Bary Berghmans
Bary BerghmansPhD, MSc, RPT, Associate Professor, Maastricht University Medical Center, The Netherlands

Obstructed Defecation Syndrome (ODS) is characterized by excessive straining at stool, incomplete rectal evacuation, and the need for perineal splinting. This condition is prevalent in young women suffering from constipation. ODS is refractory to laxative use. Typically, the block is found in the rectosigmoid portion. The main causes are divided into mechanical and functional. Mechanical causes interfere with stool passage, as can be found, for instance, in rectal prolapse. Functional causes include various neurologic or behavioral disorders leading to pelvic floor dysfunction, discoordination of the defecatory process, and impaired rectal sensation. In dyssynergic defecation, which affects many young women with chronic constipation, there is an inability to coordinate the abdominal and pelvic floor muscles to evacuate stools. Paradoxical contraction of the pelvic floor muscles during defecation hinders evacuation. ODS is characterized by persistent sensation of rectal fullness and painful, prolonged or excessive straining accompanied by a sensation of incomplete evacuation and clustering, and often requiring digital manipulation. Hemorrhoids and fissures are also related to functional ODS due to the psychology of trying to avoid pain during defecation.

A holistic approach is needed for patients with ODS, considering that most of these young women present with psychological distress, either anxiety or depression. Anismus affects many ODS patients.

Symptoms of prolonged or excessive straining, feelings of incomplete evacuation, application of perineal or vaginal pressure, or direct digital evacuation of stool (including soft stool) may be indications. A thorough history should be followed up with a pelvic floor muscle (PFM) functional assessment. Signs of no - or insufficient - perineal descent during observation and anorectal digital examination indicate pelvic floor dysfunction such as paradoxical contractions of the PFM and external anal sphincter. Medical data based on physiologic studies (colonic-transit tests, anorectal manometry, balloon expulsion tests, and defecography) can be helpful for the physical therapist before starting a physical therapeutic diagnostic consultation to further evaluate the consequences of ODS to determine if and to what extent physical therapy is warranted for the individual patient. In most cases, results of these tests are not (yet) available for the physical therapist, as they are often only performed when dietary and lifestyle changes, trials of fiber and laxatives, and physical therapy have produced no improvement.

Most conservative treatment modalities for young women with ODS up to now lack sufficient or convincing scientific or clinical evidence. We use in our clinical practice general exercises or physical activity, behavioral changes regarding fluid intake and bowel habit and regimen. Next to this, PFM training, biofeedback (BF), behavioral therapy, and electrical stimulation (ES) are provided. BF supports PFM and anal sphincter muscle training by converting intracavity electronic signals or pressure, captured with a small intra-rectal balloon or electronic probe to a computer screen which makes it possible for the young women to see (and/or hear) if and to what extent the pelvic floor is used adequately during PFM contractions and relaxations during physical activities. It is used to train patients to relax their PFM while straining and to coordinate relaxation and pushing to achieve defecation. Our experience is that BF may be helpful in young women with symptoms or findings on physical examination that suggest pelvic floor dysfunction, or who have diagnostic test results indicative of this disorder.

Defective expulsion is commonly investigated by asking the patient to defecate a 50-mL water-filled rectal balloon. Patients with functional defecation disorders usually fail this test. In these cases, as part of our behavioral therapy, we first explain the anorectal dysfunction and discuss its relevance with the patient before approaching the treatment. We train on a more effective use of the abdominal muscles and instruct on diaphragmatic breathing technique to enhance the push effort. Our patients will next be shown anal manometry or electromyography (EMG) recordings displaying their anal function and are taught through trial and error to relax the PFM and anal muscles during straining. By increasing the intra-abdominal/intra-rectal pressures with synchronized relaxation of the anal sphincters using visual and verbal feedback from manometry, we seek to improve recto-anal coordination. Visual feedback on PFM relaxation and contraction is continuously encouraged. When our patient has learned to relax the PFM during straining, the visual and auditory help can be discontinued. Another kind of training we use is an air-filled balloon attached to a catheter, which is slowly withdrawn from the rectum while the patient concentrates on the evoked sensation and tries to facilitate its passage. Then she should defecate the balloon spontaneously without any assistance. Also, in case of a hyposensitive rectum, we use the rectal balloon for sensory retraining. Usually, this kind of BF training is safe, has no side-effects, and will last up to 6 intensive supervised sessions of 30 to 60 minutes each.

