The effect of transvaginal prolapse surgery on anorectal function

Objective: Pelvic floor dysfunction can manifest as a spectrum including anorectal dysfunction, vaginal prolapse, and urinary incontinence. Sacrospinous fixation is a procedure performed by gynecologists to treat vaginal prolapse. The present study aims to evaluate the impact of transvaginal prolapse surgery on anorectal function. Materials and Methods: We conducted a retrospective review of patients undergoing sacrospinous fixation surgery for vaginal prolapse between 2014 to 2020. Those with anorectal dysfunction who had also been evaluated by the colorectal service preoperatively and postoperatively were included for analysis. These patients were assessed with symptom-specific validated questionnaires. The effect of surgery on constipation and fecal incontinence symptoms was analyzed. Results: A total of 22 patients were included for analysis. All patients underwent transvaginal sacrospinous fixation, and 95.4% also had posterior colporrhaphy for vaginal prolapse. There were a statistically significant improvements in the Fecal Incontinence Severity Index (FISI), the St. Mark's Incontinence Score (Vaizey), the embarrassment and lifestyle components of the Fecal Incontinence Quality of Life Score, the Constipation Scoring System, the Obstructed Defecation Score, and components of the Patient Assessment of Constipation Quality of Life score. Conclusion: Transvaginal prolapse surgery leads to a favorable effect on anorectal function, with improvements in both obstructed defecation and fecal incontinence scores in this small series. (AU)

Long-term outcomes of laparoscopic ventral rectopexy for obstructive defecation with overt pelvic structural abnormalities / 中华消化外科杂志

Objective:To investigate the long-term outcomes of laparoscopic ventral rectopexy (LVR) for obstructive defecation with overt pelvic structural abnormalities.Methods:The retrospective cohort study was conducted. The clinical data of 31 obstructive defecation patients with overt pelvic structural abnormalities who were admitted to the Renji Hospital of Shanghai Jiaotong University School of Medicine from June 2014 to August 2020 were collected. There were 6 males and 25 females, aged 59(range, 32?81)years. All 31 patients underwent LVR through transabdominal approach. Observation indicators: (1) the Cleveland clinic constipation score (CCCS); (2) severity of obstructive defecation; (3) patients assessment of constipation quality of life (PAC-QoL). Follow-up was conducted using telephone interview and outpatient examination up to October 2021. One professional researcher assessed the constipation symptoms and quality of life of patients through outpatient interview or mobile software platform of Questionnaire Star. Measurement data with skewed distribution were represented as M(range), and comparison before and after operation was conducted using the Wilcoxon sign rank test. Results:(1) The CCCS. All 31 patients underwent LVR for the first time and were followed up for 61.8(range, 11.0?87.0)months. The constipation symptoms of the 22 patients were improved. The CCCS of the 31 patients before surgery and at the last follow-up time were 15.8(range, 8.0?26.0) and 10.7(range, 2.0?20.0), respectively, showing a significant difference ( Z=?3.98, P<0.05). (2) Severity of obstructive defecation. The severity scores of frequency of bowel movements, difficult of bowel movements, sensation of incomplete defecation, abdominal distension or pain, time of each bowel movements, daily unsuccessful times of defecation, artificial assisted defecation for the 31 patients were 2.9(range, 1.0?4.0), 3.0(range, 1.0?4.0), 1.9(range, 0?3.0), 0.5(range, 0?3.0), 2.6(range, 2.0?4.0), 2.0(range, 0?4.0), 0.9 (range, 0?2.0) before surgery, versus 1.7(range, 0?4.0), 1.6(range, 0?4.0), 1.2(range, 0?4.0), 0.3(range, 0?3.0), 1.7(range, 0?3.0), 1.4(range, 0?3.0), 0.7(range, 0?2.0) after surgery, respectively. There were significant differences in the frequency of bowel movements, difficult of bowel movements, sensation of in-complete defecation, abdominal distension or pain, time of each bowel movements, daily unsuccessful times of defecation for the 31 patients before and after surgery ( Z=?3.38, ?3.80, ?2.54, ?2.31, ?3.64, ?2.75, P<0.05) and there was no significant difference in the artificial assisted defecation for the 31 patients before and after surgery ( Z=?1.31, P>0.05). (3) PAC-QoL. The score of physical discomfort, satisfaction, worries and concerns, psychological discomfort for the 31 patients were 2.3(range, 1.0?4.0), 3.2(range, 1.0?4.8), 2.2(range, 0.6?4.0), 1.8(range, 0.4?3.9) before surgery, versus 1.6(range, 0?4.0), 2.3(range, 0?4.0), 1.7(range, 0?4.0), 1.3(range, 0?4.0)after surgery, respectively, showing significant differences before and after surgery ( Z=?3.49, ?2.17, ?2.50, ?3.05, P<0.05). Conclusions:The long-term outcomes of LVR for obstructive defecation with overt pelvic structural abnorma-lities are satisfactory. Symptoms as frequency of bowel movements, difficult of bowel movements, sensation of incomplete defecation, abdominal distension or pain, time of each bowel movements and daily unsuccessful times of defecation will be significantly improved after LVR and the constipation quality of life of patients will be improved.

