Healing Hands Clinic is a unique and speciality clinic for constipation,piles, hernia & prevention of Lifetstyle diseases. Apart from its heart of the city location, expert consultation, state of the art technology and well qualified staff are few of its assets. It is the first clinic in the city to deliver facility of Defecography for constipation. Our focus, dedication and inner feeling of curing or treating the patients with care have given us many satisfied patients.

1. Obstructed Defecation Syndrome:
Diagnosis & Surgical Treatment
By
Dr Ashwin Porwal
Consultant Procto-Surgeon
Apollo Jehangir Hospital
Poona Hospital &
Inamdar Hospital

3. Obstructed Defecation Syndrome (ODS)
Constipation due to difficulty in passing stools once it
has reached rectum as a result of Recto rectal
Intussusceptions (Internal Rectal Prolapse) or
Rectocele
 ODS has been shown to be the result of an abnormal
function of the muscles involved in defecation or an
anatomical abnormality of the pelvic organs
 ODS is a complex and multifactorial condition which is often
referred to as an Iceberg Syndrome

4. Prevalence of Constipation
 Constipation prevalence in the general population is
estimated at around 5-15% .
 reports suggesting significantly higher levels in the
elderly, especially above the age of 65.
 reports of females being affected more then males,
male to female ratio of 1: 2.2.
 ODS is estimated to be prevalent in 7% of the adult
population and is judged to be the cause of one third of all
cases of constipation

5. NICE guidelines for STARR
Surgery for ODS
1)Failure of conservative treatment for ODS
2)Underlying structural abnormality like
Rectocele & Recto-Rectal Intussusceptions on MRI
Defecography
Efficacy of STARR in ODS
In multiple studies reviewed by NICE , It was observed that there was
significant improvement in pre operative constipation symptoms at a mean
follow up of 2 years. Post op Defecography also demonstrated correction of
Rectocele and intussusceptions in one study. Quality of life following STARR
was assessed in few studies , excellent or good outcome was reported by
70-80% of the patients.

6. Rectocele in females – A Rectovaginal Defect
Definition
• A rectocele is an out pouching of
the anterior rectal wall and
posterior vaginal wall into the
lumen of the vagina
Gradation
• high rectoceles  due to stretching or
disruption of the upper third of the vaginal
wall and uterosacral ligaments
• mid level rectoceles  most common and
are associated with loss of pelvic floor
support
• low-level rectoceles  can be caused by
obstetric trauma

7. Rectocele: Prevalence
Prevalence in young nulliparous women : 12%
• Source: Australia & NZ Journal of Obst. & Gynec. 2005 Oct;45(5):391-4
Prevalence in multifarious women
with uterus : 18.6 % without uterus : 18.3%
• Source: American Journal of Obst & Gynec
 Prevalence of Rectocele in male patients who have a history of chronic
constipation and are symptomatic for ODS is as high as 60% in my routine
clinical observation

8. Rectocele & ODS
Symptoms of Rectocele include:
– Pain or pressure in the vagina
– Pain during sexual intercourse
– Pain or pressure in the rectum
– Feeling of tissue bulging out of vagina
– Constipation: ODS (Obstructed Defecation Syndrome)
• Difficult passage of stool
• Needing to apply pressure on vagina to pass stool
• Feelings of incomplete stool passage

9. Diagnostic Approach for ODS
Before
patient sees
surgeon
• Colonoscopy to rule out tumors + IBD
• Conservative treatment with laxatives /enemas / diet failed
Patient sees
the surgeon
– Patient
Interview
•
•
•
•
Clinical
Examination
• Perinea Examination
• Proctoscopy resting / straining
• Urogenital Examination
Clinical
Evaluation
Patient history
Dr Longo’s Score (ODS Score) assessment
Incontinence / Urogenital assessment to rule out other complications
Quality of life / Patient motivation assessment
• Conventional Defecography / MRI Defecography
• Anal- manometry and Endo-anal ultrasound – only if incontinence or suspicion of
sphincter damage – otherwise not mandatory
• Colon transit – suspicion of slow bowel movement

10. Patients of ODS: Symptoms and Signs
•
•
•
•
•
•
•
•
•
•
Pain at defecation
Haemorrhoidal prolapse (!)
Extended time at the toilet
Perineal pain / discomfort when standing
Use of laxatives or enemas
Fecal Incontinence
Extreme straining to defecate
Feeling of incomplete evacuation
Fragmented defecation
Vaginal, Perineal or Rectal digitations

11. History Taking for Constipation
Obstructive
• Excessive Straining
• Poor response to Laxatives over
a period of time
• Either 2-3 visits/day or 2-3 visits
in a week to toilet
• Inadequate Defecation
• Feeling of stools obstructed in
Rectum
• Rectal and or Vaginal Digitations
for Evacuation
Functional / IBS
• Straining + • No feeling of stools obstructed
in rectum
• Usually responds to laxatives
• Inadequate Defecation +
• Multiple visits to toilet +
• Usually no history of digitation

12. Dr Longo’s ODS Score

13. Defecography
• Salient phases of Conventional / MRI
Defecography  Image captured
– During rest with filled anal bulb
– During maximum contraction of anal sphincter
and pelvic floor muscles
– During straining without evacuation
– During evacuation
– During rest when evacuation is completed

14. Case: Internal Rectal Prolapse & Rectocele
(Conventional Defecography)

15. Intussusception & Rectocele (1)

16. Intussusception & Rectocele (2)

17. Intussusception & Rectocele (3)

18. Intussusception & Rectocele (4)

19. MR Defecography

20. MRI Defecography Videos

24. ODS Cause Substantiated by
Defecography Findings
Rectal Intussusception  Internal Rectal
Prolapse
• closure of the anus by prolapse of the
rectum into the anal canal
Rectocele
• accumulation of stool in ventral protrusion
of the rectal anterior wall

