ASCRS Ch59 - Treatment of Difficult/Obstructive Defecation

Fifty-ninth chapter of the ASCRS Textbook of Colon and Rectal Surgery, 4th edition (Zutshi M, Oliveira LCC), part of "Part V: Pelvic Floor Disorders." Book pages 1007–1017, PDF pages 995–1005. Offset confirmed +12 (unchanged from Ch57/Ch58) via the copyright-line cross-check on this chapter's own first page. A discrepancy was found at the Ch59/Ch60 boundary: the copyright line on Ch60's first page (PDF page 1006) reads book page 1019, not the expected 1018 — meaning book page 1018 has no corresponding PDF page. Verified against the surrounding running headers (Ch59's last page = book 1017 at PDF 1005; Ch60's second page = book 1020 at PDF 1007, confirming 1006→1019 is correct, not a misread). Most likely explanation: page 1018 was a blank page in print (a common convention to force a new chapter to start on a recto/odd page) that was dropped when the PDF was created. The offset for Chapter 60 onward is +13, not +12.

Summary

Obstructed defecation syndrome (ODS) is presented as a subtype of constipation (alongside colonic inertia/slow-transit and IBS-associated normal-transit constipation) in which patients report straining, incomplete/painful evacuation, bowel infrequency, bloating, and sometimes digitation. The chapter covers physiology of defecation, Rome IV-based definition and etiology of dyssynergic defecation (paradoxical/inadequate puborectalis relaxation, up to 40% of constipated patients generally, ~4.6% of non-IBS patients specifically), structural causes (rectocele, enterocele/ sigmoidocele with degree- and size-based grading, internal prolapse/intussusception, and overt rectal prolapse), scoring systems (CSI, ODS score, CRQOL, PFDI/CRADI), and a diagnostic testing table (anorectal manometry/HRAM, cinedefecography, echodefecography, colonic transit study, MR defecography, EMG, PNTML).

Treatment is organized by etiology per a branching algorithm (Fig. 59.8):

• Puborectalis pathology / dyssynergic defecation: physical therapy/biofeedback first-line (with a caution that patients are often mistakenly taught Kegel exercises instead of relaxation training), then botulinum toxin A injection (200 units in 6–7 mL saline via six tuberculin syringes, injected transperineally into the levator ani) or electrogalvanic stimulation (mixed evidence vs. biofeedback), then puborectalis myomectomy (uncertain/not popularized), then fecal diversion as a last resort.
• Internal prolapse/intussusception: STARR (lost favor in the US, remains used elsewhere with variants like Transtar/TST STARR plus) or ventral rectopexy (newer preferred technique; mesh complications noted). Full technique detail explicitly deferred by the chapter itself to Chapter 60 ("Rectal Prolapse").
• Rectocele/enterocele/sigmoidocele: transanal repair (circular stapler, 30–90% symptom decrease, ~48-month recurrence), STARR for rectocele specifically (~40% long-term recurrence, declining in Europe), transperineal repair, and transvaginal repair (7.1% recurrence; meta-analysis favors native-tissue transvaginal over mesh-augmented repair). Enterocele/sigmoidocele treated via sacrocolpopexy with monofilament nylon mesh, in conjunction with urogynecology.
• Overt rectal prolapse: decision-making and surgical procedures explicitly deferred to Chapter 60.

Wiki impact

• New page: Obstructed Defecation Syndrome (ODS) — the umbrella entity, its scoring systems, diagnostic testing, and etiology-specific treatment algorithm.
• Substantially expanded: Rectocele (repair-technique recurrence rates), Constipation (new dyssynergic-defecation treatment section).
• Lightly touched (cross-reference only): Rectal Prolapse (Procidentia), Rectal Prolapse Repair.

Open items / gaps

• Internal prolapse/intussusception surgical technique (STARR, ventral rectopexy) and overt rectal prolapse treatment are both explicitly incomplete pending Chapter 60's ingest.
• No head-to-head comparative trial across the four etiology-specific treatment pathways.