Correlação entre disfunção do assoalho pélvico na ultrassonografia 3D dinâmica e parto vaginal, paridade e idade em mulheres com sintomas de defecação obstruída / Correlation between pelvic floor dysfunction on dynamic 3d ultrasound and vaginal delivery, parity, and age in women with obstructed defecation symptoms

ABSTRACT BACKGROUND: Few studies have investigated the constipation or obstructed defecation symptoms identified by using imaging, as dynamic three-dimensional ultrasound and correlate vaginal delivery, parity, and age. OBJECTIVE: The aim of this study was to assess the prevalence of pelvic floor dysfunctions in female patients with obstructed defection symptoms and to determine whether specific pelvic floor dysfunctions identified by dynamic three-dimensional ultrasonography (echodefecography) are correlated with vaginal delivery, parity, and age. The secondary goal is to report the prevalence of coexisting pelvic floor dysfunctions. METHODS: This is a retrospective cohort study including patients with obstructed defecation symptoms underwent echodefecographyto evaluate pelvic floor dysfunctions in the posterior compartment and correlate with vaginal delivery, parity, and age. RESULTS: Of 889 female: 552 (62%) had had vaginal delivery and 337 (38%) were nulliparous. The prevalence of dysfunctions identified by echodefecography (rectocele, intussusception, enterocele/sigmoidocele, and dyssynergia) was similar between the two groups and was not associated with number of deliveriesor age. However, the prevalence of sphincter defects showed higher rates in women with vaginal delivery and increased with the parity. Up to 33% of patients had coexisting dysfunctions. CONCLUSION: The prevalence of dysfunctions such as rectocele, intussusception, dyssynergia, and enterocele/sigmoidocele assessed by echodefecography in patients with obstructed defecation symptoms are found similar regardless of vaginal delivery, number of deliveries or stratified-age. In vaginal delivery, number of deliveries does impact on detection of sphincter defects and liability to fecal incontinence.

