sign in sign up
<<
Home , Anismus, Anorectal manometry, Defecation, Defecography, Obstructed defecation, Rectal prolapse

1 2 3 Best Practice Statement on Evaluation of Obstructed 4 5 INTRODUCTION 6

7 The symptoms of and are common in women with

8 disorders. Female Pelvic Medicine and Reconstructive Surgery (FPMRS)

9 specialists evaluate and treat women with these symptoms, with the initial consultation

10 often occurring when a woman has the symptom or sign of posterior compartment

11 pelvic organ (including or ), or if a rectocele or enterocele

12 is identified in pelvic imaging. This Best Practice Statement will review techniques used

13 to evaluate constipation and obstructed defecation, with a special focus on the

14 relationship between obstructed defecation, constipation, and pelvic organ prolapse.

15

16 Overview

17 Normal defecation is a complex event coordinated between colorectal motor and

18 sensory functions and appropriate behavior. In normal function, stool enters the

19 from the , leading to distention. Once the rectosigmoid stool load is

20 perceived and the setting is deemed appropriate for defecation, the puborectal angle is

21 voluntarily changed by sitting or squatting, pelvic floor and anal relaxation occur,

22 straining leads to increased intraabdominal pressure, and the rectum contracts,

23 resulting in the voluntary act of defecation.

24

25 The sensation of anorectal obstruction or blocking is one of many criteria that may be

26 used to diagnose constipation. Chronic constipation (symptoms > 6 months) is common,

27 with a prevalence in the general population of approximately 14% 1. Symptoms used to

28 define constipation include: straining, sense of incomplete evacuation, infrequent bowel

29 movements, and hard stool consistency 2. A more detailed definition is provided by the

30 Rome classification system (currently Rome III diagnostic criteria) 2 (Table 1). Causes of

31 constipation vary widely and include systemic medical issues such as metabolic and

32 neurologic disorders, obstructive intestinal disease, and medication side effects, most

33 notably related to narcotic and anticholinergic medications. Chronic constipation is

34 often divided into disordered colonic transit (slow transit constipation) and normal

35 transit which includes pelvic or anorectal dysfunction (outlet obstruction constipation or

36 obstructive defecation syndrome – ODS). Obstructive defecation is incomplete rectal

37 evacuation which may result from inadequate rectal propulsive forces and/or increased

38 resistance to evacuation 3and can be related to dyssynergic defecation or anatomic

39 abnormalities (rectoceles, , internal rectal intussusception).

40

41 Pelvic organ prolapse (POP) is a downward displacement of pelvic organs including the

42 uterus and/or vaginal compartments and neighboring organs such as bladder, rectum,

43 or bowel 4. Posterior compartment prolapse is a condition in which the posterior

44 vaginal wall descends towards the vaginal opening and include rectoceles, enteroceles,

45 sigmoidoceles, intussceptions, and perineal descent. Among post-menopausal women,

46 the prevalence of posterior vaginal wall prolapse is 18% 5. Prolapse primarily refers to

47 anatomic change with the corresponding symptoms of vaginal bulge, pelvic pressure or

48 a dragging sensation. Anorectal dysfunction symptoms which are potentially prolapse-

49 related include constipation, feeling of incomplete bowel evacuation, straining to

50 defecate, sensation of anorectal blockage, splinting or digitation, fecal urgency and post-

51 defecatory soiling 4. However, these symptoms can often be related to other etiologies,

52 such as slow transit constipation, which may require different treatment strategies.

53

54 HISTORY AND PHYSICAL EXAMINATION

55 The initial evaluation of a woman with defecatory dysfunction should include a

56 thorough history and physical examination. The history should focus on the specific

57 bothersome symptoms of defecatory dysfunction including frequency and consistency

58 of bowel movements, anorectal , bleeding, and the need to strain and use of

59 additional maneuvers with defecation, including splinting (applying pressure on the

60 vagina, , or ), digitation (use of fingers to evacuate stool), or other

61 manipulation to assist with defecation. Splinting is the only symptom reliably associated

62 with posterior pelvic organ prolapse 6.

63

64 It is imperative to assure that the patient does not have colorectal . Patients with

65 the following symptoms merit referral and evaluation by : a recent change

66 in bowel habits, excessive straining or a sense of incomplete evacuation, abdominal

67 pain, , , and 3. A complete medical history that

68 evaluates for medical causes of constipation such as neurogenic disorders and

69 hypothyroidism (Table 2) should be taken. Details on dietary preferences, medication

70 use (with a focus on medications known to cause constipation), and digestive aids and

71 use should be elicited, and family history and risk factors for colon and rectal

72 cancer should be collected.

73

74 The physical examination should include assessment of pelvic floor muscle function with

75 strength and relaxation testing, pelvic floor support evaluation with Pelvic Organ

76 Prolapse Quantification system (POP-Q), and a 3. The rectal

77 examination should be done with buttocks separated and should start with observation.

78 Specifically, look for causes of pain (grade II or greater [Figure 1], anal

79 fissure) that may be causing voluntary stool retention, a gaping or asymmetric anus

80 suggestive of neurologic injury, and any evidence of fecal soiling on the perineal skin.

