Download PDF
Zentralbl Chir 2019; 144(04): 387-395
DOI: 10.1055/a-0938-6963
Übersicht
Georg Thieme Verlag KG Stuttgart · New York

Obstruktives Defäkationssyndrom: Ätiologie, Diagnostik und Therapieoptionen

Obstructed Defecation Syndrome: Aetiology, Diagnostic Assessment and Therapeutic Options
Oliver Schwandner
Abteilung für Proktologie, Krankenhaus Barmherzige Brüder, Regensburg, Deutschland
› Author Affiliations
Further Information

Publication History

Publication Date:
14 August 2019 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Das obstruktive Defäkationssyndrom (ODS) ist durch eine Stuhlentleerungsstörung charakterisiert, wobei morphologische von funktionellen Störungen differenziert werden können. Die Differenzialdiagnostik zum Reizdarmsyndrom und zur chronischen Obstipation ist nicht selten schwierig. Bei den meist weiblichen Patienten sind die rektale Intussuszeption und die ventrale Rektozele häufige morphologische Befunde. Neben Anamnese und proktologischer Basisdiagnostik kommt der MR-Defäkografie eine zentrale Bedeutung zu. Aufgrund des benignen Leidens sollte primär eine konservative Therapie erfolgen. Erst nach frustraner konservativer Therapie sollte bei Nachweis einer morphologischen Pathologie die Indikation zur chirurgischen Therapie erörtert werden, wobei transabdominelle (z. B. Resektionsrektopexie, Rektopexie) mit transanalen Verfahren (z. B. STARR-Operation) konkurrieren. Die adäquate Therapie bleibt wegen der multifaktoriellen Ätiologie und der vielfältigen klinischen Ausprägungsformen generell eine Herausforderung – dies gilt für konservative Therapieoptionen in gleicher Weise wie für chirurgische Therapiekonzepte.

Abstract

Obstructed defecation syndrome (ODS) is characterized by disturbed defecation, and morphological disorders can be differentiated from functional pathologies. Differential diagnosis from irritable bowel syndrome and slow transit constipation is frequently difficult. Most patients are female, and rectal intussusception and anterior rectocele are frequent morphological pathologies. In addition to patientsʼ history and basic proctological diagnostic testing, MR defecography plays a central role. As ODS is a benign condition, conservative treatment should be initiated primarily. After failure of conservative treatment and in terms of a morphological disorder, the indication for surgery should be discussed, whereas transabdominal procedures (e.g. resection rectopexy, rectopexy) and transanal procedures (e.g. STARR) are available. Adequate therapy remains a challenge due to multifactorial aetiology and the variety of symptoms – this affects both conservative and surgical treatment options.

Schlüsselwörter

obstruktives Defäkationssyndrom - Rektozele - Diagnostik - Defäkografie - Therapie - Rektopexie

Key words

obstructed defecation syndrome - rectocele - diagnostics - defecography - therapy - rectopexy
 

