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The Iceberg Diagram for the Treatment of Obstructed Defecation

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The Iceberg Diagram for the Treatment of Obstructed Defecation Società Italiana di Chirurgia Colo Rettale www.siccr.org 2019; 50: 430-439 The Iceberg diagram for the treatment of obstructed defecation Mario Pescatori MD, FRCS, EBSQ Parioli Clinic, Rome and Cobellis Clinic, Vallo della Lucania, Italy Website: www.ucp-club.it E-mail: [email protected] Introduction Obstructed defecation syndrome (ODS) is a enemas or laxatives to defecate. Symptoms type of chronic constipation characterized by of ODS may be quantitatively evaluated using straining at stool, sense of incomplete the ODS score (1), which takes in account evacuation, fragmented defecation and, in different parameters such as the time spent in some cases, self digitation to assist the toilet, the use of laxatives and enema, the evacuation. Patients with ODS are most sense of incomplete evacuation etc. frequently females and often they need either Evident and Occult Diseases Patients with ODS have either a rectal and rectocele, i.e. the tip of the iceberg. But internal mucosal prolapse or a rectocele, or it is even more important to see the “rocks” both, in over 90% of the cases. They may be which are occult or “under water”, simply diagnosed carrying out a digital representing the associated disease. If we do exploration and a proctoscopy. There are not see them and we do not cure them, we surgeons who believe that excising the will not be able to cure patient’s symptoms. prolapse and repairing the rectocele they will solve the clinical problem. This is unlikely, In a previous prospective study (2) carried out because prolapse and rectocele are more in100 patients, most females, we found out effects (of excessive straining) than causes of that all of them had at least two occult ODS. When they become large, they lesions or “under water rocks”. The Iceberg represent contributory cause, but there are Diagram (ID) is represented in Figure 2. It always other underlying diseases more has been recently validated by Australian difficult to diagnose, which are responsible for gynecologists in the journal Pelviperineology. symptoms. We may call them occult Psychological disturbances (either anxiety or diseases and we may divide them in depression or both) and animus or non functional and organic. If we image a relaxing puborectalis muscle on straining are surgical ship (Figure 1) trying to avoid the the most frequent functional occult shrinkage on a stormy sea where there is an diseases or “under water rocks”, being iceberg, similar to the one which destroyed present in two-thirds and 44% of the cases, the Titanic, it is essential to see in advance respectively. Rectal hyposensation is present which are the evident rocks, or evident in one third of the cases. Pudendal lesions i.e. rectal internal mucosal prolapse www.siccr.org 430 Società Italiana di Chirurgia Colo Rettale www.siccr.org 2019; 50: 430-439 neuropathy and irritable bowel syndrome or- diseases (prostatism, colpocele, vaginal vaut and slow intestinal transit time are the other prolapse and cistocele) are the most two functional diseases. Among the occult frequent, followed by enterocele and organic lesions, urogenital associated sigmoidocele, recto-rectal intussusception and solitary rectal ucer syndrome. Figure 1 Figure 2 www.siccr.org 431 Società Italiana di Chirurgia Colo Rettale www.siccr.org 2019; 50: 430-439 Perineal Examination According to the Iceberg Diagram Special attention should be paid during the desire to defecate and would rush to the proctological exam, i.e. inspection, digital toiled (usually around 120 ml of air). At the exploration and proctoscopy, in the sense end of the examination the patient is asked to that, to follow the ID and evidentiate some of evacuate the balloon filled with 100 ml of air. the occult diseases or “underwater rocks”, we Those with anismus are likely not the expel need to examine not only the anus, anal the balloon. canal and lower rectum but the whole perineum, i.e. the posterior, the central and ANISMUS, if any, has to be investigated the anterior compartment. When dealing with during perineal examination, by inserting the a female patient, both the anorectum and the finger into the anus up to the lower rectum vagina should be examined with a bi-digital and hooking the finger posteriorly, aimed at exploration, aimed at assessing the thickness feeling the bulk of the posterior part of the of the recto-vaginal septum and the size of puborectalis muscle. Then the patient is the rectocele, if any. The patient should be instructed to take a big breath and then to asked to strain in order to evaluate a perineal gradually push down or evacuate. At this descent, if any (descent of the perineum = point, the exploring finger should feel the more than 2 cm on straining). Patients who relaxation of