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Constipation is a common problem presenting to primary care, although it is still probably under-reported due to the perceived embarrassment associated with the condition. One form of constipation is known as Obstructed Defaecation Syndrome (ODS). This syndrome refers to the normal desire to defaecate but an inability to satisfactorily evacuate the rectum.

Until fairly recently, ODS was generally managed with medical therapies, including dietary manipulation, laxatives, enemas, a variety of irrigation techniques, and pelvic floor physiotherapy regimens. Rarely did medical management produce long-lasting effects, and this is probably not surprising given that the condition is frequently associated with anatomical changes that demand an anatomical solution. We now have a far better understanding of the pathophysiology underlying ODS. In particular, it is recognised that the anatomical changes associated with the condition may include:

1) Prolapse of the internal rectal lining, otherwise known as an intussusception.
2) Hernia of the anterior rectal wall into the vagina, referred to as a rectocele.
3) Other anorectal prolapse, including haemorrhoidal disease and pathological descent of the pelvic floor.

Based on our improved understanding of ODS, an innovative new surgical procedure has been developed to correct the underlying anatomical changes and to restore the rectum to its normal structure and function. This procedure is known as Stapled Transanal Rectal Resection, or STARR. Essentially, it involves removal of the rectal prolapse and rectocele using a stapling device inserted through the anus. Results of a large European Registry have shown it to be effective in reducing symptoms of ODS and in improving associated Quality of Life¹.

Given the recent success of STARR in the treatment of constipation associated with rectocele and internal rectal prolapse, the question naturally arises as to which patients may most benefit from the procedure. Rectocele is a common condition, particularly in the multiparous female, but not all rectoceles are symptomatic or require further investigation or surgical intervention. However, if symptomatic, rectoceles may present with one or more of the following:

1) A feeling of “dragging” or discomfort in the perineum.
2) Awareness of a bulge pushing forwards from the rectum into the vagina, particularly on straining.
3) Discomfort on intercourse.
4) An inability to properly evacuate the rectum, with a feeling of incomplete emptying and the need for frequent returns to the toilet.

It is the latter group of patients, with rectal evacuatory problems, who are actually describing a rectocele combined with ODS. This diagnosis is frequently overlooked, due to a lack of awareness by both patients and healthcare providers. However, once the association is made then the patient can be appropriately directed to specialists dealing with the condition for further advice and investigation.

Figure 1 presents a schematic representation of a rectocele (R) bulging forward into the vagina (V). In front is the bladder (B). It can be appreciated how the bulging rectocele will prevent faeces from being satisfactorily evacuated from the rectum.

Figure 2 shows an intraoperative demonstration of a rectocele (R). The examining finger is inserted into the anus and the herniation of the rectum into the vagina as a rectocele is readily appreciated.

The conundrum for patients with a rectocele and ODS is whether they are best treated by traditional gynaecological rectocele repair, or whether they might be better served by a STARR procedure, which simultaneously corrects both the rectocele and improves rectal evacuatory function. The answer to this question is largely unknown as there have been no randomised controlled trials comparing the two techniques. However, logic would dictate that if the primary pathology originates in the rectum, as a herniation of the rectum into the posterior vagina, then a rectocele associated with constipation might best be approached with a transanal technique, such as STARR.

Until the results of properly controlled randomised trials are able to give us better guidance, we should not deny patients the opportunity of exploring all avenues to achieving the best possible outcome. Referral to an appropriate colorectal surgeon with experience in pelvic floor disorders should help patients clarify which approach is most likely to be beneficial and allow full discussion of the relative risks and benefits.

Will STARR become the preferred treatment for patients with rectocele and constipation in the future? – only time and more experience will tell.

References

1. DG Jayne, O Schwandner, A Stuto. Stapled Transanal Rectal Resection for Obstructed Defaecation Syndrome: one-year results of the European STARR Registry Diseases of the Colon and Rectum 2009; 52 (7): 1205-12.

This article is the sole work of the author and does not necessarily reflect the views of Johnson & Johnson Medical Limited or any of its affiliated business or companies, nor does the publication of this article on the CareMail website comprise an endorsement of its contents, for which Johnson & Johnson Medical Limited and its affiliated businesses and companies accept no responsibility. In particular no such Johnson & Johnson entity shall be liable for any damages or injury resulting from any reliance placed on any information provided in this article or for any possible inaccurate or misleading data or statements contained therein.

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