  • Literatur

  • 1 Schwandner O, Isbert C. Chronische Obstipation und Stuhlentleerungsstörung. In: Schwandner O. Hrsg. Proktologische Diagnostik. Berlin: Springer; 2016: 177-191
    CrossrefGoogle Scholar
  • 2 Schwandner O. Beckenbodeninsuffizienz aus proktologischer Sicht. In: Schwandner O. Hrsg. Proktologische Diagnostik. Berlin: Springer; 2016: 203-222
    CrossrefGoogle Scholar
  • 3 Schwandner O. Indikationen und chirurgische Therapieoptionen beim obstruktiven Defäkationssyndrom. Viszeralmedizin 2012; 28: 260-266
    PubMedGoogle Scholar
  • 4 Schwandner O. Rektozele: Symptome, Diagnostik und Therapiekonzepte aus koloproktologischer Sicht. Chirurg 2016; 87: 985-998
    CrossrefPubMedGoogle Scholar
  • 5 Schwandner O. Anorektaler Prolaps. In: Schwandner O. Hrsg. Proktologische Diagnostik. Berlin: Springer; 2016: 191-201
    CrossrefGoogle Scholar
  • 6 Herold A. Systematik der chronischen Obstipation. Coloproctology 2001; 23: 317-321
    CrossrefPubMedGoogle Scholar
  • 7 Kim M, Rosenbaum C, Schlegel N. et al. Obstructed defecation – an enteric neuropathy? An exploratory study of patient samples. Int J Colorectal Dis 2019; 34: 193-196 doi:10.1007/s00384-018-3160-1
    CrossrefPubMedGoogle Scholar
  • 8 Kim M, Isbert C. Anorektale Funktionsdiagnostik. Therapiealgorithmus für Obstruktion und Inkontinenz. Chirurg 2013; 84: 7-14
    CrossrefPubMedGoogle Scholar
  • 9 Piloni V, Bergamasco M, Melara G. et al. The clinical value of magnetic resonance defecography in males with obstructed defecation syndrome. Tech Coloproctol 2018; 22: 179-190
    CrossrefPubMedGoogle Scholar
  • 10 Suttor VP, Prott GM, Hansen RD. et al. Evidence for pelvic floor dyssynergia in patients with irritable bowel syndrome. Dis Colon Rectum 2010; 53: 156-160
    CrossrefPubMedGoogle Scholar
  • 11 Cavallero PM, Staller K, Savitt LR. et al. The contributions of internal intussusception, irritable bowel syndrome, and pelvic floor dyssynergia to obstructed defecation syndrome. Dis Colon Rectum 2019; 62: 56-62
    CrossrefPubMedGoogle Scholar
  • 12 Schwandner O, Pech O. Rektale Blutungen: einfach zu beherrschen oder doch eine Herausforderung in der Proktologie?. Chirurg 2019; DOI: 10.1007/s00104-019-0944-y.
    CrossrefPubMedGoogle Scholar
  • 13 Heymen S, Jones KR, Scarlett Y. et al. Biofeedback treatment of constipation. A critical review. Dis Colon Rectum 2003; 46: 1208-1217
    CrossrefPubMedGoogle Scholar
  • 14 Chiarioni G. Biofeedback treatment of chronic constipation: myths and misconceptions. Tech Coloproctol 2016; 20: 611-618
    CrossrefPubMedGoogle Scholar
  • 15 Juul T, Christensen P. Prospective evaluation of transanal irrigation for fecal incontinence and constipation. Tech Coloproctol 2017; 21: 363-371
    CrossrefPubMedGoogle Scholar
  • 16 Bocchini R, Chiarioni G, Corazziari E. et al. Pelvic floor rehabilitation for defecation disorders. Tech Coloproctol 2019; 23: 101-115
    CrossrefPubMedGoogle Scholar
  • 17 Schwandner O, Hillemanns P. Indikation, Technik und Ergebnisse der STARR-Operation. Chirurg 2016; 87: 909-917
    CrossrefPubMedGoogle Scholar
  • 18 Kienle P, Horisberger K. Transabdominelle Verfahren bei funktionellen Darmerkrankungen. Chirurg 2013; 84: 21-29
    CrossrefPubMedGoogle Scholar
  • 19 Isbert C, Germer CT. Transanale Verfahren bei funktionellen Darmerkrankungen. Chirurg 2013; 84: 30-38
    CrossrefPubMedGoogle Scholar
  • 20 Laubert T, Kleemann M, Roblick UJ. et al. Obstructive defecation syndrome: 19 years of experience with laparoscopic resection rectopexy. Tech Coloproctol 2013; 17: 307-314
    CrossrefPubMedGoogle Scholar
