Evaluation and Management of Chronic Constipation (2024)

Alavi Karim M.D. M.P.H.;1 Thorsen, Amy J. M.D.2; Fang, Sandy H. M.D.3; Burgess, Pamela L. M.D.4; Trevisani, Gino M.D.5; Lightner, Amy L. M.D.6; Feingold, Daniel L. M.D.7; Paquette, Ian M. M.D.8; On behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons

Diseases of the Colon & Rectum 67:p 1244-1257, October 2024.

doi: 10.1097/DCR.0000000000003430

Appendix 1. Ovid Medline Search Strategy.pdf

CLINICAL PRACTICE GUIDELINES PDF

Author Information

1Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, Massachusetts

2Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota

3Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Sciences University, Portland, Oregon

4Colon and Rectal Surgery, M Health Fairview Southdale Hospital, Minneapolis, Minnesota

5Colon and Rectal Surgery, University of Vermont Medical Center, Burlington, Vermont

6Department of Surgery, Scripps Clinic Medical Group, La Jolla, California

7Division of Colon and Rectal Surgery, Department of Surgery, Rutgers University, New Brunswick, New Jersey

8Department of Surgery Section of Colon and Rectal Surgery, University of Cincinnati, Cincinnati, Ohio

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s website (www.dcrjournal.com).

Funding/Support: None reported.

Financial Disclosure: None reported.

Correspondence: Ian M. Paquette, M.D., Colon and Rectal Surgery, University of Cincinnati College of Medicine Surgery, 2123 Auburn Ave No. 524, Cincinnati, OH 45219. E-mail: ian.m.paquette@gmail.com

The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. Although not proscriptive, these guidelines provide information based on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for use by all practitioners, health care workers, and patients who desire information on the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician considering all the circumstances presented by the individual patient.

STATEMENT OF THE PROBLEM

Constipation is one of the most common GI disorders seen in ambulatory medicine clinics and is a common reason for referral to a colorectal surgeon.[1] Constipation has a worldwide prevalence of 15% and is more frequently diagnosed in North America and Europe compared with Asia, likely because of differences in diet, culture, and environment.[2] Risk factors for constipation include age greater than 65 years, female sex, inactivity, low socioeconomic status, low-fiber diet, and non-White race.[3]

Constipation is characterized by dysfunctional colonic motility and/or outlet dysfunction. Primary constipation can be classified into 3 subtypes: constipation with normal transit, constipation with delayed transit time, and outlet dysfunction constipation. Constipation with normal transit time and irritable bowel syndrome with associated constipation (IBS-C) comprise a group of functional bowel disorders with several overlapping symptoms. The distinguishing symptom of IBS-C is the presence of abdominal pain more than once per week that resolves with flatulence or a bowel movement.[4] Based on the Rome IV criteria, functional constipation (or normal transit constipation) is characterized by the presence of 2 or more of the following: fewer than 3 spontaneous defecations per week or for more than 25% of defecations: straining, lumpy, or hard stools; incomplete evacuation; sensation of anorectal blockage; or requiring manual maneuvers to assist with defecation. To meet these criteria, symptoms cannot be associated with diarrhea and must be present for 3 to 6 months before the diagnosis.[5] The cause of secondary constipation is multifactorial and can include factors such as diet, medications, metabolic or neurological disorders, and psychosocial issues. The complex cause and variable severity of constipation symptoms mandate an individualized approach to evaluation and treatment. Given the range of specialties that manage constipation, a collaborative approach is often warranted to achieve optimal patient outcomes.

METHODOLOGY

These guidelines were based on the previous ASCRS “Clinical Practice Guidelines for the Management of Constipation,” which was published in 2016.[6] A comprehensive search was conducted in MEDLINE (Ovid), Cochrane Library (Wiley), and Scopus (Elsevier) for English-language studies including human subjects published between January 1, 2014, and February 1, 2024. The search strategy was developed in conjunction with a health sciences research librarian, and it used a combination of subject headings and keywords to identify primary literature on constipation, including chronic or idiopathic constipation, obstructed defecation, slow transit, surgery, rectocele, rectal intussusception, pelvic dyssynergia, anismus, paradoxical puborectalis, megacolon, and megarectum. Retrieved publications were limited to the English language and adult patients (see Appendix 1 at http://links.lww.com/DCR/C363 for the full search strategy). The initial search generated 4195 eligible studies, and after removing 1315 duplicates, 2880 studies were screened for initial inclusion. Abstracts were screened for relevance (details included in Fig. 1), leaving 332 studies that underwent full-text review by 5 coauthors, with all conflicts resolved by the first author. After a full-text review, 198 studies were excluded; 134 studies were included in the final article (Fig. 1). Abstract and full-text screening was performed using Covidence systematic review software.[7]

Preferred Reporting for Systematic Reviews and Meta-analyses literature search flow chart of studies on the management of constipation.