RESUMO CONTEXTO: Poucos estudos investigaram pacientes portadoras de defecação obstruída identificados por exames de imagens, como ultrassonografia tridimensional dinâmica, correlacionando parto vaginal, paridade e idade. OBJETIVO: O objetivo deste estudo foi avaliar a prevalência de disfunções do assoalho pélvico em pacientes do sexo feminino com sintomas de defecação obstruída e determinar se disfunções específicas do assoalho pélvico identificadas por ultrassonografia tridimensional dinâmica (ecodefecografia) estão correlacionadas com parto vaginal, paridade e idade. O objetivo secundário é relatar a prevalência de disfunções do assoalho pélvico coexistentes. MÉTODOS: Este é um estudo de coorte retrospectivo incluindo pacientes com sintomas de obstrução da defecação submetidas à ecodefecografia para avaliar disfunções do assoalho pélvico no compartimento posterior e correlacionar com parto vaginal, paridade e idade. RESULTADOS: De 889 mulheres: 552 (62%) tiveram parto vaginal e 337 (38%) eram nulíparas. A prevalência de disfunções identificadas pela ecodefecografia (retocele, intussuscepção, enterocele/sigmoidocele e dissinergia) foi semelhante entre os dois grupos e não foi associada ao número de partos ou à idade. No entanto, a prevalência de defeitos esfincterianos apresentou taxas mais elevadas em mulheres com parto vaginal e aumentou com a paridade. Até 33% dos pacientes apresentavam disfunções coexistentes. CONCLUSÃO: A prevalência de disfunções como retocele, intussuscepção, dissinergia e enterocele/sigmoidocele avaliada pela ecodefecografia em pacientes com sintomas de defecação obstruída são semelhantes independentemente do parto normal, número de partos ou idade estratificada. No parto vaginal, o número de partos tem impacto na detecção de defeitos esfincterianos e na possibilidade de incontinência fecal.

Biofeedback therapy combined with diet to treating ODS (Anismus): 2 years outcome / Terapia por biofeedback combinada com dieta no tratamento da SDO (Anismus): desfecho de 2 anos

ABSTRACT Object: The advantages of biofeedback therapy along with diet in patients with constipation are among the issues discussed nowadays. The aim of this study was to evaluate 2 years outcome of biofeedback therapy along with diet in patients with obstructed defecation syndrome (ODS) (Anismus). Methodology: The focus of this prospective study is a group of 129 patients with ODS constipation, who were referred to two tertiary-care referral academic centers from 2013 to 2016. Patients received biofeedback therapy combined with appropriate diet in cases group and received diet in controls group. Good response was defined as a subject with at least 50 percent improvement from before to after biofeedback therapy on a Cleveland Clinic Florida Constipation Scoring System (CCF). Factors associated with better outcome were analyzed using SPSS 20 software. Results: Out of the 129 patients, 112 patients (86.8%) were female. The mean age of patients was 42.44 ± 15.05 years. The mean CCF score of the patients before and after biofeedback therapy was 12.41 ± 4.39 and 6.00 ± 3.28 respectively in case group (p-value < 0.001). In addition, the mean CCF score of the patients before and after diet therapy was 12.82 ± 4.85 and 9.43 ± 3.79 respectively in control group (p-value < 0.001). While CCF score in both case and control groups reduced significantly after therapy, the rate of this reduction was higher in case group (p < 0.001). Conclusion: Our findings suggest that biofeedback therapy combined with diet will improve patients outcome in ODS constipation. Prospective clinical trials with larger sample sizes are recommend allowing for causal correlations.

