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The Contributions of Internal Intussusception, Irritable Bowel Syndrome, and Pelvic Floor Dyssynergia to Obstructed Defecation Syndrome

Cavallaro, Paul M., M.D.1; Staller, Kyle, M.D., M.P. H.2; Savitt, Lieba R., N.P.-C., R.N.-C., M.S.N.1; Milch, Holly, N.P.1; Kennedy, Kevin, B.S.1; Weinstein, Milena M., M.D.3; Ricciardi, Rocco, M.D., M.P.H.1; Bordeianou, Liliana G., M.D., M.P.H.1

Diseases of the Colon & Rectum: January 2019 - Volume 62 - Issue 1 - p 56–62
doi: 10.1097/DCR.0000000000001250
Original Contributions: Pelvic Floor
Denotes Associated Video Abstract
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BACKGROUND: Recently, there has been a trend toward surgical management of internal intussusception despite an unclear correlation with constipation symptoms.

OBJECTIVE: This study characterizes constipation in patients with obstructed defecation syndrome and identifies whether internal intussusception or other diagnoses such as irritable bowel syndrome may be contributing to symptoms.

DESIGN: Patients evaluated for obstructed defecation at a pelvic floor disorder center were studied from a prospectively maintained database. With the use of defecography, patients were classified by Oxford Rectal Prolapse Grade. Coexisting disorders such as enterocele, rectocele, and dyssynergia were also identified. The presence of irritable bowel syndrome was defined using Rome IV criteria, and constipation severity was quantified with the Varma constipation severity instrument.

SETTINGS: This study was conducted at a tertiary care university medical center (Massachusetts General Hospital).

PATIENTS: The study included 317 consecutive patients with defecography imaging and a completed constipation severity instrument survey from May 2007 to July 2016.

MAIN OUTCOME MEASURES: The primary outcome measures were the Varma Constipation Severity Instrument overall score and obstructed defecation subscale score.

RESULTS: Of 317 patients evaluated, 95 (30.0%) had no internal intussusception, 126 (39.7%) had intra-rectal intussusception, and 96 (30.3%) had intra-anal intussusception. There was no association between rising grade of internal intussusception and either overall constipation score or obstructed defecation subscale score. Irritable bowel syndrome was associated with an increase in overall constipation score and obstructed defecation subscale score (40.5 ± 13.6 vs 36.0 ± 15.1, p = 0.007, and 22.3 ± 5.8 vs 20.0 ± 6.6, p < 0.001). Multivariate regression found irritable bowel syndrome and dyssynergia to be associated with a significant increase in obstructed defecation subscale scores.

LIMITATIONS: The study was limited because it was an observational study from a single center.

CONCLUSIONS: Patients referred for surgical management of obstructive defecation syndrome should be screened and treated for irritable bowel syndrome and dyssynergia before considering surgical intervention. See Video Abstract at http://links.lww.com/DCR/A782.

1 Colorectal Surgery Center, Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Boston, Massachusetts

2 Digestive Healthcare Center, Department of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts

3 Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, Massachusetts

Funding/Support: None reported.

Podium presentation at the meeting of The American Society of Colorectal Surgeons, Nashville, TN, May 19 to 23, 2018.

Financial Disclaimers: None reported.

Correspondence: Paul M. Cavallaro, M.D., 55 Fruit St, GRB-425, Boston, MA 02114. E-mail: pcavallaro@partners.org

© 2019 The American Society of Colon and Rectal Surgeons