CERTAINTY OF EVIDENCE

The final grade of recommendation and level of evidence for each statement were determined using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system. The certainty of evidence reflects the extent of our confidence in the estimates of effect. Evidence from randomized controlled trials (RCTs) start with high certainty, and evidence derived from observational studies start with low certainty. For each outcome, the evidence is graded as high, moderate, low, or very low (Table 1). The evidence can be rated down for risk of bias, inconsistency, indirectness, imprecision, and publication bias. The certainty of evidence originating from observational studies can be rated up when there is a large magnitude of effect or dose–response relationship. As per GRADE methodology, recommendations are labeled as “strong” or “conditional.” Current recommendations are stated in Table 2. When agreement regarding the evidence base or treatment guideline was incomplete, the consensus from the committee chair, vice chair, and 2 assigned reviewers determined the outcome. Recommendations formulated by the subcommittee were reviewed by the entire Clinical Practice Guidelines Committee. The submission was then approved by the ASCRS Executive Council and peer-reviewed in Diseases of the Colon & Rectum. In general, each ASCRS Clinical Practice Guideline is updated approximately every 5 years. No funding was received to prepare this guideline, and the authors have declared no competing interests related to this material. This guideline conforms to the Appraisal of Guidelines for Research and Evaluation checklist.

Interpretation of strong and conditional recommendations using the GRADE approach
Summary and strength of GRADE recommendations

Initial Evaluation and Treatment of Constipation

1. A directed history and physical examination should be performed in patients presenting with constipation. Strength of recommendation: strong based on low-quality evidence.

Although constipation in and of itself is a benign condition, a history and physical examination can help ensure that a serious or even life-threatening disease is not the underlying cause of symptoms related to constipation. Patients with constipation who also report rectal bleeding, change in caliber of stools, blood in the stool, weight loss, anemia, or a family history of colorectal cancer should be evaluated endoscopically for an endoluminal neoplastic process.[1],[8] A directed history may elucidate modifiable behavioral factors, such as diet, dehydration, or immobility, as well as medications that may be contributing to constipation.[1] Opioids, antidepressants, anticholinergics, calcium channel blockers, and calcium supplements are commonly associated with constipation and may need to be stopped or adjusted for symptomatic relief. Patients may also have an associated or undiagnosed psychiatric, neurological, or endocrine disorder that may require treatment to help address constipation symptoms.[9] Patients should be questioned regarding coexisting pelvic floor conditions, such as dyspareunia, urinary symptoms, and any obstetric history, including number of pregnancies, history of hysterectomy, injuries, and repairs.[10] Consideration should be given for inquiring about a history of sexual assault or the presence of an eating disorder in both male and female patients.[11] Finally, a careful assessment of symptoms and frequency and consistency of bowel movements (BMs) may help distinguish among constipation subtypes. Patients with infrequent, hard stools may be more likely to have colonic inertia, whereas those with incomplete evacuation and straining may be more likely to have pelvic floor dysfunction, and the presence of abdominal pain may indicate IBS. However, the history alone may be inadequate to clearly establish a diagnosis because many patients will have symptoms associated with more than 1 subtype.

The physical examination is directed at the abdominal and anorectal components. Generally, the abdomen is nontender but may be remarkable for distention or discomfort on palpation. Special attention should be paid to the presence of palpable abdominal masses, which may contribute to constipation because of extrinsic compression. External anorectal inspection should include specific attention to the presence of distorted anatomy or a bulky lesion, such as a neoplasm. Digital rectal examination can reveal the presence of anal hypertonia, paradoxical puborectalis contraction, rectocele, anorectal mass, stricture, or fecal impaction. A Valsalva maneuver may help determine the degree of pelvic descent or the presence of puborectalis dysfunction. Anoscopy or rigid proctoscopy may also be helpful to evaluate internal hemorrhoids, proctitis, or masses. Any causes for constipation identified during the history and physical should be evaluated and alternative causes ruled out.

