There's a new surgical solution to a vexing problem that affects millions of women. Some 16 percent of women in the United States suffer from chronic constipation, and patients who don't respond to modifications in diet and exercise, or to laxatives, are frequently diagnosed with a condition known as obstructed defecation syndrome.
ODS results when a weakening of the wall between the back of the vagina and the front of the rectum — a defect called a rectocele — allows the rectum to bulge into the vagina during a bowel movement. The problem is typically repaired by vaginal surgery. But surgeon Dr. Mark Parker of the Alabama Colon and Rectal Institute says there are drawbacks to that procedure: "There's not only a fair amount of discomfort, but the scarring on the back of the vaginal wall can cause possible sexual side effects such as dyspareunia, or painful intercourse."
A new procedure known as STARR (stapled transanal rectal resection) is a less-invasive approach that removes the bulging excess tissue through the rectum instead. Because no external incisions are required, STARR leaves no visible scars and can shorten recovery times. It's been available in Europe for years, but has only recently been approved in the United States after successful clinical trials.
Parker, who's one of only three colorectal surgeons in Alabama certified to perform the new procedure, says a typical ODS sufferer is a woman in her 40s or 50s who has had multiple childbirths or a hysterectomy. "The rectovaginal septum, the wall between the vagina and the rectum, involves two specialties — OB/GYNs and colorectal surgeons — and is a difficult area to repair," says Parker. "But in recent years our understanding of the pelvic floor has improved, and so has stapling technology in general."
According to Ethicon Endo-Surgery, common symptoms of ODS are prolonged bowel movements, prolonged straining, incomplete passage of the stool, and a general feeling of pressure or discomfort after defecation. Patients may have to insert fingers into the vagina or anus to help the stool pass. A number of diagnostic tests are used to determine ODS, including colonoscopy, electromyography (EMG), anal manometry, colonic marker studies, and dynamic defecography. Men may also develop rectoceles, according to the American Society of Colon and Rectal Surgeons, though the condition is uncommon.
The problem of chronic constipation is far from new. According to a report in the New England Journal of Medicine, the condition results in some 2.5 million doctor visits each year, some 92,000 hospitalizations, and laxative sales of several hundred million dollars. But obstructed defecation syndrome is a fairly new term, and many physicians are not yet familiar with it.
One study shows that 37 percent of women who meet the symptom criteria for constipation don't consider themselves constipated. ODS is also a condition that women don't tend to discuss with others, Parker says, and as a result it's not as well known as it should be: "In my experience, women are far more hesitant to discuss the subject than other common procedures such as a breast biopsy or gallbladder surgery, whether it's from embarrassment or other reasons." He hopes that's changing, though.
The United States STARR pilot study found that STARR reduces ODS symptoms and significantly improves the quality of life for patients. The benefits were sustained at a one-year follow-up. European researchers found that benefits were sustained after a 20-month evaluation, and that patients experienced minimal postoperative pain and resumed normal activity or employment in six to 15 days.
Parker says that four specific complaints from patients are an indication that their constipation may require more in-depth examination:
· Fewer than three bowel movements per week.
· The need to strain at least 25 percent of the time during bowel movements.
· A feeling of not being able to complete a bowel movement at least 25 percent of the time.
· Hard or lumpy stools at least 25 percent of the time.