The hollow organs that reside within the pelvis, the rectum (bowel), vagina and bladder lie in parallel to one another and are supported from below by a sling of muscle. Weakening of these pelvic floor muscles can lead to excessive decent or to bulging of these organs into one another on straining. This disruption in spatial orientation may lead to disordered bladder and bowel function.

Constipation

There are two broad categories of constipation, those in whom the bowel has a prolonged transit time reducing the frequency of toileting (slow transit constipation) and those where the bowel transit may be satisfactory but there is difficulty in expelling the stool (obstructive defecation). Laxative usage is common in both. The distinction is important since obstructive defecation may be due to disordered anatomy from a weakened pelvic floor which may be correctable through surgery.

What are the symptoms of obstructive defecation?

Those with obstructive defecation may describe excessive straining, prolonged periods of time on the toilet and a sensation of an incomplete bowel opening after toileting. Occasionally patients may even report resorting to using a finger to help expel the motion (digital evacuation).

What exactly causes the obstruction?

Any process that deforms the shape of the rectum on straining may hinder the expulsion of stool. Ballooning forward of the rectum in to the vagina is called a rectocele. If the intestines squash the rectum from above this is termed an enterocele. The rectum itself may be pushed downward toward the back passage. Initially the slippage may be hidden from the outside but still sufficient to get in the way of stool expulsion (rectal intussuseption). Ultimately the rectum may fall out of the back passage so that its inner lining is visible as a protruding red lump – this is called a rectal prolapse. Combinations of these deformities may occur together.

So how might the problem be diagnosed?

It is important to be sure that the large bowel above the pelvis is healthy and it is usual for your surgeon to arrange a telescope test initially. A full rectal prolapse can usually be diagnosed in the clinic. Other pelvic floor defects are usually defined using a special X ray called a defecating proctogram and possibly pressure studies of the back passage (see above).

What treatment options are there?

Once the problem has been accurately defined, treatment is tailored to restore normal anatomy with a view to improving function.

The STARR procedure (Stapled Trans-anal rectal resection)

Both our surgeons are fully trained in this new technique designed to straighten the rectum for those with obstructive defecation caused by a rectocele with or without downward slippage of the rectum. A stapling device introduced in to the back passage under an anaesthetic, simultaneously removes and rejoins segments of the front and then the back of the rectal wall. The straightened rectum is able to empty much more efficiently without the sensation of a blockage.

What if an enterocele is the cause of the problem?

An enterocele may be repaired through the vagina by our gynaecologist. If there is a combination of enterocele and rectal deformity, the enterocele is repaired first and a STARR operation after if symptoms are not significantly improved.

How is a rectal prolapse dealt with?

When the rectum protrudes through the anal canal, it either needs to be hitched up (a Delorme's procedure) or removed and rejoined (Altemeirs procedure). Both these procedures are performed from 'down below'. On occasion hitching the rectum from above as an abdominal operation may be preferred.

What if I have haemorrhoids?

These are blood vessels at the top of the anal canal which may bleed. They do not normally cause obstructive defecation. Again a telescope test of the bowel is usually undertaken to be sure the bleeding is not from higher up the bowel. Treatment thereafter depends on the size of the haemorrhoids. Smaller piles can be treated in the clinic by applying rubber bands. Larger haemorrhoids may need treatment with a staple gun similar to the STARR operation. This is much less painful than the more conventional operations of excising haemorrhoids. Our unit also performs the newer technique using a Doppler machine to guide a stitch to tie off the blood vessels feeding the piles, an operation that can be performed as a day case. Our surgeons will help you decide which treatment option is best for your particular need.

What if I have a problem with bowel control?

The inability to stop the bowel opening is termed faecal incontinence. Through interview, examination and simple investigation our surgeons should be able to isolate the cause of the problem. Often nothing more than treatment by our pelvic floor physiotherapists may resolve the problem. If the ring of anal muscle is torn, we may offer surgical repair. Often no injury is found and the muscle simply works poorly. This again may be treated by our pelvic floor physiotherapist or occasionally can be helped by a stimulating electrode placed in the very lower back. Again the treatment required will be tailored to your specific needs.