Mohammed et al (2010) describe normal defecation as a ‘complex coordinated process involving the
central, autonomic and enteric nervous systems, and which requires the
integrated activities of normal colorectal motility, anorectal sensation, and
sufficient expulsive forces through a relaxed but supported pelvic floor.’
(Mohammed et al, 2010, p.1085).
If a patient has some form of rectal evacuatory
dysfunction, they may have some underlying functional bowel disorder or
Irritable Bowel Disorder and also problems with pelvic organ prolapse, and
sometimes a combination of the both. In their paper, Mohammed et al discuss
joint hypermobility as a probable link. Indeed their study suggests that 86% of
joint hypermobile patients experienced rectal evacuatory disorder compared to
64% of the non-hypermobile group <P=0.001>, thus suggesting that the link
being abnormal connective tissue. I suffer from hypermobility Ehlers-Danlos
Syndrome hEDS – a heritable disorder of connective tissue, affecting the
production of collagens. hEDS is a multisystemic disorder and other comorbid
conditions can be found alongside it including gastrointestinal disorders,
autonomic nervous system disturbances, fatigue, chronic pain, anxiety and many
other conditions.
The problem seems to be three-fold effecting general gut
function, some form of constipation and then the pelvic floor organs (rectum)
on defecation. I do experience a level of IBS or Functional Bowel Disorder.
This has been much improved by changes to diet – by having a wheat/gluten free
diet, a low carbohydrate/high protein/fat diet (and lots of fruits and
vegetables). In addition to this I have experienced constipation in the long
term – however it is not constipation in the true form. I do bowel movements
most days – and sometimes I do numerous bowel movements because they are not
satisfactory ones to adequately empty my bowel. This is the obstructive
defecation aspect or rectal evacuatory dysfunction.
Riss and Stift (2015) write that constipation is a common
disorder in the general population. Constipation, they write, is ‘often multifactorial,
and maybe put into three groupings: slow transit constipation, normal transit
constipation and evacuatory disorders – which can be a result of functional or
anatomical pelvic floor problems ‘(Riss & Stift, 2015).
The types of symptoms that sufferers from obstructive
defecation experience include straining, feelings of incomplete evacuation,
repetitive toilet visits, hard and lumpy and fragmented stools, a sense of
urgency, and sometimes even the need for use of digitation (fingers) to
evacuate the stool (Podzemmy et al, 2015; Riss & Stift, 2015).
Here – I describe what having
obstructive defecation feels like https://www.youtube.com/watch?v=7kaM-Z-02Eo
Podzemmy et al (2015) suggest that obstructive defecation
mainly effect women and that due to its complexity (and I agree), that it needs
a multidisciplinary approach to management.
Most patients, Podzemmy et al suggest, may be treated conservatively
with fibre diets, laxatives, rectal irrigation and biofeedback training and
pelvic floor re-training. They also argue for the use of psychotherapy – and I agree with this too because the
condition can lead to a very poor
quality of life and the symptoms can be very distressing. In some cases surgery
is also required for treatment – when there are pelvic organ prolapses –
including rectoceles (rectal prolapse), cystoclele
(bladder prolapse), entrocele (small bowel prolapse), anorectal intussusception
and sigmoidocele (large bowel prolapse). Vermeulen from Pozemmy et al 2015
warns, “to restore anatomy does not mean
to restore function.” Suggesting that caution is needed for surgery in
patients with obstructive defecation.
(Podzemmy et al, 2015, p.1054).
Weiss & McLemore (2008) describe Rectoanal
intussusception (RI) as a telescope infolding of the rectal wall during
defecation…. They (RI) may be graded 1-V depending upon the severity of the
findings (Grade V could be a full rectal prolapse). Often symptoms to not
improve or respond well to laxatives and biofeedback therapy has a variable
success rate. Sometimes symptoms can improve or worsen after surgery. Hany et
al (2015) write that the aim of surgery for rectal intussusception is to
correct the anatomical defect, to alleviate the bowel dysfunction, and avoid
functional sequelae (Hany et al, 2015, p53).
There are different surgical methods to repairing a
rectoanal intussusception – some might choose to repair using mesh in a ‘mesh
rectopexy’ surgery, whilst another alternative is to do what is called an
anterior resection and is more suitable – particularly (as in my case) if a
patient has a large sigmoidocle or ‘loopy’ and ‘redundant’ bowel. This involves
resecting the sigmoid colon, removing about 8-10 inches of bowels, pulling up
the rectum and then stitching/joining the ends of the colon. The risks can
involve the join or anastomosis (Hany et al, 2015). With repairing by mesh
there is risk of mesh infection. The other difference is that the
post-operative recovery time for the anterior resection is longer than for the
mesh surgery (Hany et al).
I had my anterior resection in January 2016 to repair my
rectoanal intussusception – only for that to fail some six months later when my
symptoms returned. My story will go into the past and present time as I prepare
to document a proposed second surgery for Grade 4 rectoanal intussception in
the summer of 2017.
Hany, S., El-Awady S., Ahmed S., Abo-Elkheir A., Ghazy
H., Farid, M. (2015). Laparoscopic resection rectopexy versus laparoscopic mesh
rectopexy for rectoanal intussusception. Egyptian
Journal of Surgery 34: 48-55.
Mohammed, S., Lunniss, P., Zarate, N., Farmer, A.,
Grahame, R., Aziz, Q., Scott, S. (2010). Joint hypermobility and rectal
evacuatory dysfunction: an etiological link in abnormal connective tissue? Neurogastroenterology & Motility, 22,
1085-c283.
Podzemny V., Lorenzo C., Pescatori M. (2015). Management
of obstructed defecation. World Journal
of Gastroenterology, 21(4), 1053-160.
Riss, S. & Stift, A. (2015). Surgery for obstructed
defecation syndrome – is there an ideal technique? World Journal of Gastroenterology, 21(1), 1-5.
Weiss E. & McLemore E. (2008). Functional Disorders:
Rectoanal Intussusception. Clinics in
Colon and Rectal Surgery Volume 21:2 122-128.
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