Renato Pietroletti,  Sergio Leardi*, Marika Mascio*, Antonio Giuliani*, Felice Patacchiola**, Gaspare Carta§, Gianfranco Amicucci*
U.O.S.D. Chirurgia Proctologica Universitaria Osp. Val Vibrata, Sant’Omero – Teramo
*U.O.C. Chirurgia Generale Universitaria, Osp S.Salvatore – L’Aquila
**U.O.C. Ostetricia e Ginecologia Universitaria, Osp Val Vibrata, Sant’Omero – Teramo
§U.O.C. Ostetricia e Ginecologia Universitaria Osp S.Salvatore – L’Aquila

Introduction. Obstructed defecation is a newly acquired  syndrome occurring mainly in western countries and in middle aged woman. Two types of obstructive mechanisms underline this syndrome: the first is typically functional, i.e. non relaxing puborectal; the second is purely anatomical with the presence of a bulging rectocele and/or rectoanal intussusception (1). However both mechanisms do occur in a not negligible percentage of patients (2). In the last 15 years, a great attention has been posed on obstructed defecation due to a large increase of patients’ claim on this invalidating disturbance, the availability of new diagnostic methods (defecography, defeco-MR, Endorectal Ultrasound, clinical scores) and finally to the development of dedicated surgical tools (staplers) (3). In the common experience of colorectal surgeons, two historical periods can be individuated; the first, up to the end of the nineties and the second starting from the 2000s, when the large diffusion of the knowledge of the obstructed defecation and the availability of new technologies made possible the identification and successful treatment of a large amount of patients. On the basis of our experience matured between 1990 and 2014, we aimed to compare patients affected by obstructed defecation in two historical periods, namely 1990-99 and 2000-14, with respect to epidemiological, clinical and treatment issues.                                                                                                   
Materials and Methods. In the period 1990-99 out of 5532 patients observed in the outpatient  clinic of coloproctology, constipation was reported by 353 cases that is 6.5%. Among these, 39 females and 19 males complained of obstructed defecation symptoms (16.4%). Features of solitary rectal ulcer syndrome were reported in 15.5% of these patients. During the period 2000-14, 11152 patients were observed in the coloproctology clinic and 760 of these complained of constipation (6.8%).  194 were classified as affected by obstructed defecation (25.5%). In the first period, patients were assessed mainly by means of clinical symptoms and defecography, whereas in the second period clinical scores (4) and defecography contributed to the diagnosis. Endoscopy and functional sphincter studies as well as endoanal ultrasound were not performed routinely, but strictly on the basis of specific clinical indications.
Results. During the years 1990-99, our approach to obstructed defecation, was mainly conservative (diet, bulk laxatives). Surgical treatment consisting in transanal  suturing of rectocele according to Block’s procedure, was done in 11 cases (18.9%). In 12 patients (9 males) anterior mucosal prolapse was treated by rubber banding. Improvement of symptoms was reported by 86% of patients treated conservatively. Results of Block procedure were less satisfactory with mild recurrence of symptoms in 8 patients requiring further treatment, however by means of rubber banding of mucosal prolapse, and 2 requiring stapled prolapsectomy, in recent years. In the period 2000-14, out of 194 patients, 61 underwent surgical treatment (30.5%). 52 were treated with double stapling PPH (S.T.A.R.R. procedure), 4 with Trans S.T.A.R.R. and 5 with Block. 35 presented rectoanal intussusception, associated to a significant rectocele in 26. Symptoms were characterized as follows: prolonged defecation time in 100%, frequent toilet visit in 61%, self-digitation in 35%, straining in more than 50% of defecation in 36%. In addition, a mild fecal incontinence (gas, soiling), was reported  by 62.7% of the patients. Mortality was nil  and morbidity was 3.2% (two cases of severe bleeding in the first 15 S.T.A.R.R. procedures). Results of surgical treatment were satisfactory as depicted by the improvement of constipation score and constipation quality of life (Tab.1). Also symptoms of fecal incontinence, although mild, showed a sharp improvement. Nine patients (14.7%) complained of a persistent urgency at long term follow up and judged poor their quality of life. Associated symptoms regarded genital prolapse in 38% of the patients and urge urinary incontinence in 73%.
Conclusions. Our data clearly show the improvement of the global care in the field of obstructed defecation. Interestingly, from the epidemiological point of view, patients reporting  the symptom “constipation” , were observed with comparable incidence in both periods; however the percentage of those complaining of obstructed defecation in the period 2000-14, was far higher than that observed in previous years (25.5 vs 16.4%). This data reflects the improved attention paid by the physician to symptoms of obstructed defecation, coupled with an increased awareness of the patient about bowel habit. The percentage of surgical treatment rose from 18.9%  during the previous years to 30.5% in the period 2000-14, reflecting the new availability of safe and effective surgical procedures, aimed at removing the outlet obstruction. It is unquestionable that the advent of PPH for the S.T.A.R.R and the dedicated Contour Stapler for the Trans-S.T.A.R.R., with the right indications and adequate expertise, played a revolutionary role in the surgical treatment of obstructed defecation. Indeed the results of surgical treatment between the two periods are not comparable, either in terms of incidence of surgery (18.9% of patients vs 30.5%) and in terms of satisfactory results, as depicted in Tab. 1. Accordingly,  rubber banding of anterior mucosal prolapse has disappeared due to the overwhelming efficacy of stapled resection of internal prolapse. The amount of complications observed in the literature, also severe and life threatening,  is not negligible (5); this can be considered the drawback of the  rapid diffusion of surgical instruments for the treatment of obstructed defecation, employed too often without an adequate training and rigorous methodologic approach to the patient. Not rarely obstructive symptoms represent the tip of the iceberg of more complex functional and anatomical alterations of the pelvic floor or, even worse, psychological and comportamental disturbances (6). Our selective approach in such difficult patients, helped very much in keeping morbidity low (7). The adoption of scoring scales was a fundamental tool as well; there are many multiple choice questionnaires, producing a  scoring system that enables us in transforming subjective symptoms in figures. This is of utmost importance since the value of the score gives from the start the impact of the disease on the patient’s life; in addition the comparison of pre and postoperative scores helps us in the follow up of the patient. In conclusion, the contemporary approach to the obstructed defecation syndrome requires a dedicated team of specialists for the surgical treatment, also involving uro-gynecologist, looking carefully at  the role of rehabilitation that is fundamental in improving results of surgery.