81 Test for perineal descent during simulated evacuation and elevation during a squeeze

82 and the anal reflex (tested by a light pinprick or scratch). This demonstrates pelvic floor

83 coordination and confirms intact sacral reflexes.

84

85 In addition to the customary screening for masses and scarring, digital rectal

86 examination assesses the anal sphincter resting tone and augmentation with squeeze.

87 At the start of digital rectal examination, the patient can be asked to bear down on the

88 examiner’s finger to assess the ability of the sphincter to relax with straining. Finally,

89 assessment for anoperineal or rectovaginal pocketing should be done. This involves

90 inserting a finger and palpating towards the vagina to elicit weakness in the rectovaginal

91 septum and perineal body. Extensive pocketing large enough to 2-3 cm of stool is

92 indicative or rectocele or perineocele.

93

94 Correlation between specific defecatory symptoms and physical examination is not

95 clear. Multiple studies show no relationship between POP-Q and bowel symptoms 7–9,

96 constipation 10, and obstructed defecation symptoms 7, while weak correlation has been

97 found between worsening posterior vaginal wall prolapse and the need for vaginal,

98 rectal, or perineal splinting 6,11. This lack of consensus is likely related to limitations

99 inherent to the POP-Q examination 12 which evaluates vaginal topography only.

100 Posterior defects, even when large, often bulge anteriorly within the vagina and not

101 necessarily outward beyond the hymen. Nonetheless, bowel symptoms resolve in many

102 patients once the vaginal wall defect is corrected by posterior colporrhaphy 13,14.

103 Corrected vaginal support is associated with a reduced risk of postoperative straining,

104 feeling of incomplete emptying 13, and difficulty evacuating 14. In most women with

105 bulge symptoms and posterior vaginal wall prolapse no imaging is required prior to

106 surgery.

107

108 No specific symptom or physical examination finding is sensitive and specific for

109 obstructed defecation syndrome. The apparent lack of correlation between the

110 anatomic assessment and anorectal symptoms highlights the complexity of anorectal

111 dysfunction. This disconnect commonly prompts providers to seek additional testing

112 which usually includes and imaging studies.

113

114 ANORECTAL TESTING

115 Additional information regarding function may be obtained by physiologic testing (anal

116 manometry, latencies, and electromyography). Anorectal manometry

117 utilizes pressure sensitive catheters to measure anorectal motility, including rectal

118 sensation and compliance, reflexive relaxation of the (rectoanal

119 inhibitory reflex), and manometric patterns produced upon attempted expulsion of a

120 balloon. Data from anorectal manometry helps with the diagnosis of dyssynergic

121 defecation (paradoxical contraction or failure of anal relaxation with attempts to empty

122 the rectum of contents) and rectal sensory problems. It is important to distinguish

123 between diagnoses, as dyssynergic defecation and sensory problems are rarely treated

124 surgically. Prior to testing, the patient empties the lower with the

125 use of one or two two hours prior to the study. To assess reflex pathways, a

126 small balloon attached to a catheter is inflated in the rectum. The patient is asked to

127 squeeze, relax, and push at various times. The anal sphincter muscle pressures are

128 measured during each of these maneuvers. Pressures generated from the rectal balloon

129 give some indication of abdominal pressures generated during attempted defecation

130 while pressure recordings of the anal sphincter indicate relaxation or inappropriate

131 contraction of the . Next, a balloon is inserted into the rectum

132 and inflated with water (usually 50mL). The patient attempts to expel the balloon from

133 the rectum as a simulation of defecation. The amount of time it takes to expel the

134 balloon is recorded, with <60 seconds representing normal values 15 ; Figure 2.

135

136 Studies show no correlation between prolapse and anorectal testing 16. The physiology

137 of defecation and the correlation between manometric findings and other objective

138 measures of anorectal function are not completely understood 16,17. Additionally,

139 artifact due to psychologic factors may affect test results in the laboratory setting. For

140 example, in 20 percent of healthy controls, the anal sphincter does not relax on anal

141 manometry during attempted defecation 18, as seen in women with pelvic floor

142 .

143

144 Optimal patient selection for anorectal manometry in the evaluation of constipation is

145 not well-established and the methods used are not standardized. Anorectal manometry

146 may be useful in constipated patients in whom non-mechanical causes of obstructive

147 defecation are suspected and can assist in the diagnosis of decreased rectal sensation,

148 pelvic floor dyssynergia, and Hirschsprung disease. In decreased rectal sensation, the

149 patient can tolerate increasing volumes (>90mL) 19 prior to detecting pressure or pain.

150 This is associated with increased rectal compliance or megarectum, which is often seen

151 in patients who have experienced chronic . In pelvic floor dyssynergia,

152 women do not straighten the anorectal angle during defecation as a result of failed

153 relaxation of the puborectalis muscle and the external anal sphincter. In these patients,

154 anorectal manometry demonstrates inappropriate contraction of the external anal

155 sphincter while the patient is attempting to stimulate defecation. Anal manometry may

156 be used to provide in the treatment of chronic constipation, specifically

157 pelvic floor dyssynergia.

