Monday, March 13, 2017
What is Obstructive Defecation or Rectal Evacuatory Dysfunction?
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.