Obstructive Defecation Syndrome

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. So welcome to another episode of Butts and Guts. I'm your host, Dr. Scott Steele, the president of Main Campus Submarket here at Cleveland Clinic in beautiful Cleveland, Ohio. And today, I'm super pleased to have our expert, Dr. Dr. Emanuela Alvarenga, who is a colorectal surgeon at Cleveland Clinic Florida Tradition Hospital. And today, we're going to talk about one of my favorite topics as a colorectal surgeon: obstructive defecation syndrome. Dr. Alvarenga, thanks so much for joining us on Butts and Guts.

Dr. Emanuela Alvarenga: Thank you for having me.

Dr. Scott Steele: So before we jump into it, if you could just tell us a little bit more about your background, where you're from, where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Emanuela Alvarenga: Yes. I was born in Brazil, São Paulo, and I grew up in an institution for girls also in São Paulo and this was a wonderful place. Against many odds, I got my medical degree and I did my residencies in general surgery and coloproctology at the University of Goiânia Goiás with Helio Moreira, Jr., who encouraged me to spend a year at the colorectal surgery department at Cleveland Clinic Florida, which I did. And after this experience as an international clinical fellow under Dr. Wexner, I decided to stay in the US. I re-trained in general surgery at Florida State University and returned later to Cleveland Clinic Florida as an ACGME-accredited colorectal surgery fellow and subsequently as a clinical associate, and eventually, and now, joined the new campus in Florida at the Tradition Port St. Lucie campus.

Dr. Scott Steele: Well, you've had some wonderful mentors. So today, we're going to talk a little bit about obstructive defecation syndrome or ODS. So to start, at a high level, can you share what ODS is for our listeners?

Dr. Emanuela Alvarenga: Certainly. ODS is essentially a type of constipation, a subtype of constipation. We have constipation as a general term and it's normally divided in three major groups. We have one group where their entire length of the bowel has a low trend time and we call it colonic inertia, the group where colonic trend time is normal and the constipation is due to irritable bowel syndrome, or constipation-predominant IBS, and the group we'll be talking a little bit more about which is the constipation due to pelvic outlet difficulties or difficult evacuation, also known as paradoxical fibrorectalis contraction, anismus, or pelvic floor dyssynergia. Some patients have a combination of types and this makes the diagnosis and the treatment not easy.

Dr. Scott Steele: So how common is ODS?

Dr. Emanuela Alvarenga: Quite frequent, unfortunately. Constipation is one of the most prevalent symptoms and defecation difficulties can occur in up to 40% of all constipated patients. It is estimated that about 18% of the population suffers from a wide range of conditions known as obstructive defecation syndrome.

Dr. Scott Steele: So you mentioned a little bit about constipation, but what are some of the symptoms specifically as it relates to ODS, obstructive defecation syndrome?

Dr. Emanuela Alvarenga: Well, the patients represent simply as constipated most of the time. They will tell you that they feel they can poop when they want to or they're not pooping often enough, or they're pooping everything out all the way and it feels as something is blocking the poop from coming out. They might also even tell that it's painful to poop. So the most common symptoms include straining with minimal passage of stools, sensation of an incomplete evacuation. The stool texture may also vary. They are, most of the times, hard and lumpy, but it can also be watery or loose. If backed up stool overflows, patients will commonly have the urge to defecate and it's common that they sit on the toilet for prolonged times and some patients might even need some assistance, digital assistance, to expel the stool from the rectum or require some maneuvers of perineal splinting to enable passage of the stools.

And this ineffective evacuation oftentimes leads to abdominal symptoms such as distension, bloating, cramping, which in turn can lead to poor appetite and early satiety, for example. Usually, there's not a single test that can be applied to make the differential diagnosis easier and the tests need to be tailored to each individual patient. And as much as this testing might point to a diagnosis, clinical correlation should always be used. And then rectal physiology testing includes mainly an anal manometry, which is a test that measures how well the muscles and the nerves work together to push poop out. Where a catheter with a balloon is attached at the end of it and is inserted to the patient's rectum, the balloon is inflated with warm water in the other end of the catheter is attached to a machine that will measure muscle activity. That might be done with electromyography or not in combination to assess puborectal relaxation.

Another adjunct is the defecography, a radiologic test through a fluoroscopy, x-ray, or an MRI where a healthcare provider can see how different muscles and organs are moving when the patient is evacuating. And for our audience, you don't poop real poop in the test. Instead, the healthcare provider technician will fill your rectum with a medical substance that has the same consistency as poop. You will evacuate the paste in a private photographic chamber while they watch your organs on a computer screen and outside. If these findings are normal, then it's reasonable to proceed with investigations such colonic transit, and this can be performed with radiopaque markers, scintigraphy, or wireless motility capsules. The radiopaque markers are most commonly used because they are widely available. They're inexpensive and easy to use.