158

159 In Hirschsprung disease (congenital ), the absence of intramural ganglion

160 cells of the submucosal and myenteric plexi leads to a segment of spastic, non-relaxing

161 and nonpropulsive bowel. Proximal to this, the colon is severely dilated. On anal

162 manometry, the internal anal sphincter does not relax with rectal distention. The

163 accuracy of manometry testing to make this diagnosis (sensitivity and specificity of 83%

164 and 93% respectively) is good, but full thickness is necessary for confirmation 20.

165 This diagnosis should be considered and excluded in young adults with severe

166 constipation from birth.

167

168 Pudendal nerve terminal latency assessment 21 does not have evidence supporting its

169 use in the workup of obstructed defecation syndrome. Electromyography can assist in

170 the detection of dyssynergic defecation but is usually not necessary as the diagnosis can

171 be made using less invasive methods.

172

173 IMAGING STUDIES

174

175 Imaging studies are not a part of routine evaluation of pelvic floor disorders but may be

176 obtained when the symptoms do not correlate with the physical examination findings or

177 surgical correction does not alleviate the symptoms. Several modalities are available

178 including fluoroscopic , dynamic magnetic resonance imaging (MRI), and

179 ultrasound. Transit studies can be used to evaluate the upper and lower gastrointestinal

180 function and may be a useful adjunct in diagnosing patients with constipation and

181 defecatory complaints.

182

183 Transit Studies

184 Transit studies are most useful in those patients with infrequent bowel movements,

185 refractory to laxative or other conservative measures. These studies help rule out slow

186 transit constipation, which is defined as a long transit time through the colon 22. Patients

187 may present with complaints of bloating, abdominal discomfort and infrequent urge to

188 have a bowel movement; the symptoms are not typically relieved by the usual

189 interventions such as fiber supplementation 23. If slow transit constipation is diagnosed,

190 it is critical to evaluate the possible etiologies and to treat this prior to considering

191 obstructed defecation syndrome.

192

193 The Sitzmark transit study is the test most often used for the evaluation of slow transit

194 constipation and was first described in 1969 by Hinton et al 24. The patient is instructed

195 to stop taking , enemas or suppositories for 5 days prior to the test. On day 0

196 the patient takes one gelatin capsule containing 24 precut radiopaque polyvinyl chloride

197 markers. An x-ray of the is then obtained on day 5. The evaluation is

198 considered normal if 19 or more markers (80%) are expelled. Patients who have 6 or

199 more markers remaining are considered to have a positive study. If the markers are

200 scattered throughout the colon the diagnosis is likely colonic inertia, or slow transit

201 constipation. If the accumulation is mostly in the rectosigmoid the etiology is more likely

202 outlet obstruction 25 (Figure 3).

203

204 Fluoroscopic Defecography

205 Fluroscopic defecography, also known as dynamic proctography, provides a functional

206 assessment of the defecatory mechanics and the dynamic interaction between different

207 anatomical compartments. Cystodefecography is a test similar to defecography, in

208 which the rectum, the vagina, and bladder are opacified with contrast. The two

209 techniques are described interchangeably in the literature.

210

211 The rectum should be emptied prior to the study. Oral contrast of dilute barium

212 solution (gastrograffin, barium suspension and water) is given 30-45 minutes prior to

213 the study in order to opacify the small bowel. If vaginal opacification is desired, contrast

214 mixed with ultrasound gel is injected into the vagina. Rectal contrast is mixed with a

215 specific rectal paste to stimulate stool consistency and inserted rectally prior to the

216 study in order to visualize the rectum 26. During the examination the patient sits on a

217 , which is positioned on the footrest of the fluoroscopic table, sideways to

218 obtain a lateral view. For the patient’s privacy and to minimize the radiation exposure,

219 the radiologist and technologist remotely control .

220

221 As discussed above, the physiological defecation process is preceded by a strong urge,

222 which is triggered by rectal distention. Because defecography relies on volitional control

223 of the pelvic floor and passive rectal emptying, it does not replicate the exact

224 physiological response. There are three stages in the evaluation: rest, evacuation, and

225 recovery. During the resting stage, the should be closed. Leakage of stool

226 contents during this phase should lead patient questioning about .

227 The anorectal junction (ARJ) and the anorectal angle (ARA) are measured. ARJ is the

228 uppermost point of the anal canal and is measured in relationship to the fixed bony

229 point such as the ischial tuberosity or the pubococcygeal line. The craniocaudal

230 migration of ARJ indirectly represents the elevation and descent of pelvic floor. ARA is

231 an angle measured between the longitudinal axis of the anal canal and the posterior

232 line, parallel to the longitudinal axis of the rectum, averaging about 90 degrees. The ARA

233 is an indirect indicator of the puborectal muscle activity, becoming more acute with

234 muscle contraction (75 degrees) and more obtuse with relaxation (Figure 4).