The diagnostic workup for patients with constipation should address other potential causes, such as colorectal cancer or endocrine disorders. Laboratory testing can identify hypothyroidism, hyperparathyroidism, or diabetes mellitus but is nonspecific for constipation.[12] Imaging studies such as CT scans can demonstrate colonic dilation or fecal loading but are unlikely to demonstrate an anatomic abnormality or obstruction unless patients report symptoms that are suspicious of these findings.[12]

A meta-analysis of 8 cross-sectional studies investigating constipation as an indication for colonoscopy found that constipation alone, as a presenting symptom, was not associated with an increased risk of colorectal cancer.[13] However, a retrospective study of 985 patients in South Africa who underwent colonoscopy as part of their evaluation for constipation reported a polyp detection rate of 9.7%, and 9 patients (6.3%) were diagnosed with colorectal cancer, consistent with prior studies.[14] In general, a colonoscopy should be recommended if patients meet guideline criteria for general screening or if patients present with concerning symptoms, such as hematochezia, weight loss, or change in bowel habits; have a strong family history of colorectal cancer; or have anemia and warrant further investigation.[1],[15]

2. Objective measures assessing the nature, severity, and impact of constipation on quality of life can be useful when evaluating patients with constipation. Strength of recommendation: conditional recommendation based on low-quality evidence.

Objective measures that assess the severity of constipation and its impact on quality of life may help direct the course of treatment and whether to pursue further diagnostic studies.[16] Although the Rome criteria are often used to identify constipation and its subtypes, these do not assess disease severity.[17],[18],[19],[20] Several instruments have been developed to assess constipation specifically. These include the Constipation Assessment Scale,[21] the Constipation Scoring System,[8],[22] the Patient Assessment of Constipation Symptom Questionnaire,[23],[24] the Knowles-Eccersley-Scott Symptom Score,[25] the Garrigues Questionnaire,[26] the Chinese Constipation Questionnaire,[27] and the Constipation Severity Instrument.[28] Other available instruments assess comprehensive bowel function, including fecal incontinence, or address only 1 aspect of constipation, such as obstructed defecation. The primary aim of these instruments is to develop a consistent means of categorizing the baseline severity of the disease and to follow the response to treatment over time. The Pelvic Floor Disorders Consortium, composed of colorectal surgeons, urologists, urogynecologists, pelvic floor therapists, and gastroenterologists, recommended using the Patient Assessment of Constipation Symptom Questionnaire and the Constipation Severity Instrument when assessing patients presenting with constipation.[29]

3. The initial management of patients with symptomatic constipation involves dietary modifications and ensuring adequate fluid intake and fiber supplementation. Strength of recommendation: strong based on low-quality evidence.

Dietary modification and increasing water and fiber consumption are considered firstline treatments in the management of constipation and are typically recommended before investigations of pelvic floor function and colonic motility are performed.[30],[31],[32] Fortifying a diet by increasing the intake of food items high in fiber offers a strategy that is considered a gentler alternative to using laxatives and enemas.[33],[34],[35],[36],[37] A randomized trial of 72 patients reported that ingesting a combination of soluble and insoluble fiber resulted in similar increased bowel motility but was better tolerated than using psyllium alone.[38] Daily dietary fiber supplementation with oat bran has been shown to allow discontinuation of laxatives in 59% to 80% of elderly patients with chronic idiopathic constipation and is well tolerated.[34] Similarly, a moderate increase in dietary fiber intake increases bowel frequency and fecal bulk and has been shown to be a safe and convenient alternative to laxatives in patients with chronic idiopathic constipation, even in the setting of pelvic outlet obstruction.[33],[35],[39],[40] However, 80% of patients with slow colonic transit and 63% of patients with constipation because of outlet obstruction may not respond adequately to increased dietary fiber, whereas 85% of patients without an underlying pathological finding may see symptomatic improvement.[41] A systematic review of the efficacy of soluble and insoluble fiber supplementation in the management of chronic idiopathic constipation identified 6 RCTs comparing fiber with placebo or no therapy in adult patients with chronic idiopathic constipation.[42] A formal meta-analysis was not undertaken in this study because of concerns related to methodology issues across the studies. Compared with placebo, soluble fiber led to improvements in global constipation symptoms (86.5% vs 47.4%, p < 0.001), straining (55.6% vs 28.6%, p = 0.003), pain on defecation, stool consistency, and mean number of stools per week (3.8 stools per week after therapy compared with 2.9 stools per week at baseline), as well as a reduction in the number of days between stools. A meta-analysis reported that fiber supplementation was beneficial in patients with mild to moderate chronic constipation and IBS-C. The majority of the studies included in this analysis were underpowered, with less than 50 patients per arm, and included predominantly elderly and female patients, and there was variability in the type and duration of fiber administered among the studies.[43] A RCT of female patients (n = 54) randomly assigned to psyllium husk or placebo for 4 weeks reported improvement in straining (55.2% vs 8.0% p < 0.001), less than 3 BMs per week (86.2% vs 20%, p < 0.001), stool consistency (62.1% vs 32%, p = 0.027), and pain with BMs (58.6% vs 28.0%, p = 0.024), and less feeling of incomplete defecation (65.5% vs 16.0%, p < 0.001) related to fiber use. Interestingly, this study also reported a significant change in gut microbiota in samples taken after 4 weeks of fiber therapy; in the fiber supplementation group, the gut microbiota was consistent with patients without constipation.[44]