RESUMO Objetivo: As vantagens da terapia por biofeedback, juntamente com a dieta, em pacientes com constipação se situam entre os tópicos atualmente em discussão. O objetvo desse estudo foi avaliar os resultados, após 2 anos, da terapia por biofeedback associada à dieta em pacientes com síndrome da defecação obstruída (SDO) (Anismus). Metodologia: O enfoque desse estudo prospectivo é um grupo de 129 pacientes com constipação por SDO, encaminhados a dois centros acadêmicos de referência para atendimento terciário entre os anos de 2013 e 2016. Os pacientes receberam terapia por biofeedback em combinação com dieta apropriada no grupo de estudo (casos), e apenas dieta no grupo de controle. Boa resposta foi deinida como o paciente com pelo menos 50% de melhora desde antes até após a terapia por biofeedback, com o uso de um Sistema de Pontuação para Constipação do Centro Médico Cleveland Clinic Florida (CCF). Os fatores associados a melhor desfecho foram analisados com o uso do programa SPSS 20. Resultados: Dos 129 pacientes, 112 (86,8%) eram mulheres. A média de idade dos pacientes era de 4244 ± 15,05 years. O escore CCF médio dos pacientes antes e depois da terapia por biofeedback foi 12,41 ± 4,39 e 6,00 ± 3,28 respectivamente no grupo de casos (P < 0,001). Além disso, o escore CCF médio dos pacientes antes e depois da dietoterapia foi 12,82 ± 4,85 e 9,43 ± 3,79 respectivamente no grupo de controle (P < 0,001). Embora o escore CCF tanto no grupo de casos como no grupo de controle tenha apresentado redução significativa após a terapia, o grau dessa redução foi mais elevado no grupo de casos (P < 0,001). Conclusão: Nossos achados sugerem que a terapia por biofeedback em combinação com a dieta melhora o resultado para os pacientes apresentando constipação por SDO. Recomendamos a realização de estudos clínicos prospectivos com amostras mais expressivas, que permitam o estabelecimento de correlações causais.

Clinical research of improved STARR in the treatment of moderate and severe rectocele / 中国基层医药

Objective To study the therapeutic effect of improved STARR (Sehapayak as a control)in the treatment of moderate and severe rectocele.Methods 70 patients diagnosed with rectocele from Jan.2015 to Oct. 2015 were selected and randomly divided into 2 groups,35 cases in each group.They were treated with either improved STARR or Sehapayak surgery.The operation time,intraoperative blood loss,postoperative pain scores, patients'satisfaction and hospitalization days were compared between 2 groups.The ODS scores and therapeutic effects were compared in 1st week,1st month,3rd month and 6th month after treatment.The defecography was implemented and compared between 2 groups before treatment and 1st week and 6th month after treatment.Results The operation time,intraoperative blood loss,postoperative pain scores,hospitalization days and time to return to work were signifi-cantly lower in STARR group than those in Sehapayak group[(29.76 ±8.40)min vs (48.38 ±9.04)min;(14.43 ± 8.16)mL vs (77.80 ±20.58)mL;(4.29 ±1.76)points vs (6.71 ±2.04)points;(6.71 ±1.22)d vs (11.23 ± 3.64)d;(7.20 ±1.36)d vs (13.14 ±2.60)d;t =8.934,16.935,5.338,6.955,11.959,all P 0.05). The ODS score was (20.97 ±4.38)points before treatment,(4.71 ±1.30)points 1week after treatment,(2.94 ± 0.91)points 1month later,(1.68 ±1.04)points 3months later and (0.97 ±0.88)points 6mons later in the observa-tion group.The ODS scores in the control group were (19.88 ±4.09)points,(4.65 ±1.28)points,(3.51 ±1.15) points,(2.88 ±1.67)points,(1.85 ±1.31)points,respectively.The postoperative ODS scores of the two groups of patients were compared with the preoperative decreased significantly (t =20.666,23.904,26.127,26.401,all P 0.05);1 month,3 months and 6 months after surgery,the differences of ODS score of the two groups were statistically significant(t =2.313,3.585,323.3,all P 0.05).After treatment,they were all significantly decreased (t =21.779,20.646,all P 0.05).Conclusion Compared with Sehapayak,improved STARR surgery has the advantage of excellent curative effects,less trauma,shorter hospitalization,less complications and higher patient satis-faction.Improved STARR surgery is conducive to the prevention of rectocele relapse.