235

236 The evacuation stage takes place when the patient strains to evacuate. The pelvic floor

237 descent that takes place during this phase is measured as the change in distance of the

238 ARJ from the anatomic fixed point (between rest and strain). The degree of caudal

239 migration of ARJ is considered normal when less than 3.5 cm relative to the resting

240 position. During straining, as the canal opens, the rectum begins to empty. It is common

241 to note a bulge of the anterior rectal wall, and this is not considered clinically significant

242 if less than 2 cm (in the anteroposterior diameter).

243

244 Once the rectum is emptied, as well as prolapse in other compartments

245 can be evaluated with the patient maximally straining. Rectocele is evaluated using the

246 system proposed by Wiersma 27 (Figure 5), and the enterocele (Figure 6-7) grading

247 system is based on the degree of bowel herniation: grade 0: normal position; grade I:

248 reaching the distal to the distant half of the vagina; grade II: small bowel reaching down

249 to the perineum; grade III: herniation out of the vaginal canal.

250

251 Structural abnormalities during defecation seen on imaging may include internal

252 intussusception, rectoceles, enteroceles, sigmoidoceles, and rectal prolapse21. Findings

253 on defecography can enhance the understanding of obstructive defecation symptoms.

254 In pelvic floor dyssynergy, the evacuation is significantly delayed (more than 30

255 seconds), the anorectal angle does not widen adequately, and the anal canal narrows

256 during straining due to a non-relaxing puborectalis muscle 28. Rectal prolapse is noted

257 when the rectal wall intussuscepts into or through the anal canal (Figure 8). When the

258 vagina and small intestines are also opacified, the relationship between pelvic organs

259 during defecation can be appreciated including the presence of vaginal or uterovaginal

260 prolapse and enteroceles.

261

262 One problem with defecography is the overlap in findings between patients with chronic

263 constipation and asymptomatic, healthy volunteers. In one study evaluating normal

264 volunteers undergoing standard defecography, approximately two-thirds of subjects

265 demonstrated abnormal radiologic findings 29. Additionally, the formation of rectocele

266 during defecation is a very common finding in healthy, asymptomatic women 30.

267 Therefore, anterior rectoceles seen on imaging that are not symptomatic do not need

268 treatment.

269

270 When considering patients with chronic constipation, studies demonstrate poor

271 correlation between the size of the rectocele on defecography and the clinical

272 evaluation of prolapse (POP-Q point Bp)11, 31, 32, 33 as well as symptoms 34.

273

274 Dynamic Magnetic Resonance Imaging (MRI)

275 Dynamic MRI provides a functional assessment of the structures of the pelvic floor using

276 a cine loop obtained at rest, squeeze, strain and/or defecation 35. Unlike fluoroscopy,

277 MRI has no radiation exposure, allows selection of multiple imaging planes, and offers

278 excellent temporal resolution and unparalleled soft tissue contrast, making it the best

279 modality to visualize soft tissue injury. These qualities make it a unique tool in the

280 evaluation of patients with pelvic floor disorders. But MRI is expensive, not always

281 accessible, and clinical implications are unclear, therefore, it is not widely utilized

282 outside of the research setting.

283

284 When performing MR imaging during defecation, various rectal preparations may be

285 used. The rectum should be filled with a contrast agent of a viscosity similar to that of

286 fecal matter. Some authors suggest the use of ultrasound gel for rectal 36. A

287 closed system MRI evaluates the patient in the supine position which is non-

288 physiological, particularly with regards to defecation. If an open, vertical system is

289 available, the positioning simulates real-life anatomy, likely improving the quality of the

290 study. While the patient is in a sitting position on a commode, the rectum is filled with

291 contrast and the study takes place with a flexible radiofrequency coil wrapped around

292 the . The images are obtained in the midsagittal plane at 2 second intervals at rest,

293 at maximal sphincter contraction, during straining, and during defecation.

294

295 To evaluate pelvic prolapse on MRI, reference lines are drawn between various bony

296 landmarks. The pubococcygeal line (PCL) is a line from the inferior border of the

297 symphysis pubis to the last coccygeal joint 37. Midpubic line (MPL) is a line extending

298 along the longitudinal axis of the symphysis pubis in the sagittal plane. The MPL roughly

299 corresponds to the level of the hymen, which is the reference point for the POP-Q

300 evaluation.

301

302 , internal rectal prolapse, or enterocele may also be noted on MRI. In addition,

303 defecation is described as complete or incomplete, depending on the presence or

304 absence of the contrast material at the end of defecation.

305

306 There are three unique enterocele classification systems underlying the importance of

307 communication between surgeon and radiologist. In one system, the PCL is used as the

308 reference for enterocele classification. The extent of enterocele is measured at 90

309 degrees to the PCL from the lowest margin of herniation content during the evacuation

310 effort. They are classified as small (<3cm below the PCL), moderate (3-6 cm below), and

311 large (>6cm below the PCL) 36. As a normal cul-de-sac extends 4-5 cm along the

312 posterior vaginal wall, small bowel in the posterior cul-de-sac (enterocele) is found in

313 normal, asymptomatic women and should not be considered pathologic 29,30.