  1. Bartolo DC et al. Evacuation proctography in obstructed defecation and rectal intussusception. Br J Surg 1985;72:S111-6
  2. Fucini C et al. Electromyography of the pelvic floor musculature in the assessment of  obstructed defecation symptoms. Dis Colon Rectum 2001;44:1168-75
  3.  Boccasanta P et al. Stapled transanal rectal resection for outlet obstruction: a prospective multicenter trial. Dis Colon Rectum 2004;47:1285-97
  4. Boccasanta P et al. Stapled transanal rectal resection in solitary rectal ulcer associated  with prolapse of the rectum: a prospective study. Dis Colon Rectum  2008;51:346-54
  5. Dodi G et al.  Bleeding, incontinence, pain and constipation after STARR, transanal double stapling rectotomy for obstructed defecation. Tech Coloproctol 2003;7(3):148-53.
  6. Pescatori M et al. A prospective evaluation of  occult disorders in obstructed defecation using the “iceberg diagram”. Colorectal Dis 2007;9:452-6
  7. Podzemny V et al. Management of obstructed defecation. World J Gastroenterol 2015;21:1053-60


Table 1 Patient assessment of constipation related quality of life

                                                         PRE-OP                    POST-OP
CONSTIPATION SCORE (0-30)          26.3                             4.5                   P<0.001      

SATISFACTION SCALE (4-16)           14.1                             5.2                   P<0.002
Higher values worse constipation and poorer QoL