the muscular bulk. If no report either fecal urgency or anal relaxation occurs or if the opposite, i.e. a incontinence need to be carefully examined contraction, is appreciated, the patient is searching for an either delayed or slowered likely to suffer from anismus. It should be anal reflex, which may be elicited touching noted that the lack of relaxation of the the perianal skin with a needle and observing puborectais muscle of the patient might be an the reflex response of the external sphincter artefact, due to the ambulatory outpatients contraction. An alteration of anal reflex, setting, to the digital exploration or the brain- together with a short, i.e. not adequately nerve tension. That is why the diagnosis of mantained, sphincter’s contraction (less than animus needs to be confirmed by a transanal 20 seconds) and a reduced rectal sensation ultrasound and/or a defecography. are likely to be present in patients with PROCTOSCOPY has to be carried out both pudendal neuropathy. Those at risk are at rest and on straining aimed at evaluating multiparous vaginal females and patients with the presence and the degree of a rectal perineal descent. In order to assess rectal internal mucosal prolapse, if any. According sensation, a latex balloon connected to a to our classification, we define it as 1st rubber catheter is gently inserted through the degree if the apex of the prolapsing mucosa anus for 6 – 7 cm and then slowly inflated descends through the anorectal ring without with air. The balloon may be simply reaching the dentate line, 2nd degree if it constructed with the finger of a surgical glove. reaches the dentate line, 3rd degree if it Three levels of rectal sensation are recorded, descends down to reach the anal verge. the first one being onset of feeling, i.e. when Surgery is never indicated for first degree the patient realizes that “something” has been prolapse, mostly rubber band ligation is inflated inside the rectum (usually 20-30 ml indicated for second degree prolapse and of air), the second one being call for stool, surgical excision is usually indicated in case i.e. when the patients feels the need to of third degree prolapse. evacuate (usually 50-70 ml of air), and the third being maximal urgency, i.e. when the patient feels a strong and almost painful www.siccr.org 432 Società Italiana di Chirurgia Colo Rettale www.siccr.org 2019; 50: 430-439 Prior to insert the proctoscope through the the patient to strain and cough. Enterocele anus, an examination of central and anterior or sigmoidocele are more likely to occur in compartment should be carried out inserting females who had a hysterectomy and feel the proctoscope through the vulva. First, the pelvic heaviness and/or abdominal low posterior aspect of the vagina should be hypogastric pain. Finally, the tip of the examined searching for the bulk of a proctoscope should be orientated anteriorly, rectocele, if any. Then the central part looking aimed at evidentiating either a cystocele or a for the bulk of an enterocele, if any, asking uretrocele, if any. Cystocele is more likely to occur in females with urinary incontinence. Further Details on the Diagnosis and Treatment of Both Evident and Occult Lesions in the ODS Evident Lesions or “Tips of the Iceberg” 1. Rectal Internal Mucosal larger than 3 cm, when entraps barium on the Prolapse (or Recto-Anal straining phase of defecography and when Intussusception). the patient has to digitate in order to evacuate. There are three types of digitation The diagnosis can be made either under , one consists of extracting the stool from the visualization on straining, simply detecting a rectum using fingers, the second one without small piece of pink mucosa protruding any insertion, but just touching-stimulating the through the anal verge, in case of third perianal space anteriorly at the skin level and degree prolapse or by means of transanal thus eliciting a rectal peristalsis mediated by ultrasound or by defecography. At transanal means the superficial and deep transverse ultrasound with a rotating probe (either 7 or ani muscles; the third type of digitation 12 MHz), the prolapse is more evident if consists in pressing the anterior lower part of anterior and appears as an area of mixed the vagina, aimed at correcting the anterior echogenicity inside the hypoechogenic circle deviation of the rectum, i.e. the rectocele of the internal sphincter and-or of the lower itself. In other words, to keep vertical the anterior rectal muscle. The treatment may be direction of stool expulsion. A rectocele repair carried out by a rubber band ligation if 1st - 2nd may be carried out by several techniques. degree and by a surgical excision if 2nd - 3rd degree. In case of circumferential rectal One of the simplest is the Block operation, internal mucosal prolapse a transanal circular which consists of a transanal obliteration of stapled excision can be carried out (3).
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