314

315 Intussusception (internal or occult rectal prolapse) may be classified as intra-rectal or

316 intra-anal prolapse if its apex penetrates the anal canal and remains there during

317 straining. Once the rectal wall through the anal canal the rectal prolapse is

318 usually evident on clinical examination. Dynamic MRI with an evacuation phase is able

319 to distinguish between a mucosal internal prolapse and a full thickness prolapse 38.

320 Detection of these differences is critical as treatment plans are distinct.

321

322 Similar to fluoroscopic defecography, MRI may reveal anismus, or inability to relax the

323 or anal sphincter muscles with attempted defecation, leading to prolonged

324 attempted defecation (longer than 30 seconds) and/or incomplete defecation.

325 Additionally, in patients with anismus, the ano-rectal angle is noted to decrease instead

326 of increasing, likely due to the lack of pubrectalis relaxation 39.

327

328 When comparing supine dynamic MRI to fluoroscopic defecography, a small study

329 reported agreement between the two modalities in identifying the presence and the

330 degree of prolapse in different compartments 37. Like defecography, MRI correlates

331 poorly to the clinical examination of the posterior compartment.

332

333 Imaging studies of defecation are most physiologic when done on a commode. Since

334 open MRI in a sitting position is considered more physiologic with the vast majority of

335 studies demonstrating superiority to the supine position 40, it is recommended to

336 perform studies in this position when possible.

337

338 Ultrasound

339 Transperineal, translabial or endovaginal 3-D ultrasonography is another dynamic

340 imaging modality that provides functional assessment and is becoming more popular in

341 the evaluation of pelvic floor disorders. It is an office procedure which is more

342 accessible, inexpensive, and well-tolerated by the patient. A major disadvantage is that

343 it is challenging to add a defecography component to the evaluation due to patient

344 positioning, and because the examiner is directly performing the examination bedside,

345 which limits information.

346 Typically, the ultrasound assessment is performed with the patient in lithotomy

347 position. An abdominal 3-D probe is then placed on the perineum or at the labia,

348 applying gentle pressure. The bladder is half-filled and the rectum may be instilled with

349 ultrasound gel. Images are acquired at rest, with contraction and maximal straining. The

350 images then can be rendered in a 3-D view, and a 4-D cine loop, can also be obtained,

351 demonstrating the dynamics of multi-compartment interaction 41. A reference line may

352 be placed through the margin of the symphysis pubis and descent is analyzed against

353 this line when comparing the image at rest versus at maximum Valsalva.

354

355 An anterior rectocele is seen as a ballooning of the anterior rectal wall into the vagina.

356 An enterocele is visualized as the small bowel descends into the vagina with apparent

357 and an isoechoic appearance, occasionally with intraperitoneal fluid 41. An

358 intussusception is seen as an expansion of the anal canal and inversion of the rectal wall

359 into the canal.

360 As with fluoroscopic defecography and MRI, ultrasound findings do not correlate well

361 with POP-Q measurements of the posterior compartment35. However, one study

362 demonstrated that a widened anorectal angle (ARA) is associated with obstructive

363 defecation symptoms and a narrow levator plate descent angle is associated with

364 obstructive defecatory symptoms 42. When compared to fluoroscopic defecography,

365 transperineal ultrasound findings were comparable with a high degree of concordance43,

366 44. Ultrasound and MRI findings have been shown to be comparable when assessing

367 levator ani muscles 42, but to date there is no study specifically correlating MRI to

368 ultrasound assessment of the posterior compartment.

369 Ultrasound technology is an evolving modality in the assessment of pelvic floor defects.

370 Standardization of imaging is challenging because ultrasonography imaging acquisition is

371 operator dependent and because of variation in ultrasound technology.

372

373 Summary

374 Multiple studies suggest that while defecatory symptoms are often associated with

375 pelvic organ prolapse, the pathophysiology may be different and related to the

376 abnormalities in the ano-rectal anatomy more than the vaginal topography. There is

377 little relationship between symptoms and POP-Q values. In most studies, imaging and

378 POP-Q values have no significant relationship and there is no standardized radiologic

379 prolapse grading system. The finding of a posterior vaginal prolapse or anorectal

380 pocketing on physical examination is not specific nor related to the severity of

381 obstructive defecatory symptoms45 and is a common finding in asymptomatic women.

382 Likewise, the radiologic diagnosis of rectocele has not been shown to correlate with

383 defecatory symptoms and is also a common finding in healthy, asymptomatic women 30.

384

385 No specific imaging finding is sensitive and specific for obstructed defecation syndrome.

386 The role of imaging in the diagnosis of defecatory dysfunction is not well established.

387 Furthermore, abnormalities seen on imaging should be interpreted with caution as the

388 data concerning normal values for some parameters are not well established, and there

389 is substantial overlap between findings in symptomatic women and normal volunteers.

390 Defecatory imaging studies in normal volunteers reveal radiologic features that are

391 considered pathologic. Because of this, treatment decisions should be based on

392 symptoms rather than findings on imaging. Imaging should be reserved for cases in

393 which gastrointestinal dysfunction is suspected or the history is unclear or not

394 consistent with examination findings.

