). ConclusionsIn conclusion, we believe this procedure has good results in short term follow up (3 months after surgery), but a high recurrence rate in the middle term follow up. Therefore, this procedure is no longer recommended.

Dynamic fluoroscopic defecography: updates on rationale, technique, and interpretation from the Society of Abdominal Radiology Pelvic Floor Disease Focus Panel.

Whether used as the primary diagnostic test or reserved as a problem-solving examination, fluoroscopic defecography (FD) remains an important tool in the workup and treatment of defecatory disorders. FD is a well-established, simple, and rapid examination that most closely resembles the actual process and position that a patient uses to enable defecation and provides both qualitative and quantitative information on the defecatory process. FD is indicated when re-creating the act of defecation is necessary, especially in patients with symptoms of obstructed defecation and where symptoms do not correlate with prior examinations such as MRI. Also, FD may help the patient understand the severity of their condition, better informing them of the structural and functional pathology, and aid in discussions with the surgeon regarding plans for treating their complex pelvic floor and defecatory problems. This review provides an up-to-date, comprehensive summary of FD and describes the indications for, techniques of, and common pathology encountered.

Obstructed Defecation: Relevance of Sacral Neuromodulation

After successful implementation of sacral nerve stimulation in the treatment of fecal incontinence, the first cohort studies showed promising results for sacral neuromodulation in the treatment of conservative refractory chronic constipation and obstructed defecation. However, these results have not been confirmed with long-term data or with studies of the highest level of evidence. Randomised trials failed to show any difference between patients with and without sacral nerve stimulation. In the long term, many patients suffer from loss of efficacy or adverse events, leading to high explantation rates. On the basis of existing clinical trials, it cannot be concluded that sacral neuromodulation should be included in the treatment algorithm of chronic constipation and obstructed defecation. So far it is unclear whether and which patient cohort may benefit from sacral nerve stimulation. Therefore further trials are needed to identify possible selection criteria for sacral nerve stimulation in the treatment of chronic constipation and obstructed defecation. The aim of this narrative review is to give an overview of the existing literature on sacral nerve stimulation in chronic constipation and the subgroup of obstructed defecation.

Obstructed Defecation Syndrome: Aetiology, Diagnostic Assessment and Therapeutic Options

Obstructed defecation syndrome (ODS) is characterized by disturbed defecation, and morphological disorders can be differentiated from functional pathologies. Differential diagnosis from irritable bowel syndrome and slow transit constipation is frequently difficult. Most patients are female, and rectal intussusception and anterior rectocele are frequent morphological pathologies. In addition to patients' history and basic proctological diagnostic testing, MR defecography plays a central role. As ODS is a benign condition, conservative treatment should be initiated primarily. After failure of conservative treatment and in terms of a morphological disorder, the indication for surgery should be discussed, whereas transabdominal procedures (e.g. resection rectopexy, rectopexy) and transanal procedures (e.g. STARR) are available. Adequate therapy remains a challenge due to multifactorial aetiology and the variety of symptoms - this affects both conservative and surgical treatment options.