4. Osmotic laxatives are an appropriate firstline medical therapy to manage chronic constipation. Stimulant laxatives, such as bisacodyl, can be considered for rescue therapy or as a second-line therapy, if needed. Strength of recommendation: strong based on moderate-quality evidence.

Osmotic agents used in the treatment of constipation include polyethylene glycol (PEG)–based solutions and magnesium salt–based products. Osmotic laxatives are generally preferred over stimulants, such as senna or bisacodyl, given the short-term and long-term efficacy and safety with PEG-based treatment.[15],[45] A meta-analysis of 10 RCTs comparing PEG with lactulose demonstrated the superiority of PEG in terms of improving stool frequency and consistency, relieving abdominal pain, and reducing the use of other laxatives.[46] Magnesium salt laxatives such as magnesium sulfate also have been shown to improve stool frequency and consistency compared with placebo[47] and have safety profiles comparable to PEG[48],[49] solutions.

The stimulants sodium picosulfate and bisacodyl are prodrugs that are hydrolyzed by colonic bacteria and intestinal and colonic brush border enzymes, respectively, into the active metabolite (bis-(p-hydroxyphenyl)-pyridyl-2-methane), which has antiabsorptive, secretory, and prokinetic effects. A meta-analysis evaluating drug therapies for chronic idiopathic constipation demonstrated superior efficacy for sodium picosulfate and bisacodyl at achieving complete spontaneous BMs at 4 weeks compared to prescription motility agents and secretagogues; the most frequent side effect was abdominal pain. The prokinetic agent prucalopride appeared to be superior at 12 weeks.[50] Studies with longer treatment duration are necessary to establish the efficacy and safety of these agents as maintenance therapy for patients with chronic idiopathic constipation. There is a lack of RCTs documenting the safety and efficacy of anthraquinone stimulant laxatives, which include the popular over-the-counter ingredients senna, cascara, and aloe, in treating chronic constipation.[51]

Treatment of Defecatory Disorders

5. Patients who fail to improve with dietary changes, fiber therapy, and osmotic laxatives should be evaluated for outlet dysfunction. Anorectal physiology testing or dynamic imaging by fluoroscopic defecography, MRI defecography, or dynamic ultrasound may help identify functional or structural causes related to an evacuation disorder. Strength of recommendation: conditional based on low-quality evidence.

Evacuation disorder or outlet dysfunction are accepted terms used to describe a patient’s inability to satisfactorily expel stool. Evacuation disorders may be caused by structural and/or functional phenomena[52] and are the most common cause of medically refractory chronic constipation; hence, further evaluation is indicated after failure of first-line therapies.[53]

The balloon expulsion test (BET) is a widely used, easily performed direct test of evacuation. BET assesses the time a patient requires to expel a 50 mL water-filled balloon; a prolonged or failed expulsion suggests impaired evacuation. Although BET has good test reproducibility, is highly specific, and can predict response to biofeedback therapy, the test has a low sensitivity of 50% and does not delineate the underlying cause of an evacuation disorder.[12],[54],[55]