  • 21 DʼHoore A, Cadoni R, Penninckx F. Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg 2004; 91: 1500-1505
    CrossrefPubMedGoogle Scholar
  • 22 Samaranayake CB, Luo C, Plank AW. et al. Systematic review on ventral rectopexy for rectal prolapse and intussusception. Colorectal Dis 2010; 12: 504-512
    PubMedGoogle Scholar
  • 23 Emile SH, Elfeki HA, Youssef M. et al. Abdominal rectopexy for the treatment of internal rectal prolapse: a systematic review and meta-analysis. Colorectal Dis 2017; 19: O13-O24
    CrossrefPubMedGoogle Scholar
  • 24 Mäkelä-Kaikkonen J, Rautio T, Kairaluoma M. et al. Does ventral rectopexy improve pelvic floor function in the long-term?. Dis Colon Rectum 2018; 61: 230-238
    CrossrefPubMedGoogle Scholar
  • 25 Altomare DF, Picciarello A, Memeo R. et al. Pelvic floor function following ventral rectopexy versus STARR in the treatment of obstructed defecation. Tech Coloproctol 2018; 22: 289-294
    CrossrefPubMedGoogle Scholar
  • 26 Schwandner O, Stuto A, Jayne D. et al. Decision-making algorithm for the STARR procedure in obstructed defecation syndrome: position statement of the group of STARR Pioneers. Surg Innov 2008; 15: 105-109
    CrossrefPubMedGoogle Scholar
  • 27 Lehur PA, Stuto A, Fantoli M. et al. Outcomes of stapled transanal rectal resection vs. biofeedback for the treatment of outlet obstruction associated with rectal intussusception and rectocele: a multicenter, randomized controlled trial. Dis Colon Rectum 2008; 51: 1611-1618
    CrossrefPubMedGoogle Scholar
  • 28 Biviano I, Badiali D, Candeloro L. et al. Comparative outcome of stapled trans-anal rectal resection and macrogol in the treatment of defecation disorders. World J Gastroenterol 2011; 17: 4199-4205
    CrossrefPubMedGoogle Scholar
  • 29 Giarratano G, Toscana C, Toscana E. et al. Stapled transanal rectal resection for the treatment of rectocele associated with obstructed defecation syndrome: a large series of 262 consecutive patients. Tech Coloproctol 2019; 23: 231-237 doi:10.1007/s10151-019-01944-9
    CrossrefPubMedGoogle Scholar
  • 30 Madbouly KM, Abbas KS, Hussein AM. Disappointing long-term outcomes after stapled transanal rectal resection for obstructed defecation. World J Surg 2010; 34: 2191-2196
    CrossrefPubMedGoogle Scholar
  • 31 Picciariello A, Papagni V, Martines G. et al. Post-operative clinical, manometric, and defecographic findings in patients undergoing unsuccessful STARR operation for obstructed defecation. Int J Colorectal Dis 2019; 34: 837-842 doi:10.1007/s00384-019-03263-9
    CrossrefPubMedGoogle Scholar
  • 32 Naldini G. Serious unconventional complications of surgery with stapler for haemorrhoidal prolapse and obstructed defaecation because of rectocele and rectal intussusception. Colorectal Dis 2011; 13: 323-327
    CrossrefPubMedGoogle Scholar
  • 33 Boenicke L, Reibetanz J, Kim M. et al. Predictive factors for postoperative constipation and continence after stapled transanal rectal resection. Br J Surg 2012; 99: 416-422
    CrossrefPubMedGoogle Scholar
  • 34 Dvorkin LS, Knowles CH, Scott SM. et al. Rectal intussusception: characterization of symptomatology. Dis Colon Rectum 2005; 48: 824-831
    CrossrefPubMedGoogle Scholar
  • 35 Wijffels NA, Jones OM, Cunningham C. et al. What are the symptoms of internal rectal prolapse?. Colorectal Dis 2013; 15: 368-373
    CrossrefPubMedGoogle Scholar
  • 36 Pescatori M, Spyrou M, Pulvirenti dʼUrso A. A prospective evaluation of occult disorders in obstructed defecation using the “iceberg diagram”. Colorectal Dis 2006; 8: 785-789
    CrossrefPubMedGoogle Scholar