395

396 Obstructed defecation and the associated symptoms and signs may be consequences of

397 gastrointestinal dysfunction rather than the cause. Therefore, evaluation of

398 gastrointestinal function is paramount in the treatment of defecatory dysfunction as the

399 surgical repair addresses the defect in the anatomy not its underlying cause.

400

401

402 Summary and Recommendations 403 404 • No specific symptom, physical examination finding, or imaging finding is sensitive and 405 specific for obstructed defecation. 406 407 • Treatment decisions should be based on symptoms rather than findings on imaging. 408 409 • In most women with bulge symptoms and posterior vaginal wall prolapse no imaging is 410 required prior to surgery. 411 412 • Imaging may be most helpful in cases in which symptoms do not match physical 413 examination findings (e.g. defecography showing dyssynergic pelvic floor contractions in a 414 woman with defecation dysfunction). 415 416 • Anterior rectoceles seen on imaging that are not symptomatic do not need treatment. 417 418 • Small bowel in the posterior cul-de-sac (enterocele) is found in normal, asymptomatic 419 women and should not be considered pathologic. 420 421 • MRI, US, and Fluoroscopy defecography provide functional studies of pelvic organs. 422 423 • Imaging studies of defecation are most physiologic when done in a sitting position. 424 425 • MRI is the best modality to visualize soft tissue injury. 426 427 • Slow transit constipation should be ruled out in patients with infrequent bowel movements, 428 refractory to laxative or other conservative measures. 429 430 • Patients with a recent and persistent change in bowel habits, excessive straining or a sense 431 of incomplete evacuation, , rectal bleeding, weight loss, and anemia have 432 risk factors for and warrant endoscopic gastrointestinal evaluation. 433 434 435

436 Table 1: Rome III Criteria

437

438 Diagnostic criteria* 439 Must include two or more of the following: 440 a. Straining during at least 25% of . 441 b. Lumpy or hard stools in at least 25% of defecations. 442 c. Sensation of incomplete evacuation for at least 25% of defecations. 443 d. Sensation of anorectal obstruction/blockage for at least 25% of defecations. 444 e. Manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of 445 the pelvic floor). 446 f. Fewer than three defecations per week. 447 g. g. Loose stools are rarely present without the use of laxatives. 448 h. h. Insufficient criteria for . 449 * Criteria fulfilled for the last 3 months with symptom onset 450 at least 6 months prior to diagnosis.

451 Functional Defecation Disorders

452 Diagnostic criteria* 453 The patient must satisfy diagnostic criteria for functional constipation (see above). 454 During repeated attempts to defecate must have at least two of the following: 455 456 a. Evidence of impaired evacuation, based on balloon expulsion test or imaging. 457 b. Inappropriate contraction of the pelvic floor muscles (i.e., anal sphincter or puborectalis) or 458 less than 20% relaxation of basal resting sphincter pressure by manometry, imaging, or EMG. 459 c. Inadequate propulsive forces assessed by manometry or imaging. 460 * Criteria fulfilled for the last 3 months with symptom onset and at least 6 months prior to 461 diagnosis. 462 463 Dyssynergic Defecation 464 Diagnostic criterion 465 Inappropriate contraction of the pelvic floor or less than 20% relaxation of basal 466 resting sphincter pressure with adequate propulsive forces during attempted 467 defecation. 468 469 Inadequate Defecatory Propulsion 470 Diagnostic criterion 471 Inadequate propulsive forces with or without inappropriate contraction or less than 472 20% relaxation of the anal sphincter during attempted defecation.

473

474 Table 2: Causes of Chronic Constipation

475

476 Reproduced with permission from: Wald A. Management of chronic constipation in 477 adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on June 21, 478 2017.) Copyright © 2017 UpToDate, Inc. For more information visit 479 www.uptodate.com. 480

481

482 483

484

485 Figure 1: Hemorrhoids, a cause of anal pain 486

487 488 489 490 491

492 Figure 2.

493

494 Manometry catheter with balloon

495

496 497

498 Figure 3.

499 A. If 5 or fewer markers B. Most rings are C. Most rings are remain, patient has scattered about the gathered in the grossly normal colonic colon. Patient most likely rectosigmoid. Patient has transit. has hypomotility or functional outlet colonic inertia. obstruction. 500

501 “Reprinted with permission, Cleveland 502 Clinic Center for Medical Art & Photography © 2017. All Rights Reserved." 503

504

505 Figure 4

SB

AR A

506

507 508 509

510 Figure 5. (Groenendijk)

511

512

513 514 “Reprinted with permission, Cleveland 515 Clinic Center for Medical Art & Photography © 2017. All Rights Reserved." 516