Anorectal manometry and sensation testing are indirect tests that can clarify functional causes of defecation disorders. Rectal and anal pressures are recorded during rest and with the squeeze and push maneuvers. High-resolution anal manometry allows for both quantitative and qualitative functional assessment with the aid of color plots. Balloon sensation testing evaluates the rectoanal inhibitory reflex, which is absent in Hirschsprung disease, as well as rectal hypersensitivity or hyposensitivity. These data, along with the BET, are used by the London protocol classification of defecatory dysfunction: 1) disorders of the rectoanal inhibitory reflex; 2) disorders of anal tone and contractility; 3) disorders of rectoanal coordination; and 4) disorders of rectal sensation. The London protocol classification was developed to standardize the language and testing protocol in the evaluation of patients with anorectal dysfunction.[56]

Defecography, which is the only direct test of evacuation, evaluates anatomical and functional causes of defecation disorders.[52] Using fluoroscopy or MRI, contrast paste is placed into the rectum as a stool surrogate, and images are acquired as the patient evacuates the contrast. Physical barriers to expulsion, such as rectocele, enterocele, or intussusception, can be illustrated, as well as the coordination of the pelvic floor musculature during evacuation.[52],[57] A systematic review of 63 studies providing data on outcomes of 7519 barium defecographies and 668 MR defecographies in patients with chronic constipation demonstrated pathological high-grade (Oxford III and IV) intussusception in 23.7% of patients and large (>4 cm) rectoceles in 15.9% of patients. Enterocele descent was observed in 16.8% and perineal descent was observed in 44.4% of patients.[52] Although MRI, performed in the supine position, permits excellent assessment of all pelvic floor compartments and the surrounding musculature,[58] fluoroscopic defecography, performed in the seated position, is considered the evacuation examination with the most construct validity.[55] Dynamic ultrasound, including both transperineal and echodefecography (transrectal technique with rectal gel contrast), can identify paradoxical pelvic floor contraction with Valsalva as well as prolapse of pelvic floor structures, but its use is limited by operator availability and expertise.[59],[60]

6. Colonic motility and transit should be measured before surgical intervention is considered. Strength of recommendation: strong based on low-quality evidence.

Evaluating colonic transit can elucidate the underlying cause of constipation. The transit time of radiopaque markers through the colon remains the most common motility testing modality[61] given the wide availability, low cost, and ease of use.[12],[62],[63],[64],[65] Although previous studies suggested that the distribution of markers in the rectosigmoid colon is suggestive of pelvic floor dyssynergia, a multicenter study suggested the contrary and recommended pelvic floor assessment with digital rectal examination and BET to definitively confirm pelvic floor dyssynergia.[66]

Other techniques to evaluate colonic transit include radionuclide scintigraphy and the wireless pH-pressure capsule. These studies correlate well with the transit of radiopaque markers in the evaluation of colonic transit[67],[68] and appear to be most useful when additional information on gastric emptying or small-bowel transit is needed.[1] An advantage of scintigraphy over radiopaque markers is that scintigraphy requires avoiding motility agents for only 24 to 48 hours compared with 5 to 7 days for radiopaque marker studies.[64] Colonic manometry is offered in only a few centers and is more widely used in the evaluation of constipation in pediatric patients.

7. Biofeedback therapy is considered a firstline treatment for patients with symptomatic pelvic floor dyssynergia. Strength of recommendation: strong based on moderate-quality evidence.

Biofeedback is a firstline treatment for dysfunctional neuromuscular rectoanal coordination of the pelvic floor and can improve rectal sensitivity and compliance. After completing initial training, periodic reinforcement is needed to sustain the efficacy of biofeedback over time. The success of pelvic floor physical therapy relies on the motivation and participation of the patient in an individualized biofeedback plan tailored to a patient’s needs.[69] A systematic review of 7 RCTs including 413 patients demonstrated that electromyography biofeedback was superior to non-electromyography biofeedback at improving pelvic floor dysfunction (OR 6.74; 95% CI, 2.91–15.58; p < 0.001).[70] A systematic review reported that dyssynergic defecation is underrecognized and that biofeedback is the most efficacious and safe treatment available for this condition.[71] A Cochrane Review that included 17 randomized trials with 911 patients demonstrated that biofeedback was successful in 80% of patients (43/54) with pelvic floor dysfunction compared to only a 22% success rate in patients treated with laxatives and dietary and lifestyle modifications (relative risk 3.65; 95% CI, 2.17–6.13). There were mixed results comparing biofeedback to surgical procedures such as partial division of the puborectalis and stapled transanal rectal resection (STARR), as well as to botulinum toxin (BTX) type A (BTX-A).[72] The authors cautioned that most of the studies were limited because of small sample sizes, variability in biofeedback treatment techniques, and inconsistencies in the definition of pelvic dyssynergia. A retrospective study of 116 consecutive patients evaluated the short-term outcomes of biofeedback combined with diet modifications in patients with obstructive defecation secondary to anismus and reported that 59% of patients had a satisfactory response (decrease in constipation score of more than 50%).[73] The coexistence of IBS does not appear to impact the success rate of biofeedback for patients with constipation.[74]

