Many people will suffer from constipation at some time in their lives. In some people this may become a chronic and embarrassing condition associated with laxative dependency and prolonged toileting. Identification and constipation treatment of these patients can be life changing.
What is chronic constipation?
Constipation occurs when bowel movements become less frequent. This may be because the bowel activity is reduced (true constipation) or because the rectum simply cannot expel its contents (obstructive defecation or ODS). This is an important distinction as if treatment is to be effective it must be directed to the underlying cause.
What is ODS?
This is a form of constipation which affects many people (particularly women) and may result in their having to plan their lives around their bowel movements. Often it is part of a more generalised weakening of pelvic support structures. In addition to infrequent bowel opening and the need for laxatives, clues to poor evacuation include:
- Excessive straining
- A sensation of incomplete evacuation
- The need to apply pressure to the perineum or even to insert a finger in to either the front or back passage to expel the stool
What is ODS/ Chronic Constipation Treatment?
ODS or constipation treatment may involve:
- An interview with a consultant.
- A camera test of the bowel may be necessary as a check to see all is healthy
Thereafter most patients will respond to non-surgical measures such as dietary advice, specialist physiotherapy exercises and so on which would be tailored to the individual’s requirement.
What if the ODS doesn’t improve?
First line therapy for ODS is nearly always conservative. Many patients will respond to simple measures such as dietary change, exercise and weight reduction and possible laxatives. If these methods fail then specialised pelvic floor physiotherapy may be beneficial. In about a third of cases these methods fail to achieve the desired improvement and surgery may become an option. Careful anatomical assessment of the pelvic floor through clinical assessment and a special X ray called a defecating proctogram is required.
A procedure called Stapled Transanal Rectal Resection (STARR) is one form of surgery that might be appropriate. This is a surgical procedure using stapling devices carried out through the anus with no external scaring. It is used to correct a low symptomatic bulge between the rectum and vagina called a rectocele together with a slipping of the rectum in on its self known as intussusception. The operation can be conducted as either a day case or with one night in hospital. Careful selection and counselling is always essential to achieve optimal results in this operation.
A procedure called Laparoscopic Ventral Mesh Rectopexy (Lap VMR) is a form of surgery when there is a more substantial weakness within the pelvic floor, the small bowel may flatten and push the rectum downward from above. This bulge is known as an enterocele. When the pelvic floor is very lax a combination of a deep enterocele and excessive Intussusception may result in the rectum being pushed out through the anal canal as a full thickness rectal prolapse. Symptomatic enteroceles and full thickness rectal prolapse need an operation from the abdomen to pull the pelvic floor structures back inside and in to correct alignment. The Lap VMR is a key hole operation that allows a piece of synthetic or biological material to be fixed between the rectum and vagina which is then lifted and anchored to a bone at the top of the pelvic inlet called the sacral promontory.
Patients are typically in hospital for one to three days with minimal recovery time after leaving hospital.