Evaluación de la disinergia del piso pelviano mediante manometría anorrectal y ecografía dinámica (ecodefecografía): estudio comparativo de la utilidad de ambos métodos / Evaluation of pelvic floor dyssinergy using anorectal manometry and dynamic ultrasound (echodefecography): a comparative study of the usefulness of both methods

Objetivo: Evaluar el grado de concordancia entre la manometría anorrectal y la ecografía dinámica del piso pelviano (ecodefecografía) mediante la medición del índice kappa, en la detección de la contracción paradojal del haz puborrectal en pacientes que presentan dificultad evacuatoria (DE) ocasionada por pujo disinergico. Material y Método: Se efectuaron manometría anorrectal y ecodefecografía, en 89 pacientes (9 hombres y 80 mujeres) en un centro ambulatorio de coloproctología, a pacientes que presentaban síntomas de obstrucción defecatoria en el período comprendido entre mayo 2011 y mayo 2014. Se reportó la presencia de contracción paradojal del haz puborrectal durante el pujo en las manometrías. En la ecodefecografía se analizó el movimiento del músculo puborrectal, comparando el ángulo anorrectal. durante el reposo y pujo. En caso de constatarse una disminución del mismo durante el esfuerzo evacuatorio se interpreto como contracción paradojal del haz puborrectal. Resultados:. Se obtuvo un índice kappa de 0.87 (IC 95% 0,73-0,97), dando un muy buen grado de acuerdo entre los resultados de ambos estudios, con resultados estadísticamente significativos (p=0,05). Conclusión: La ecodefecografía es una herramienta útil que puede confirmar casos de disinergia demostrada por manometría, pero si bien ambos métodos presentan muy buen grado de acuerdo entre sí, ningún estudio puede reemplazar al otro ya que ambos métodos tienen sus resultados falsos positivos.

Objective: To assess the degree of agreement between anorectal manometry and dynamic pelvic floor ultrasound (echodefecography) by calculating kappa index in patients with symptoms of obstructed defecation. Material and Methods: Anorectal manometry and echodefecography were performed in patients with obstructed defecation symtpoms between May 2011 and May 2014. When the anorectal manometry was performed, the pressures during attempted defecation were recorded. Dyssinergic pattern was defined if a rise in pressures was noted. When the echodefecography was performed, the angle between the internal edges of the puborectalis with a vertical line according to the anal canal axis was calcultated at rest and during straining. Results: Anorectal manometry and echodefecography was performed in 89 patients with defecatory disturbances symptoms. Male:female 9male, the mean age of patients was 57 years old (range 25-78). The assessment of the degree of agreement or concordance between dynamic ultrasound and anorectal manometry yielded a kappa index of 0.87 (very good agreement) with statistically significant results (p=0.05). Conclusion: Ultrasonography may be used to assess patients with obstructed defecation, as it is able to detect the same anorrectal dysfuntions found by another pelvic floor studies. It is a minimally invasive, well tolerated method, and avoids exposure to radiation. Although both methods shows very good agreement with each other, they cannot replace them since both methods have false positive results.

Clinical observation and thinking of procedure for prolaps and hemofrhoids in treatment of mixed hemorrhoids combined with non-functional obstructed defecation syndromes / 中国医师进修杂志

Objective To observe the clinical effect of procedure for prolaps and hemofrhoids (PPH) in treatment of mixed hemorrhoids combined with non-functional obstructed defecation syndromes (ODS).Methods The clinical data of 50 patients with mixed hemorrhoids combined with non-functional ODS treated by PPH were retrospectively analysed.All these patients were followed up for 12 months,the treatment outcome was observed.Results Eleven cases were basic cured,apparently effective in 12 cases,and effective in 12 cases,invalid in 15 cases,the total effective rate was 70％ (35/50),inefficacy patients were mainly combined with rectocele.None patients had serious complications such as death,anastomotic infection and pelvic sepsis.Conclusion PPH convenient operation,small trauma,for the treatment of mixed hemorrhoids combined with internal rectal prolapse is safe and effective,but the effective is poorer in treatment of mixed hemorrhoids combined with rectocele.