Dr. Scott Steele: Emanuela, you mentioned a little bit that ODS seems to have many causes in both organic, as well as functional. Can you talk about the differences between the two?

Dr. Emanuela Alvarenga: By all means. It is crucial to make that differentiation as treatment options may differ greatly. Various causes can cause the pelvic floor muscle to lose coordination and thus being unable to maintain normal continence and achieve normal evacuation. And the process of defecation is determined by very complex and not very well-understood integration of mechanisms involving interaction of multiple organ systems, the brain, the spinal cord, enteric neurons, and the muscles of the colon, the anus, and the pelvic floor. So defecatory disorders can be a result of several different functional and anatomical abnormalities and the theology sometimes is unclear and can be multifactorial. That's the big challenge.

So functional causes of ODS include non-relaxation or inappropriate contraction of the pelvic floor muscles, more specifically the puborectalis muscle as part of the levator ani muscles. This functional ODS is clinically-defined by clinically observing normal relaxation or paradoxical contraction of the puborectalis at the anorectal junction, while asking the patient to bear down as if trying to have a bowel movement when these muscles are expected to relax in a normal defecatory event. And this is best done clinically with a digital examination and can be confirmed further with an anal manometry or defecography.

ODS might also be a consequence of an organic or anatomic issue such as an organ prolapse, one of the pelvic organs such as bladder, uterus, rectum, bowel has fallen out of place and is bulging into another organ or falling out of the body. Rectal prolapse can present as an internal prolapse. We also call it rectal intussusception, which is the funnel-shaped in-folding of the rectal wall that occurs during the defecation, but it does not exteriorize beyond the anal canal, or as a clinically visible prolapse where there is a full thickness intussusception of the rectal wall with protrusion beyond the anal canal. There is also a rectocele, which is a bulge that's felt within the vagina, or an enterocele or a sigmoidocele, which are the presence of a small bowel or a sigmoid colon between the rectum and the vagina reaching lower down to the pelvis during the evacuation effort. Any of those conditions can lead to obstructive defecation symptoms.

Dr. Scott Steele: So as you said, there's a wide degree of causes, but what are some of the more common treatments for ODS?

Dr. Emanuela Alvarenga: I believe ODS might be one of the most challenging in colorectal surgery in terms of treatment. It is so important that clinicians discuss goals and set expectations for the therapy, which eventually are improvements of the defecation mechanisms and the stool texture. So treatment options can vary based on physical exam and test results, but overall initial management for nearly all patients of ODS starts with conservative management, lifestyle advice, high fluid and high fiber intake, stool softeners or laxatives or home enemas, bowel retraining programs, and psychotherapy. Psychological support and counseling have been shown to be helpful in patients with depression and/or anxiety, and it is important to remember that up to one-third of the females complaining of ODS and proctalgia have been exposed to sexual abuse or trauma during their childhood or adolescence.

For ODS due to pelvic muscles lacking appropriate coordination, the pillar of the treatment is pelvic floor rehabilitation with pelvic floor physical therapy and biofeedback. There are main four types of biofeedback. They can be done with manometric guidance, with balloons, electromyography, or [inaudible 00:10:29] ultrasounds. Essentially, the biofeedback offers a visual or audio feedback for the patients during any muscular training or contraction, which is usually performed unconsciously. And our job as healthcare providers is to educate the patients that these abnormal muscle contractions can be unlearned and pelvic muscle relaxation can be taught through one of these several types of biofeedback techniques.

The patients should continue physical therapy for multiple visits before considering the therapy a failure. In patients with no access to a trained physical therapist, home-based physical therapy is a possibility. The thing is finding the perfect combination of medications, diet, physical therapy exercise can take several months and why it's so important to carry out a honest talk with the patient, to set reasonable expectations and reduce anxiety. If physical therapy is unsuccessful, especially when there is a component of pelvic pain, there are less commonly-offered options of treatment, for example, with injections of botulinum toxin, or Botox, into the pelvic muscles to cause it to relax. Although, the results of these therapies vary and are temporary.

In terms of surgical management of anatomical issues, this is somewhat limited and typically not recommended as first-line treatment, except for patients with obvious rectal prolapse. These patients should be managed surgically. Several different procedures have been described, although the best procedure has yet to emerge from the literature. Rectoceles, when symptomatic, can be repaired by plication or fixation of the rectal wall, for example, by a posterior colporrhaphy. For thickness in symptomatic internal rectal prolapses it can be repaired by restoring the rectum to its normal position by a rectopexy, often with mesh to support it. And sometimes, this also involves removal of part of the colon. And in case of multiple organ prolapse, these operations can and ideally should be performed in collaboration with urogynecology to also restore the anatomy of the uterus and vagina or bladder altogether.