8. Injecting BTX into the puborectalis and external sphincter muscle may be considered in patients with outlet dysfunction constipation related to nonrelaxing puborectalis muscle. Strength of recommendation: conditional based on low-quality evidence.

Injecting BTX into a nonrelaxing puborectalis has shown variable success in improving symptoms of obstructed defecation syndrome (ODS) with a nonrelaxing puborectalis muscle. The symptomatic relief is typically temporary, with a decrease in efficacy within 3 months postinjection.[71] In an observational cohort study, 31 selected patients with nonrelaxing puborectalis muscles who were unresponsive to biofeedback underwent an injection of 100 units of BTX-A into the puborectalis and external sphincter muscles with subsequent biofeedback training 2 weeks after BTX-A injection. Twenty-three patients (74.2%) who had failed the BET before the BTX-A injection were able to successfully expel the balloon after the BTX-A injection. The constipation symptom questionnaire showed an improvement from 14.3 ± 2.49 to 6.4 ± 3.20. The addition of biofeedback training after BTX-A injection presumably allowed for the durability of results. This study was limited by its small sample size, selection bias, and overall study design.[75] A systematic review of 11 studies, including 3 RCTs and involving 248 patients evaluating the role of BTX-A injection (transanal approach with varied doses) as a treatment option for pelvic floor dyssynergia, found that symptomatic improvement ranged between 29.2% and 100%.[76]

9. Patients with significant outlet dysfunction from a rectocele may be considered for surgical repair after addressing any concomitant functional causes, such as nonrelaxing puborectalis muscle. Strength of recommendation: conditional based on moderate-quality evidence.

Thirty to seventy percent of patients with rectoceles report symptoms of obstructed defecation, including difficulty evacuating stool from the rectum, sensing a blockage, increased straining on defecation, fecal incontinence, and the need for vaginal digitation (ie, splinting) to evacuate bowel contents.[77],[78],[79] Imaging, such as defecography, may demonstrate that the rectocele does not spontaneously empty. In general, surgical repair should be considered only after addressing coexisting functional causes of ODS, such as pelvic organ prolapse (enterocele or sigmoidocele) and pelvic floor dysfunction.[77],[78],[80] It is important to recognize that many patients will be found to have incidental rectoceles during workup. The surgeon needs to use their experience to decide whether a repair is indicated on the basis of the previously listed factors.

Several approaches for rectocele repair have been described, including transanal, transvaginal, transperineal, and abdominal, with or without the interposition of mesh.[77],[78],[79],[81],[82],[83],[84],[85],[86],[87],[88],[89],[90],[91],[92],[93] There is little evidence to guide the decision of which technique to choose. Studies on the best surgical approach for rectocele are limited by small sample size, selection bias, short follow-up intervals, generalizability, and a lack of a unified definition for success. In general, success rates are variable and range from 50% to 100%.[94]

A RCT evaluated the outcomes of transperineal repair (TPR; n = 32) versus transvaginal repair (TVR; n = 32) of rectoceles in 64 patients with ODS. The TVR cohort had a shorter length of hospital stay (2.1 TVR vs 2.4 TPR, p = 0.03), a greater decrease in constipation score (6.4 ± 1.4 TPR vs 4.9 ± 1.3 TVR at 6 months, p < 0.0001; 7.2 ± 1.4 TPR vs 5.4 ± 1.6 TVR at 12 months, p < 0.0001), and a significant improvement in sexual-related quality of life at 6 and 12 months after surgery.[77] A systematic review including RCTs and prospective and retrospective comparative and single-group studies compared the transvaginal approach to the transanal approach and found the transvaginal approach was associated with greater improvement in anatomic outcomes and obstructive defecation symptoms and had a lower chance of rectal injury but had a higher incidence of dyspareunia.[95]

A systematic review evaluating the long-term outcomes of patients who underwent transperineal versus transanal rectocele repairs concluded that transperineal rectocele repair was associated with better symptomatic improvement in fecal incontinence and constipation and had complication rates similar to the transanal rectocele repairs.[93] Transvaginal and transperineal approaches may be augmented with synthetic or biologic mesh, albeit at an increased risk for mesh erosion, infection, migration, and pain. In fact, the Food and Drug Administration has identified serious safety and efficacy concerns over the use of mesh for the TVR of rectocele.