517

518

519

520 521 522 Figure 6: Rectal intussception with enterocele

523

524

525 Figure 7: Large enterocele

526 527

528 Figure 8: Rectal prolapse

529

530 531 REFERENCES

532 1. Suares, N. C. & Ford, A. C. Prevalence of, and risk factors for, chronic idiopathic 533 constipation in the community: systematic review and meta-analysis. Am. J. 534 Gastroenterol. 106, 1582–91, 1592 (2011). 535 2. Longstreth, G. F. et al. Functional Bowel Disorders. 130, 1480– 536 1491 (2006). 537 3. Bharucha, A. E., Pemberton, J. H. & Locke, G. R. American Gastroenterological 538 Association Technical Review on Constipation. Gastroenterology 144, 218–238 539 (2013). 540 4. Haylen, B. T. et al. An International Urogynecological Association (IUGA) / 541 International Continence Society (ICS) Joint Report on the Terminology for Female 542 Pelvic Organ Prolapse (POP). Neurourol. Urodyn. 35, 137–168 (2016). 543 5. Hendrix, S. L. et al. Pelvic organ prolapse in the Women’s Health Initiative: gravity 544 and gravidity. Am. J. Obstet. Gynecol. 186, 1160–6 (2002). 545 6. Erekson, E. A., Kassis, N. C., Washington, B. B. & Myers, D. L. The Association 546 Between Stage II or Greater Posterior Prolapse and Bothersome Obstructive 547 Bowel Symptoms. Female Pelvic Med. Reconstr. Surg. 16, 59–64 (2010). 548 7. Grimes, C. L. et al. Outcome measures to assess anatomy and function of the 549 posterior vaginal compartment. Int. Urogynecol. J. 25, 893–899 (2014). 550 8. Burrows, L. J., Meyn, L. A., Walters, M. D. & Weber, A. M. Pelvic Symptoms in 551 Women With Pelvic Organ Prolapse. Obstet. Gynecol. 104, 982–988 (2004). 552 9. Fialkow, M. F., Gardella, C., Melville, J., Lentz, G. M. & Fenner, D. E. Posterior 553 vaginal wall defects and their relation to measures of pelvic floor neuromuscular 554 function and posterior compartment symptoms. Am. J. Obstet. Gynecol. 187, 555 1443–1449 (2002). 556 10. Kahn, M. A. et al. Pelvic Organ Support Study (POSST) and bowel symptoms: 557 straining at stool is associated with perineal and anterior vaginal descent in a 558 general gynecologic population. Am. J. Obstet. Gynecol. 192, 1516–22 (2005). 559 11. Ellerkmann, R. M. et al. Correlation of symptoms with location and severity of 560 pelvic organ prolapse. Am. J. Obstet. Gynecol. 185, 1332-7-8 (2001). 561 12. Bump, R. C. et al. The standardization of terminology of female pelvic organ 562 prolapse and pelvic floor dysfunction. Am. J. Obstet. Gynecol. 175, 10–7 (1996). 563 13. Gustilo-Ashby, A. M., Paraiso, M. F. R., Jelovsek, J. E., Walters, M. D. & Barber, M. 564 D. Bowel symptoms 1 year after surgery for prolapse: further analysis of a 565 randomized trial of rectocele repair. Am. J. Obstet. Gynecol. 197, 76.e1-5 (2007). 566 14. Kenton, K., Shott, S. & Brubaker, L. The anatomic and functional variability of 567 rectoceles in women. Int. Urogynecol. J. Pelvic Floor Dysfunct. 10, 96–9 (1999). 568 15. Chiarioni, G., Kim, S. M., Vantini, I. & Whitehead, W. E. Validation of the balloon 569 evacuation test: reproducibility and agreement with findings from anorectal 570 manometry and electromyography. Clin. Gastroenterol. Hepatol. 12, 2049–54 571 (2014). 572 16. da Silva, G. M., Gurland, B., Sleemi, A. & Levy, G. Posterior vaginal wall prolapse