Dr. Scott Steele: My goodness, there's a lot to unpack there and thank you for being so thorough. So truth or myth. Truth or myth for all people. For all people. Healthcare providers recommend 30-40 grams of dietary fiber per day to help maintain a healthy bowel.

Dr. Emanuela Alvarenga: Truth, with a caveat. It is always important to eat fiber in your diet, any form of fruits, vegetables, and grains, and the goal of fiber is to bulk this stool, and the fiber supplements such as Metamucil, Benefiber, and so it can be helpful. But for patients with constipation, fibers and pills or supplements, they may worsen the symptoms if the stool is already hard, so they may also worsen abdominal bloating, cramping, or gas. So if a fiber supplement does worsen your symptoms, you should switch to a stool softener instead in order to optimize your bowel regimen.

Dr. Scott Steele: So is this a chronic condition or can this be permanently corrected?

Dr. Emanuela Alvarenga: Well, it does not have to be a chronic illness. Certainly, a lifestyle change and home remedies like laxatives and enemas may be needed indefinitely, but they can offer real relief. And therapies such as biofeedback and psychotherapy require time and commitment to end results, but they can offer lasting improvements for motivated patients. It's very important to point out also that the surgery has uneven results and seems to be more successful when combined with other conservative management.

Dr. Scott Steele: So are there any advancements on the horizon when it comes to ODS?

Dr. Emanuela Alvarenga: There have been substantial advancements of ODS management from the surgical aspect in terms of optimization of repairs of pelvic floor prolapse, for example, by addressing the multi-organ prolapse at once as a unit. And through minimally invasive methods such as laparoscopy or robotic platforms, this approach allows for a very speedy recovery. And in our group, these patients are discharged home on the same day of the surgery, and this is a huge win for them. And as we learn more about pelvic floor and refine our techniques, I trust and I believe there will be even more advancements on the surgical end.

Dr. Scott Steele: So now it's time for our quick hitters, a chance to get to know our guests a little bit better. So first of all, what's your favorite food?

Dr. Emanuela Alvarenga: Fresh, plant-based food.

Dr. Scott Steele: Fantastic. What is your favorite sport, either to play or to watch?

Dr. Emanuela Alvarenga: To watch, swimming competitions. And to play, actually, I like dance.

Dr. Scott Steele: Fantastic. Any specific type of dance there?

Dr. Emanuela Alvarenga: Salsa forró, which is a very specific rhythm in Brazil.

Dr. Scott Steele: That's awesome. And so what was your favorite toy as a kid?

Dr. Emanuela Alvarenga: Oh. It wasn't a real toy. I used to make a doll with bottles of shampoo and I used to make them different styles, so I used to have fun with that.

Dr. Scott Steele: Absolutely. Fantastic. And so finally, what is a must-see place for our listeners to be able to go to, or maybe a place that you want to go to in the future or you've been?

Dr. Emanuela Alvarenga: Bora Bora is in my list and hopefully that's next.

Dr. Scott Steele: Fantastic. And so give us a final take-home message for our listeners about ODS.

Dr. Emanuela Alvarenga: Many symptoms can result from pelvic floor dysfunction with obstructive defecation. It's very important that the symptoms are evaluated by a medical professional. They can overlap with lots of other medical problems, so specific testing might be necessary. Overall initial management is lifestyle advice, laxatives, and fiber supplementation, and they can be very, very helpful. For functional dyssynergia, pelvic floor training with biofeedback and psychotherapy can be very effective for motivated compliant patients. For patients with full thickness rectal prolapse or asymptomatic rectoceles, they should undergo surgery. In the case of multi-organ prolapse, this should be addressed all together at once. These patients might still benefit from pelvic floor rehabilitation therapies afterwards and it's essential to manage the patient's expectations, and one way to accomplish this is ensuring that the patients understand the multifactorial nature of the ODS.

Dr. Scott Steele: Well, that's fantastic. And so to learn more about obstructive defecation syndrome or to schedule an appointment for treatment at the Cleveland Clinic Florida, please call 877.463.2010. That's 877.463.2010. You can also visit clevelandclinicflorida.org/digestive for more information. That's clevelandclinicflorida.org/digestive. Dr. Alvarenga, thanks so much for joining us here on Butts and Guts.

Dr. Emanuela Alvarenga: Oh, thank you for this opportunity, Dr. Steele.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.