10. STARR is not recommended for the repair of a rectocele or internal rectal intussusception because of the high complication rates associated with this procedure. Strength of recommendation: strong based on moderate-quality evidence.

A systematic review examining postoperative outcomes of STARR performed for rectocele or rectal intussusception was notable for significant postoperative morbidity, including bleeding, infection, pain, fecal urgency, and incontinence.[96] A prospective observational cohort study evaluated 262 women with rectoceles who underwent STARR for ODS and reported that 23% experienced postoperative complications, including rectovaginal fistula, rectal diverticulum, total rectal obliteration, anastomotic leak, recurrence of rectocele, staple line bleeding, and urinary retention and urgency.[82] A retrospective cohort study of 450 patients who underwent STARR for ODS reported postoperative urinary retention (7.8%), rectal bleeding (2.9%), pelvic hematoma (1.1%), pelvic sepsis (1.3%), fecal urgency (27.8%), and staple line dehiscence (4.2%). The relatively high rate of complications was attributed to surgeons’ early learning curve.[97] Other studies have reported similar complication rates after STARR ranging between 10% and 78%.[80],[90],[92],[98],[99],[100],[101],[102],[103],[104],[105],[106],[107]

11. Repair of rectal intussusception may be considered in patients with severe obstructed defecation in whom nonoperative treatments were unsuccessful. Strength of recommendation: conditional based on low-quality evidence.

During evacuation, rectal intussusception or occult rectal prolapse is a telescoping of the proximal rectal wall into the distal rectum. Several approaches to treat outlet obstruction attributed to rectal intussusception have been described, including rectopexy, Delorme, STARR, and ventral mesh rectopexy. Although surgery may restore normal rectal anatomy, patients may not see improvement in function or may even experience worse function after surgery.[108],[109] In general, studies regarding the operative management of intussusception and ODS are limited by their small sample size and their lack of direct comparisons between different procedures and long-term functional outcomes data.

The Delorme procedure is a mucosal proctectomy that excises the redundant mucosa proximal to the dentate and plicates the underlying muscularis. A single-institution experience of 100 patients who underwent a Delorme procedure for internal intussusception and ODS reported improved Cleveland Clinic Constipation Scores and ODS scores at 6 months compared to baseline (18.9 to 5 and 18.5 to 5, respectively; p < 0.0001).[110] The recurrence rate was 6%, with an excellent overall safety profile consistent with previous studies.[111]

Early studies suggested that ventral rectopexy, when performed for the treatment of rectal intussusception, is associated with improvement in constipation in 80% to 95% of patients with minimal new-onset constipation and a 5% recurrence rate.[112],[113] In a retrospective series of 40 patients who underwent ventral mesh rectopexy without sigmoid resection in the setting of rectal intussusception with a mean follow-up of 38 months, 65% of patients reported being “cured” on a self-assessment questionnaire and another 33% reported being “improved,” and most patients reported significant improvement in symptoms of fecal incontinence.[113] Another retrospective study of 51 patients assessed the long-term functional outcomes and quality of life after ventral mesh rectopexy for rectoanal intussusception and/or rectocele at a median follow-up of 60 months. There were no mesh-related complications, and constipation and fecal incontinence scores improved after 1 year and remained significantly reduced at 7 years.[89]

12. Patients with isolated refractory colonic slow-transit constipation may benefit from total abdominal colectomy with ileorectal anastomosis. Strength of recommendation: conditional based on low-quality evidence.