Physical therapy for ODS aims to improve or restore normal bowel function and relieve symptoms such as abnormal or excessive straining during defecation, bloating, and feelings of incomplete evacuation. In case of pelvic floor dyssynergia we offer PFMT with BF, alone or in combination with prescribed medication, to stimulate coordination, improve timing and facilitate selective contractions/relaxation of the PFM including the external anal sphincter. It is important to offer intense home and office training and follow up on adherence to the protocols. In young women with ODS, physical therapy is an essential part of the patient-centred multidisciplinary approach. In that sense it is paramount that this kind of treatment be provided by a well-trained, experienced but also empathic physical therapist.

Silvana Uchôa
Silvana UchôaPhD, MSPT, Specialized in Women’s Health, Brazil

Conservative Management of Obstructed Defecation Syndrome in Young Women

Obstructed Defecation Syndrome (ODS) is a functional pooping disorder, and the management is essentially conservative and holistic, with pelvic floor rehabilitation, laxatives, rectal irrigation, fiber diet, hydrocolontherapy, biofeedback, transanal electrostimulation, and psychotherapy. A minority of patients require surgery, including rectocele repair, prolapse excision, rectopexy and, more rarely, transanal rectal resection. People with ODS have trouble evacuating their bowels, resulting in constipation. It may be for a variety of reasons, both mechanical and psychological.

ODS is truly an ‘iceberg syndrome’ in which two out of ten patients have ‘underwater rocks’ or occult disorders, such as anismus, rectal hypo sensation and anxiety/depression, which mostly require conservative management.

ODS is the most frequent form of functional constipation, and it can be merely functional (anismus), mechanical (rectocele, rectal prolapse) or both. A detailed examination is required to determine the most effective therapeutic approach. ODS is characterized by fragmented tools, sense of incomplete evacuation, need for straining at defecation, tenesmus, self-digitation, urgency, and pelvic heaviness.

The Brazilian practice of pelvic physiotherapists generally includes taking a detailed history with a global assessment and an assessment of the abdomen and the anterior and posterior compartment of the pelvic floor. The pelvic physiotherapists receive a referral from the physicians with results from anorectal manometry and sometimes defecoressonance. In our assessment we use the Renzi ODS Score or Modified Longo Score for ODS. The Modified Longo score is the most used scoring system to decide treatment strategy for ODS patients as well as to see the percent and total change in ODS symptom score from baseline after physiotherapeutic interventions in the short term. However, we still need long-term follow up trials and there is no consensus till date on cut off score.

On physical examination, the paradoxical contraction of the pelvic floor can be assessed by palpation of the puborectalis muscle while the patient is straining. Perineal descent >3 cm, mucous discharge or mucosal prolapse may also be seen when the patient is asked to strain for stools. Surface Electromyography (SEMG) of the pelvic floor and the balloon expulsion test (BET), are the most frequently used tests. In SEMG, the activity of the pelvic floor is assessed with surface electrodes, or with an anal plug inserted in the anal canal to evaluate external anal sphincter and puborectalis muscle activity, with the patient in laying or sitting position. In pelvic dyssynergy, EMG shows a paradoxical increase in activity of the puborectalis muscle during straining. In BET, a balloon filled with air or water is installed in the rectum and after positioning the patient in the left lateral or sitting position, the patient is asked to expel the balloon. Inability to expel the balloon supports the diagnosis of ODS. Some studies show that anal EMG and BET are the best modalities for the diagnosis of pelvic dyssynergy.

After this assessment, our patients go for five to ten sessions consisting of biofeedback training (BT), electrostimulation if necessary, pelvic floor muscle training (PFMT), behavioral therapy and balloon training. BT is very beneficial in showing the patient, in real time, what is going on, and then strategies for addressing the problem can be determined.  If the patient is not aware of their musculature or cannot contract, electrical stimulation may help. Behavioral therapy includes lifestyle modifications, changes in diet, fiber diet and fluid intake, and learning the correct position to evacuate, among others. And last but not least, in a pelvic physiotherapy consultation you will work from the diaphragm, simulating the act of defecating with muscle coordination, exercises of contraction, relaxation, strength and resistance. All this must be performed individually according to what was evaluated by the pelvic floor physiotherapist. It is important to instruct the patient to avoid foods, such as chocolate, that increase stool viscosity thus making stool expulsion more difficult.

Based on the above considerations, we think that ODS is a problem that is frequently encountered in females and the conservative management should be tailor-made to each clinical scenario to be effective.