Obstructive defecation syndrome is a voiding disorder of the rectum and manifests itself particularly in women. Symptomatically, the disorder is manifested by persistent urge to defecate, usually with incomplete evacuation and the need for vigorous pressing. Conservative and surgical therapeutic steps may be considered.
What is obstructive defecation syndrome?
Various diseases and symptoms that affect defecation are grouped together as voiding dysfunction of the rectum. Obstructive defecation disorder is one of these diseases. The most common symptom of the phenomenon is chronic constipation. Patients usually feel persistent urge to defecate and even after a bowel movement they feel that they have achieved only incomplete defecation. Obstructive defecation syndrome is a relatively common occurrence. Women are more often affected by the syndrome than men. In particular, women who have had several births or who have had their uterus removed in the past are at increased risk for obstructive defecation syndrome. The most common age for the condition is around the sixth decade of life. Changes in bowel segments are observed in association with the syndrome in almost all cases. These changes may be age-related or due to primary conditions such as chronic constipation.
Causes
The frequent association of obstructive defecation disorder with previous births or hysterectomy suggests that the phenomena are related. This would also explain the gender preference of the disorder. According to current medical opinion, the voiding disorder of the rectum may be due to two different bowel changes. On the one hand, a ventral rectocele may be present. This is an internal bulge in the rectum that points forward. Secondly, the cause of the symptoms may be an internal rectal prolapse. In this phenomenon, part of the rectum bulges in on itself. The phenomenon is also called rectoanal internal intussusception. Ventral rectocele is the most common change that can be observed in connection with defecation disorder. Most often, this rectocele is associated with other pelvic floor dysfunction, as may occur after childbirth or uterine surgery. Although the definitive cause of obstructive defecation disorder depends on the individual case, pelvic floor dysfunction is thus considered to be sometimes the most common primary cause.
Symptoms, complaints, and signs
Obstructive defecation syndrome can manifest clinically in a variety of ways. Typically, affected individuals report in the history that they suffer day after day from futile, prolonged visits to the toilet, during which they either have to push hard to defecate or have no success at all. They have a permanent feeling of incomplete emptying. In addition, they often suffer from discomfort or even pain because of the increased pressure on the pelvic floor area. Abdominal pain or nausea may occur as part of the persistent constipation. The defecation disorder can develop into fecal incontinence in the sense of a weakness in stool retention, which initially corresponds to a smearing of stool and then often progresses progressively. Often the use of certain laxatives or enemas is reported anamnestically. Also defecation with the help of the fingers can be characteristic. In addition to a general feeling of pressure, bleeding occurs in individual cases, usually due to intense pressing. The pressing can also lead to enlarged hemorrhoids as a late consequence.
Diagnosis and course of the disease
During the history taking, the physician develops an initial suspicion of obstructive defecation syndrome. Subsequent basic diagnostics include a physical examination with a rectoscopy and ultrasound of the sphincter. Often, a pressure measurement of the sphincter muscle is also performed. An additional diagnostic procedure is a defecography as an X-ray examination under contrast medium administration, which clarifies the changes of the intestine. Differentially, the physician must exclude diseases such as chronic constipation, colonic transport disorder, segmental transport disorder and functional disorders.The classification of the bowel changes is one of the most decisive moments in diagnostics, since only with the identification of the actual causal problem can a promising therapy be developed. The prognosis for patients with obstructive defecation disorder is considered favorable.
Complications
Obstructive defecation disorder should always be treated, as its symptomatology is always worsening due to the present connective tissue weakness otherwise. In most cases, this does not lead to life-threatening complications. But the quality of life suffers greatly. Complications can occur, especially when trying to successfully defecate by pressing hard. Thus, although strong pressing usually does not help, it enlarges the externally visible rectal prolapse and can cause bleeding due to the further development of hemorrhoids. As a further consequence, the development of fecal incontinence is possible. In some women, a so-called cystocele may also occur. A cystocele represents the prolapse of the bladder into the anterior septum. It leads to permanent urinary disorders, urinary retention or even urinary incontinence. Without treatment, there is a constant progression of symptoms with a severe reduction in the quality of life. This can also result in mental illness. Chronic pain, the feeling of incomplete emptying as well as fecal and urinary incontinence can lead to sleep disorders, psychosomatic illnesses or even depression. In rare cases, untreated obstructive defecation disorder also leads to an enterocele. This is a prolapse of segments of the small intestine into the pocket-shaped depression of the peritoneum between the uterus and rectum (Douglas space). With an enterocele, there is always a risk of developing an intestinal obstruction.
When should you see a doctor?