25. Patient Inclusion Criteria for STARR
Surgery
Symptomatic  Dr Longo’s Score more than 15
• Evacuation by prolonged or repeated straining
• Frequent calls to defecate prior to or following evacuation
• Use of digital means to effect evacuation
• Laxative and or Enema use required to defecate
• Sense of incomplete evacuation
• Excessive time spent on the toilet
• Pelvic Pressure, Rectal discomfort, and Perinea pain
Radiological & Clinical Findings
• Recto rectal Intussusceptions
• Reconcile
Failure with medical management for 3-6 Months: By Means of Diet & Pelvic floor
physiotherapy

26. Patient Exclusion Criteria for Surgery
General Exclusion Criteria
•
•
•
•
•
Active anorectal infection
Concurrent severe anorectal pathology
Proctitis (Inflammatory Bowel Disease (IBD), Radiation)
Enterocele at rest (low, stable)
Chronic Diarrhea
Relative Exclusion Criteria
• Previous transanal surgery (Rectal anastomosis)
• Presence of foreign material adjacent to the rectum (mesh)
• Concurrent psychiatric disorder

27. Surgical Treatment for ODS –
Stapled Transanal Rectal Resection(STARR)

28. Treatment for ODS
STARR (Stapled Transanal Rectal Resection)
• Transanal resection of the lower rectum
• Full thickness resection of the anterior rectum wall by stapler after
longitudinal stitches at 10, 12 and 2 o‘clock positions. Similar approach
at the posterior wall with stitches at 4, 6 and 8 o‘clock positions.
• Suturing of the overlaping dog ears at 3 and 9 o‘clock positions.

29. STARR Videos

31. Complications
rectovaginal fistula
(0,3%)
bleeding (needing intervention)
(3,7%)
stenosis
(1,1%)
constant pain
(4,0%)
suture-insufficiency
(0,3%)
urgency
(9,4%)

32. Conclusion
STARR is a safe and effective procedure to treat
ODS (Obstructd Defecation Syndrome)
The surgery needs only 24hrs of hospitalisation &
patient can resume his routine work from 3rd day
The key to success is patient selection
Problem could be the cost involved

33. Treating ODS - A Patient Case Study!
History Taking
Diagnosis
STARR Surgery
After Care & Follow up
 Complain: Chronic Constipation since 3 years
 Patient Profile: 26 year old nulliparous female
 Patient History:
 Chronic constipation for over 3 years
 Symptoms: Need to go to the toilet 3-4 times in a day, Excessive
straining, Extended time in toilet (15 min. minimum), Digitations,
Fragmented defecation, Hard stool, Feeling of stool obstructed within
the rectum
 No relief with diet and pelvic floor physic for 6 months
 Diagnosis:
 P/R examination  Anterior Rectocele
 Dr Longo’s ODS Score  24
 MR Defecography findings  Moderate anterior Rectocele with severe
descent of the Rectum
 Advise  STARR Surgery

34. Patient Case Study continued...
History Taking
History Taking
Diagnosis
STARR Surgery
STARR Surgery
After Care & Follow up
Follow up
 Surgery  Stapled Transanal Rectal Resection (STARR)
 3hrs after surgery  the patient complained of mild pain in the anal region,
Was advised to discontinue NBM and take regular Maharashtrian dinner.
 12hrs after surgery  bearable pain, passed motion with slight discomfort
and observed a few drops of blood during defecation.
 Discharged 24 hrs after hospitalization and subsequently the patient
resumed work after 4 days.
 Follow up
 2 Weeks:
 Less difficulty to pass motion, No h/o straining, No h/o digitation,
Patient was on laxative but it helped her, Satisfactory defecation at least
70% of the time.
 1 Month:
 Motion was fine, evacuation was complete with lesser dose of
laxatives.

35. Patient Case Study continued...
History Taking
Diagnosis
STARR Surgery
After Care & Follow up
 Follow up
 3 Months:
 Patient was not on laxative but motion was sooth and without straining
 Findings of MR Defecography repeated after 3 months
 Normal with absence of Rectocle or any obstruction
 Patient was advised to stop all medication and also advised to take a high
fiber diet with plenty of water

36. My experience of 1st 100 STARRs…
Patient inclusion criteria
• Symptomatic with Dr Longo’s ODS score above 15
• Rectocele > 3cm & Recto rectal Intussusceptions
Patient distribution
• Male 43 , Female 57
• Age 37 < 40 yrs, 63 > 40 yrs
• Nulliparous Female 33%
• Rectocele  Males: 67 % Females: 90%
• Recto rectal Intussusceptions  Males: 87% Females: 53%
Follow up Schedule
• 2 weeks, 1 Month, 3 Months, 6 Months & 1 Year
Findings
• Average Dr Longo’s ODS score pre operatively = 26
• Average Dr Longo’s ODS score 12 months post operatively =8

37. ODS Score for 1st 100 STARR Cases
Mean Pre-op
Score
Mean 12 Months
Post-op Score
Defecation frequency
1
0
Straining Intensity
1
0
Extension of time in defecation
Sensation of incomplete
evacuation
2
1
3
1
Recto/perineal pain/discomfort
2
1
Activity reduction per week
4
2
Laxatives
5
3
Enemas
3
0
Digitation
5
0
Mean Dr Longo’s ODS Score
26
8
Symptoms

38. Thank You!