Presentación de nueva técnica: ecografía tridimensional dinámica endorrectal (Ecodefecografía) en el estudio de pacientes con síndrome de obstrucción del tracto de salida. Técnica y resultados. Primera experiencia en la Argentina / Presentation of new technique dynamic three dimensional endorectal ultrasound (Echodefecography) in the patients study with obstructed defecation syndrome. Technique and results. First experience in Argentina

Objetivos: describir un reciente método para evaluar pacientes con síntomas de obstrucción del tracto de salida, y mostrar nuestra experiencia inicial y resultados obtenidos. Material y Métodos: se estudiaron, en el período comprendido entre mayo 2011 y mayo 2013, a pacientes con síntomas de dificultad evacuatoria utilizando la ecografía anorrectal dinámica según la técnica descripta. Los estudios fueron efectuados por 2 operadores entrenados en el método. Resultados: se realizaron 89 ecodefecografías en 88 pacientes, en un período de 24 meses. La ecodefecografía detectó rectocele en el 65% de los pacientes estudiados, seguido de intususcepción y anismo en el 54 y 45%, respectivamente. Conclusión: la ecodefecografía es un método útil para evaluar pacientes con síntomas de obstrucción del tracto de salida. Permite obtener los mismos resultados que la videodefecografía. Es un estudio mínimamente invasivo, evita la exposición a radiación y pone en evidencia todas las estructuras anatómicas involucradas en la evacuación.

Purpose: to describe a novel method to assess Obstructed Defecation Syndrome (ODS) and to show the results of our experience. Material and Methods: patients referred with symptoms of ODS between May 2011 and May 2013 were studied by anorrectal dynamic ultrasonography technique. We use the technique of echodefecography described by Murah-Regadas et al. The test was analyzed by two experienced investigators. Results: we performed 89 echodefecography in 88 patients in a period of 24 months. EDF revealed rectocele in 65%, intussusception in 54% and anismus in 45% of patients. Conclusion: echodefecography may be used to assess patients with obstructed defecation, as it is able to detect the same anorrectal dysfunctions found by defecography. It is a minimally invasive, well tolerated method, that avoids exposure to radiation and clearly shows all the anatomical structures involved in defecation.

Early Experience with a Stapled TransAnal Rectal Resection for Obstructed Defecation Syndrome

PURPOSE: This study was designed to assess the early outcome of a stapled transanal rectal resection (STARR) in obstructed defecation syndrome (ODS) patients with rectocele and rectal intussusception. METHODS: From January to December in 2005, 41 patients with the symptoms of obstructed defecation and the findings of rectocele and rectal intussusception in defecography, who failed in conservative management, were enrolled in this study. All patients underwent the STARR procedure. Preoperatively all patients received colonoscopy, a colon transit time test, cinedefecography, etc. The constipation score was evaluated by using the Cleveland Clinic Florida (CCF) constipation score preoperatively and at 1 month and 3 months after operation. RESULTS: The mean age of the patients was 55.3 (19~76) years. There were three males and thirty-eight females. The mean operation time was 39.3 (25~80) minutes, and the mean hospital stay was 4.2 (4~6) days. Complications were fecal urgency in 9 cases (21.9%), which improved after 3 months, bleeding in 5 cases (12.2%), and anastomotic stenosis in 1 case (2.4%). At postoperative defecography, both intussusception and rectocele had disappeared in most patients. All constipation symptoms were significantly improved (P < 0.01). The mean CCF constipation score was 17.6 (11~24) preoperatively, and improved to 9.1 after 1 month and 8.2 after 3 months (P < 0.01). The overall patient satisfaction was graded as excellent, good, fairly good and poor in 19 cases (46.3%), 13 cases (31.7%), 4 cases (9.7%), and 5 cases (12.2%), respectively. CONCLUSION: The STARR procedure seems to be a safe and effective procedure in ODS patients with rectocele and rectal intussusception. However, further study of the long-term results is required.