In obstructive defecation disorder, defecation is disturbed due to incomplete emptying of the bowel. This problem definitely belongs to a doctor because of the distress it can cause. Those who experience a constant urge to defecate are severely limited in their quality of life. Normal constipation usually resolves after the bowels have been emptied. It is often sufficient to change the diet for persistent constipation problems. More fiber, a greater fluid intake and more exercise will solve this problem. This does not require a visit to the doctor. But with obstructive defecation disorder, there may be accompanying symptoms and pain. There is also a risk of developing fecal incontinence, cystocele or hemorrhoids in the medium term. Rectal prolapse due to heavy straining would also be possible. A visit to the doctor should therefore be made if obstructive defecation disorder is suspected. Treatment options available include conservative or surgical methods. Complicating the diagnosis is the proximity of obstructive defecation disorder to other voiding disorders. For this reason alone, a physician should be consulted if problems with defecation persist. Whether it is a condition requiring treatment, a correctable disorder, or a psychological problem with voiding must be clarified.
Treatment and therapy
Patients with obstructive defecation syndrome can be treated conservatively, as well as surgically. If there are no changes in the bowel, conservative symptomatic therapy is used. This treatment primarily includes a change in diet, which is usually combined with the administration of stool softening medications. If, on the other hand, changes in the intestine are present, surgical causal therapy usually takes place. Ideally, therefore, the symptoms are not treated symptomatically in the course of this therapy, but are remedied causally. Thus, the defecation disorder is considered a curable disease. One possible surgical treatment is transanal resection of the lower rectum, also known as STARR surgery. This procedure is based on two circular stackers and corresponds to a rather recent treatment option for defecation syndrome. The treatment option was developed for causes such as internal rectal prolapse or ventral rectocele and is designed to restore healthy rectal anatomy. The rectal muscle wall regains continuity through surgery, so any stool retention problems can also be corrected through surgery. The rectum returns to its average normal capacity.Anatomically, the procedure permanently corrects rectocele or rectal prolapse.
Outlook and prognosis
Obstructive defecation disorder has a good prognosis. The earlier a diagnosis is made and thus treatment can be started, the better the further health outcome. Medication is administered to alleviate the existing symptoms. The symptoms gradually subside until recovery is achieved. If the course of the disease is difficult, surgery must be performed. This is associated with risks and side effects. Nevertheless, in most cases it proceeds without further complications. After the wound has healed, the patient is usually completely free of symptoms within a few weeks or months. Without medical treatment, the disease may progress. The symptoms gradually increase in intensity and extent. As a result, the quality of life is considerably impaired. Spontaneous healing does not occur in most cases. Rather, secondary diseases and functional disorders are possible. In a particularly unfavorable course, intestinal obstruction occurs. This poses a potential threat to human life. Because of this possible development, cooperation with a physician should be sought already at the first irregularities. Although the treatment is usually unpleasant, it nevertheless leads to regression and complete recovery. Furthermore, it is crucial for the further positive course to make use of further control examinations.
Prevention
A promising preventive measure for obstructive defecation disorder is, above all, a suitable diet that gives the stool a normal soft consistency and thus counteracts chronic constipation. Pelvic floor exercises may also reduce the risk of defecation disorder. Apart from this, hardly any preventive measures exist against age-related changes.
Aftercare
Once the cause of obstructive defecation disorder has been treated, follow-up care is usually of critical importance. This is because defecation dysfunction is often behaviorally caused, namely by heavy straining during defecation. To avoid this, it is essential to pay attention to stool regulation during follow-up care. Constipation promotes straining, so bowel movements should be soft and ideally also voluminous. Affected persons achieve this through a high proportion of dietary fiber in their diet. Fruits and vegetables are just as recommended in this context as whole grain products. It is also better for those affected to avoid sugar in large quantities. The same applies to a high proportion of meat in the diet and the consumption of alcohol. Yogurt products, on the other hand, can often have a beneficial effect. It is also important to drink sufficient amounts of fluids, preferably water and unsweetened herbal teas. Exercise is also an important factor in the aftercare of obstructive defecation disorder that should not be neglected. Walking or exercising, ideally in the endurance range, stimulates the natural movement of the bowels and thus promotes emptying. Massages in the abdominal area can also activate these movements of the intestines. Those who nevertheless continue to be prone to defecation problems can often overcome them by adopting a squatting position on the toilet, with the feet placed slightly elevated and the upper body leaning slightly forward.
Here’s what you can do yourself
The most important self-help measure for obstructive defecation disorder is a medium- and long-term change in diet. It is to be fallen back here above all on food, which promotes a regular and soft stool. Dietary fiber plays a decisive role here. Whole grain products, legumes, seeds and grains are ideal for this purpose. Good chewing reinforces the effect. In addition, plenty of fluids should be drunk. However, since digestion works differently for each person, a little experimentation is possible. For some people, dairy products or fruit, for example, also lead to softer and more regular bowel movements. In addition, exercise can alleviate the suffering caused by obstructive defecation disorder. Particularly light endurance sports such as swimming, jogging or walking can stimulate peristalsis and relieve a perceived constipation.It can be useful to perform defecation in a squatting position. To do this, place your feet on a stool about 20 to 30 centimeters high in front of the toilet. The upper body is bent slightly forward so that there is an angle of about 35 degrees between the thighs and the upper body. This position is evolutionarily intended for defecation and is maintained by most mammals. Accordingly, it also allows humans to facilitate defecation and reduce the risk of incomplete defecation.