Although segmental colectomy for the treatment of slow-transit constipation can have a failure rate as high as 100%,[114] total abdominal colectomy with ileorectal anastomosis (TAC-IRA) is associated with clinical improvement in 50% to 100% of patients.[115],[116],[117] Morbidity after TAC-IRA may include anastomotic leak, bowel obstruction, and prolonged postoperative ileus.[115],[117],[118],[119] Although constipation generally improves after TAC-IRA for slow-transit constipation, patients may experience diarrhea, abdominal pain, fecal incontinence, or recurrent constipation. In a retrospective series of 42 patients with slow-transit constipation who underwent TAC-IRA with a 15-year follow-up, 50% of patients had less than 4 BMs per day (mostly Bristol stool 6), and 21% experienced severe incontinence. Overall patient satisfaction was high; however, 8 patients (19%) eventually underwent a permanent ileostomy.[120] Other symptoms experienced by patients after TAC-IRA included abdominal pain, bloating, need for BM assistance, incontinence to gas or liquid stool, and lower quality-of-life score (Medical Outcomes Study Short Form-36) compared with the general population.[121] A survey of 75 patients after TAC-IRA reported diarrhea in 46% of patients and lower GI quality-of-life scores associated with abdominal pain, diarrhea, and incontinence. Regardless of these outcomes, more than 90% of patients reported that they would undergo TAC-IRA again to treat their constipation.[122]

An alternative operation for the treatment of slow-transit constipation has been described. The Jinling procedure is a subtotal colectomy with side-to-side cecorectal anastomosis. This procedure can theoretically relieve slow-transit constipation with potentially less risk of diarrhea because of the preservation of the ileocecal valve. In a retrospective review of 117 patients who underwent the Jinling procedure, there was a significant reduction in the Cleveland Clinic Florida constipation scores observed at 1 month that was maintained at 48 months, as well as significant improvements in postoperative GI quality of life and high satisfaction rates, but there was no direct comparison to TAC-IRA.[123] Similarly, retrospective data on this procedure appear to show good immediate postoperative outcomes, good postoperative function with a mean of 4.8 ± 7.5 BMs daily, and improved satisfaction, with 78% of patients stating that they would undergo this surgical procedure again.[124],[125],[126],[127],[128] A retrospective comparison of cecorectal anastomosis versus ileosigmoid anastomosis demonstrated that cecorectal anastomosis was more often associated with persistent constipation and lower patient satisfaction (73% vs 93%).[129] The efficacy of these procedures compared with TAC-IRA remains unclear. Studies have failed to demonstrate significant differences in the median number of BMs per day, quality of life, or incidence of postoperative complications.[130],[131]

13. Fecal diversion may be considered in patients with intractable constipation refractory to other treatment options. Strength of recommendation: conditional based on low-quality evidence.

Patients who have failed other available treatment options may be considered for a permanent ostomy as a last resort. The majority of available evidence has described the use of an ileostomy in this setting.[132],[133],[134] A retrospective analysis of 24 patients with constipation reported that an ileostomy was successful in alleviating constipation in 96% of patients.[133] Successful relief of constipation must be weighed against the risk of chronic complications, such as dehydration, parastomal herniation, and stomal retraction. Another series of 38 patients with stoma-related complications were followed and asked whether they regretted the intervention. With a median follow-up of 34 months (range, 7–74), 49% of patients had no regret and 27% of patients had minimal regret about the decision for a stoma. Fifty-five percent of patients had additional procedures related to the stoma, some undergoing up to 5 operations.[135]

There is less evidence to support the use of diverting colostomy in the setting of constipation. One series of 8 patients with refractory constipation with chronic colon or rectal dilation treated with diverting sigmoid colostomy reported that 100% of patients with rectosigmoid dilation improved (n = 6), whereas the 2 patients with pancolonic dilation did not benefit from a colostomy.[134] The psychosocial and health-related quality of life of individuals undergoing ostomy surgery for severe, chronic constipation was evaluated in 1 series of 24 patients. Study outcomes were evaluated retrospectively using clinical notes and prospectively via administration of the City of Hope Ostomy quality-of-life questionnaire, the Medical Outcomes Study Short Form-36, the Hospital Anxiety and Depression tool, and a specially designed ostomy-specific questionnaire. Of the 58.3% of patients who responded to the postal questionnaires, representing 14 patients (13 women, median age = 47.5 years; interquartile range, 23–70 years), more than 70% were satisfied (median follow-up = 17 months; interquartile range, 0.16–8 years) with their quality of life despite a reoperation rate of 20%.[136]

ACKNOWLEDGMENTS

The committee thanks Becky Baltich Nelson for conducting the systematic literature review for this project.

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