Surgical Management of Obstructed Defecation

There are three groups of patients with constipating symptoms; those with obstructed defecation, slow transit constipation, or both. The treatment of obstructed defecation (pelvic outlet obstruction) is often challenging because the underlying disorders are diverse with a wide range of and clinical symptoms. The underlying anatomical and pathophysiological changes in patients with obstructed defecation are complex and often poorly understood. As a consequence, many medical, surgical, and behavioral approaches have been described, with no single panacea. For successful outcomes, preoperative physiologic testing is mandatory to differentiate between obstructed defecation caused by pelvic outlet obstruction and slow transit constipation. Obstructed defecatory disorders can distress patients both socially and psychologically and greatly impair their quality of life. For the great majority of patients, dietary adjustment with an increased fiber and liquid supplement can resolve the symptoms. The surgical approach depends upon the etiology, severity of symptoms, and operative risks. In a small group of patients with a rectocele or a third degree sigmoidocele, surgical intervention yields a high success rate. Division or resection of the puborectalis muscle is not recommended. In patients with a mixed pattern of slow transit colon and pelvic outlet obstruction, surgical intervention alone is often not successful; these patients can experience better outcomes by conservative treatment of pelvic outlet obstruction, followed by a colectomy. Stapled transanal rectal resection has recently become a recommended surgical procedure for obstructed defecation syndrome. One problem when using a transanal stapling device for rectal surgery is the potential damage to the structures located in front of the anterior rectal wall. The laparoscopic approach can shorten the hospital stay with good outcomes and is well tolerated in elderly patients with rectal prolapse. Despite the progress in modern surgery, the choice of the surgical procedure of pelvic outlet obstruction is still controversial. Preoperative counseling of all patients undergoing surgery is of extreme importance, in particular to explain the evolving nature of pelvic floor dysfunction and the possible need for further reconstructive surgery. To identify patients who will benefit from surgery for obstructed defecation, a careful selection of candidate patients remains the crucial issue in the diagnostic assessment. Surgical intervention should be limited only to the patients with identifiable, surgically correctable causes of outlet obstruction. This review gives an overview of surgical treatment options in patients with obstructed defecation.

Diagnosis and Management of Functional Evacuation Disorders

Over the last decade, anorectal physiologic investigations have emerged as a useful adjunct for patients with functional evacuation disorders. Through application of new sophisticated techniques and armamentarium, it has been possible to find more specific aspects of the colorectal function in patients with refractory defecation disorders. There are three groups of patient's with constipating symptoms. These patients have obstructed defecation, slow transit constipation, or a combination of both. Slow transit constipation is a severe disorder of colonic motility presenting predominantly in women. Obstructed defecation is a clinical problem frequently thought to be due to functional abnormalities of the pelvic floor leading to outlet obstruction. Defecation is an integrated process of colonic and rectal emptying, and has led to the realization that obstructed defecation is more complex than just a simple disorder of the pelvic floor muscles. Anorectal manometry establishes a quantitative measure of the pressure generated by the anal sphincters. Defecography is used to diagnose a variety of anatomical abnormalities of the rectum, including rectocele and intussusception. Tests of motor and sensory conduction in the pudendal nerves may indicate nerve damage, which accompanies chronic straining at stool. Colonic transit is an important variable and should always be considered in the assessment of patients with pelvic floor abnormalities, and measurement of colon transit by radioopaque markers or radioisotope techniques is an essential part of the workup of these patients. For the great majority of patients, dietary adjustment with increased fiber and liquid supplement can resolve these symptoms. Patients with slow transit colon can be expected to have a satisfactory outcome from colectomy and ileorectal anastomosis, but it is now appreciated that these patients form only a small proportion of those with chronic idiopathic constipation. Current management strategies for patients with obstructed defecation should be based on carefully identifying the underlying pathophysiological disorder and the use of conservative nonsurgical methods, including pelvic floor retraining (biofeedback) where appropriate. Surgical intervention should be limited to the very few patients with identifiable, surgically correctable causes of outlet obstruction.