573 does not correlate with fecal symptoms or objective measures of anorectal 574 function. Am. J. Obstet. Gynecol. 195, 1742–1747 (2006). 575 17. Papachrysostomou, M. & Smith, A. N. Effects of biofeedback on obstructive 576 defecation--reconditioning of the defecation reflex? Gut 35, 252–6 (1994). 577 18. Minguez, M. et al. Predictive value of the balloon expulsion test for excluding the 578 diagnosis of pelvic floor dyssynergia in constipation. Gastroenterology 126, 57–62 579 (2004). 580 19. Ahn, J. Y. et al. Effect of Biofeedback Therapy in Constipation According to Rectal 581 Sensation. Gut 7, 157–162 (2013). 582 20. De Lorijn, F. et al. Diagnosis of Hirschsprung’s disease: a prospective, comparative 583 accuracy study of common tests. J. Pediatr. 146, 787–92 (2005). 584 21. Pfeifer, J., Salanga, V. D., Agachan, F., Weiss, E. G. & Wexner, S. D. Variation in 585 pudendal nerve terminal motor latency according to disease. Dis. Colon Rectum 586 40, 79–83 (1997). 587 22. Alame, A. & Bahna, H. Evaluation of Constipation. Clin. Colon Rectal Surg. 25, 588 005–011 (2012). 589 23. Voderholzer, W. A. et al. Clinical response to treatment of chronic 590 constipation. Am. J. Gastroenterol. 92, 95–8 (1997). 591 24. Khaikin, M. & Wexner, S.-D. Treatment strategies in obstructed defecation and 592 fecal incontinence. World J. Gastroenterol. 12, 3168–73 (2006). 593 25. Tillou, J. & Poylin, V. Functional Disorders: Slow-Transit Constipation. Clin. Colon 594 Rectal Surg. 30, 076–086 (2016). 595 26. Maglinte, D. D. T. & Bartram, C. Dynamic imaging of posterior compartment 596 pelvic floor dysfunction by evacuation proctography: techniques, indications, 597 results and limitations. Eur. J. Radiol. 61, 454–61 (2007). 598 27. Wiersma, T. G., Mulder, C. J., Reeders, J. W., Tytgat, G. N. & Van Waes, P. F. 599 Dynamic rectal examination (defecography). Baillieres. Clin. Gastroenterol. 8, 600 729–41 (1994). 601 28. Thompson, J. R., Chen, A. H., Pettit, P. D. m & Bridges, M. D. Incidence of occult 602 rectal prolapse in patients with clinical rectoceles and defecatory dysfunction. 603 Am. J. Obstet. Gynecol. 187, 1494-9-500 (2002). 604 29. Freimanis, M. G., Wald, A., Caruana, B. & Bauman, D. H. Evacuation proctography 605 in normal volunteers. Invest. Radiol. 26, 581–5 (1991). 606 30. Shorvon, P. J., McHugh, S., Diamant, N. E., Somers, S. & Stevenson, G. W. 607 Defecography in normal volunteers: results and implications. Gut 30, 1737–49 608 (1989). 609 31. Weber, A. M., Walters, M. D., Ballard, L. A., Booher, D. L. & Piedmonte, M. R. 610 Posterior vaginal prolapse and bowel function. Am. J. Obstet. Gynecol. 179, 1446- 611 9-50 (1998). 612 32. Jelovsek, J. E., Barber, M. D., Paraiso, M. F. R. & Walters, M. D. Functional bowel 613 and anorectal disorders in patients with pelvic organ prolapse and incontinence. 614 Am. J. Obstet. Gynecol. 193, 2105–2111 (2005). 615 33. Altman, D. et al. Assessment of posterior vaginal wall prolapse: comparison of 616 physical findings to cystodefecoperitoneography. Int. Urogynecol. J. 16, 96–103

617 (2005). 618 34. Carter, D. & Gabel, M. B. Rectocele--does the size matter? Int. J. Colorectal Dis. 619 27, 975–80 (2012). 620 35. Broekhuis, S. R. et al. POP-Q, dynamic MR imaging, and perineal ultrasonography: 621 do they agree in the quantification of female pelvic organ prolapse? Int. 622 Urogynecol. J. Pelvic Floor Dysfunct. 20, 541–9 (2009). 623 36. Bolog, N. & Weishaupt, D. Dynamic MR imaging of outlet obstruction. Rom. J. 624 Gastroenterol. 14, 293–302 (2005). 625 37. Kelvin, F. M., Maglinte, D. D., Hale, D. S. & Benson, J. T. Female pelvic organ 626 prolapse: a comparison of triphasic dynamic MR imaging and triphasic 627 fluoroscopic cystocolpoproctography. AJR. Am. J. Roentgenol. 174, 81–8 (2000). 628 38. Dvorkin, L. S. et al. Open-magnet MR defaecography compared with evacuation 629 proctography in the diagnosis and management of patients with rectal 630 intussusception. Colorectal Dis. 6, 45–53 (2004). 631 39. Halligan, S. et al. Predictive value of impaired evacuation at proctography in 632 diagnosing anismus. AJR. Am. J. Roentgenol. 177, 633–6 (2001). 633 40. Maglinte, D. D. T., Hale, D. S. & Sandrasegaran, K. Comparison between dynamic 634 cystocolpoproctography and dynamic pelvic floor MRI: pros and cons: which is 635 the "functional" examination for anorectal and pelvic floor 636 dysfunction? Abdom. Imaging 38, 952–73 (2013). 637 41. Dietz, H. P. Translabial ultrasound in the assessment of pelvic floor and anorectal 638 function in women with defecatory disorders. Tech. Coloproctol. 18, 481–94 639 (2014). 640 42. O’Leary, D., Rostaminia, G., Quiroz, L. H. & Shobeiri, S. A. Sonographic predictors 641 of obstructive defecatory dysfunction. Int. Urogynecol. J. 26, 415–20 (2015). 642 43. Martellucci J, Naldini G. Clinical relevance of transperineal ultrasound compared 643 with evacuation proctography for the evaluation of patients with obstructed 644 defecation. Colorectal Dis. 2011 Oct;13(10):1167-72. 645 44. Perniola, G. et al. Defecation proctography and translabial ultrasound in the 646 investigation of defecatory disorders. Ultrasound Obstet. Gynecol. 31, 567–571 647 (2008). 648 45. Hicks, C. W. et al. Are rectoceles the cause or the result of obstructed defaecation 649 syndrome? A prospective anorectal physiology study. Color. Dis. 15, 993–999 650 (2013). 651 652 653 654 655 656