Internal Intussusception, Irritable Bowel Syndrome and Pelvic Floor Dyssynergia: Contributors to Obstructed Defecation Syndrome
Key findings
- In a prospective study of 317 patients with obstructed defecation syndrome, about one-third of those with internal intussusception also had irritable bowel syndrome (IBS) and about two-thirds also had pelvic floor dyssynergia
- Compared with rising grades of intussusception, dyssynergia and IBS had greater impacts on the severity of constipation
- Patients suspected of having obstructed defecation syndrome should first be screened for both IBS and dyssynergia and managed appropriately
Ventral rectopexy is used increasingly often as a surgical treatment for patients who have obstructed defecation syndrome (ODS) due to internal intussusception. Yet functional disorders, such as pelvic floor disorders, may contribute to ODS and be refractory to surgical treatment. In addition, irritable bowel syndrome (IBS) has been shown to be correlated with dyssynergia and subjective symptoms of ODS.
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Liliana G. Bordeianou, MD, MPH, chief of the Colorectal Surgery Program at Massachusetts General Hospital, Paul M. Cavallaro, MD, surgeon in the Colorectal Surgery Program, and colleagues recently found that patients referred for evaluation of constipation secondary to obstructed defecation syndrome often had dyssynergia or IBS. In Diseases of the Colon & Rectum, they recommend screening for and treating dyssynergia and IBS before considering surgery.
A Prospective Study
Between May 2007 and July 2016, 317 adults with symptoms of ODS constipation were evaluated at the Pelvic Floor Disorders Center at Mass General who underwent radiologic evaluation with defecography and completed the 16-item Varma Constipation Severity Instrument (CSI), which is designed to separate ODS from slow-transit constipation.
Defecography showed that 30% of the patients had no internal intussusception, 40% had intrarectal intussusception and 30% had intra-anal intussusception. Patients were referred for pelvic floor physiologic testing at the discretion of the evaluating colorectal surgeon.
Constipation Severity
Patients with intrarectal or intra-anal intussusception did not differ from those without intussusception in terms of constipation severity. That was true with regard to the overall CSI score and the score on every CSI subscale, including the obstructed defecation subscale.
Similarly, none of the other anatomic pelvic floor disorders that defecography identified (enteroceles, rectoceles and rectoceles with retained contrast) were associated with an increase in overall CSI score.
Dyssynergia
64% of patients with intra-rectal intussusception and 66% of those with intra-anal intussusception also had dyssynergia (paradoxical nonrelaxation/contraction of the puborectalis). Dyssynergia was linked to significant increases in the overall CSI score and the CSI obstructed defecation score.
IBS
35% of patients with intrarectal intussusception and 31% of those with intra-anal intussusception also had IBS with predominant constipation, meaning lumpy or hard stools more than 25% of the time. IBS was associated with significant increases in overall CSI score and the CSI obstructed defecation score. The increase in overall CSI score persisted when patients were stratified by intussusception grade.
Multivariate Regression Analysis
IBS and dyssynergia were each associated with a significant two-point increase in the CSI obstructive defecation score, whereas intra-rectal intussusception, intra-anal intussusception, enterocele and rectocele with retained contrast were not. Thus, IBS and dyssynergia, not intussusception, were the major contributors to constipation severity.
Advice to Surgeons
Surgeons treating patients with pelvic floor disorders should screen for and manage IBS and dyssynergia before suggesting surgical repair of intussusception. The following algorithm is proposed for evaluating constipation secondary to obstructed defecation.
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