Obstructed defecation: how it manifests itself and how to treat this form of chronic constipation

By Cristiano Antonino On Nov 21, 2022

Obstructed defecation is a form of chronic constipation (lasting more than 6 months) that manifests itself due to an obstruction in the proper expulsion of stools of a hard consistency

Seeking the advice of a good specialist, who will understand the problem and immediately establish a therapeutic course of action, is the most correct approach to this type of disorder.

What is obstructed defecation

In obstructed defecation, the problem is due to the person’s difficulty in expelling stools that have regularly arrived.

It is a problem that mainly affects female subjects.

This malfunction is manifested by some specific symptoms such as a difficult defecation with prolonged and excessive ponzamento (intense abdominal effort to evacuate) in an attempt to expel stools (of a rather hard consistency) that, more often than not, occurs incompletely and fractionally.

After ruling out organic causes such as, for instance, colorectal cancer, complicated diverticular disease, chronic inflammatory diseases, it is necessary to investigate whether there is an obstruction to defecation at the level of the rectum, the last tract of the intestine.

Causes

The expulsive difficulty is usually caused by the presence of a prolapse of the rectum within the rectum itself.

It can be likened to a telescope: the more one closes it, the more the free lumen is reduced.

Thus, as the free lumen of the rectum becomes smaller and smaller, evacuation becomes more difficult and the faeces stagnate and come out in a fragmented and incomplete manner.

All this, combined with the patient’s effort to pass bowel movements, leads to a flattening of the anterior wall of the rectum, which is called a rectocele, i.e. a herniation of the rectum towards the vagina (a sort of pouch) in which the faeces stagnate, which, together with the prolapse, contributes to the obstruction.

Many times the prolapse of the rectum is also associated with a uro-gynaecological prolapse and often the treatment of the latter also corrects the prolapse of the rectum.

Therefore, a specialist visit is essential in order to study and treat such pathologies in the most correct way.

Sometimes, the difficulty in expulsion can also be caused by a functional pathology, i.e. by an inadequate relaxation of the pelvic floor muscles that, when the patient pushes to defecate, instead of relaxing and opening the anal canal to let the faeces out, contract and close it.

When the patient contracts the abdominal muscles to defecate, but encounters significant incoordination of the pelvic floor muscles that, instead of synergistically promoting expulsion, hinder it, pelvic floor dyssynergy occurs.

This cannot be resolved surgically, but with cycles of pelvic floor physiotherapy that re-educate the pelvic floor to proper function.

Symptoms of obstruction

The patient begins to complain that he or she can no longer expel faeces.

Then he says that he is able to defecate at several times, i.e. fractionally up to 3 or more times a day.

He reports feeling still full after going to the toilet, then a frank sensation of incomplete defecation, up to a painful feeling of weight in the anus.

In the most extreme cases, the patient is forced to apply pressure with his fingers around the anus, to make the faeces return to the correct position in order to exit.

When there is an obstruction at the level of the faeces outlet due to a prolapse, it makes no sense to chronically resort to laxatives, which do not resolve the pathology, but it is necessary to unblock.

How obstructed defecation is diagnosed

For a correct diagnosis of obstructed defecation, after a specialist examination, a colpocystodefecography is first used, a very simple radiological examination in which a small enema of contrast medium is administered into the patient’s rectum.

He is then made to sit on a radiolucent potty, and by means of an X-ray study, while he is ponctating and expelling, we observe

how much prolapse (‘canthus’) is formed;
whether a rectocele is present and its extent;
whether dyssynergy is present;
above all, how much residual contrast remains after the patient has completed defecation.

In addition to this, a colonoscopy should always be performed, which is useful to exclude the presence of more serious organic causes of the bowel, and possibly also an anorectal manometry, should dysynergy be suspected.

How to treat it

If we are in the presence of a dyssynergic obstruction, physiotherapy is sufficient; if, on the other hand, we are in the presence of a prolapse-rectal obstruction, it is necessary to resort to disostructive surgery.

If the prolapse and/or rectocele is also accompanied by dyssynergy, a combination of surgery and physiotherapy will be used.

If the rectal prolapse is associated with a uro-gynaecological prolapse, the multidisciplinary specialist approach will decide on a uro-gynaecological, rectal or combined solution intervention only.

Obstructed Defecation, Surgery

Surgery for the treatment of obstructed defecation by the rectal route is routine and simple.

It consists of the removal of the rectocele and prolapse through mechanical suturing.

The surgical wound is closed with small metal staples that are expelled spontaneously by the patient with defecation within 6 months.

The surgical wound is placed inside the anal canal, in an area that is not innervated and therefore not painful.

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There are no external wounds and no bothersome tampons are inserted.

The patient is fed immediately and can go to the toilet regularly.

Hospital stay is a maximum of 2 days, after which the patient can go home without pain, only with slight discomfort.

He can eat and go to the toilet without any problem and resume his activities immediately with a simple check-up after 7 days.

How to prevent recurrences

In spite of surgery, all the rules that apply in constipation should always be implemented to avoid recurrences and thus for preventive purposes.

Among these, the most important are

maintaining the position at 35 degrees during defecation;
a varied diet, rich in liquids (especially in the warm months) and waste (fruit and vegetables);
adequate physical activity, avoiding sedentariness as much as possible.

The correct position for defecating

It must be known that we westerners are in the habit of evacuating by typically maintaining a 90° sitting position.

This is an incorrect position, because it does not facilitate the proper outflow of faeces.

The ideal position would be at an acute angle, 35°, with legs flexed over the torso.

The 35° position is a position that relaxes the pelvic floor muscles, especially the pubo rectus, which is normally a muscle that participates in continence by closing the rectum.

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