Obstructive defaecation syndrome (ODS) is a form of defaecatory dysfunction that includes a spectrum of abnormal evacuation symptoms such as straining, incomplete emptying, repetitive toilets visit, need for vaginal and/or perineal splinting and manual evacuation/digitation. ODS can be caused by functional disorders, anatomical abnormality or a combination of both.
In terms of patients’ management, conservative approach should be the first line management in this group of patients due to the minimal risk and the higher rate of success with completion of therapy. Surgery may be indicated where conservative measures fail to treat symptoms attributable to a correctable anatomical defect. The aim of the study was to review our cohort of patients presenting with ODS and understanding the efficacy of our interventions.

A retrospective review of prospectively collected data was performed for patients presenting to a tertiary referral pelvic floor unit for the assessment of ODS over a period of 4 years (2013-2017). All patients underwent a dedicated telephone triage assessment clinic (TTAC), where symptoms severity scores were assessed and completed using Obstructive defaecation score (ODS), ICIQ-BS (International Consultation on Incontinence Modular Questionnaire-Bowel Symptoms), St Mark’s faecal incontinence grading system and Bristol stool chart. Obstructive defaecation syndrome (ODS) has been assessed using the main symptom reported from patients and evaluating scores from different questionnaires used. 
In all patients, the data collected included demographics, practitioner directed history, risks factors for ODS (such as previous pelvic floor surgery, anorectal surgery, number of vaginal deliveries and traumatic vaginal deliveries) and neurological comorbidities. Based on gravity of symptoms at presentation, patients had pelvic floor investigations such us endoanal ultrasound, (EAUS), pelvic floor ultrasound (PFUS), anorectal manometry and defecography. Information about results of these pelvic floor tests have been recorded as well as conservative or surgical treatment received. 
Depending on the symptoms and severity, a decision was made whether the patient would benefit from further investigations, conservative management, consultant clinic or referral to another specialist service.

During the study period, 545 patients were referred to our third referral centre with the main symptoms of ODS, 471 females (86.4%) and 74 males (13.6%). The mean age at presentation was 50.5 years old (range 18-89). 
In total, 331 (60.7%) patients had vaginal delivery, with the median number of vaginal deliveries 2.2 (range 1-9). History of episiotomy or traumatic vaginal delivery was recorded in 202 (42.9%). Forty-seven patients (8.6%) had previous anal surgery, among females 103 (21.87%) had previous hysterectomy 77 (16.3%) had previous pelvic floor surgery. 
Median ODS score was 9.8 and St Mark’s score 8. We have divided ICIQ-BS score in Bowel pattern score (5.14), bowel continence score (6.6) and Quality of life (13.9). Bristol stool chart had a median of 2.6. 
In terms of pelvic floor tests, 403 (74.9%) had endoanal ultrasound, of whom 88.6% had normal internal anal sphincter and 79.4% normal external anal sphincter. Same patients had anorectal manometry, with 44.4% having low resting pressure and 48.1% low squeeze pressure. Rectal balloon sensation was normal in 68.5% patient, hyposensitive in 11.9% and hypersensitive in 9.6%. Defaeacting proctography was performed in 385 (70.6%), with low grade intussusception present in 32.7%, high grade intussusception in 30.4% and external rectal prolapse in 1.3%. In total, 260 (55.2%) females have rectocoeles, 115 (44.2%) were small, 103 (39.6%) medium and 42 (16.2%) were large.  
Regards interventions, 485 (89%) patient had conservative treatment, with a median number of sessions of 4.28 (range between 0-16) and a length of follow-up of 14.4 months (range 0-67.7), while 51 (9.4%) had surgery when conservative measures failed to achieve patients’ satisfactory improvements.  Conservative measures include counselling and correct toilet position training, information leaflets, pelvic floor exercises, prokinetics (19.8%), laxatives (37.1%), medications to increase the stools consistency (6.2%), use of suppositories (71.7%) and selective us of low and high volume irrigation (41.8%).
Surgical interventions were offered to 51 (9.4%) patients in the form of laparoscopic ventral mesh rectopexy in 10 (19.7%), transvaginal rectocoele repair in 21 (41.2%), Delorme’s procedure 3 (5.9%), panproctoloctomy in 1(2%),  loop colostomy in 1 (2%), loop ileostomy in 1 (2%), other proctological procedures in 14 (27.2%). 
Patients’ improvement was recorded at discharge appointment and assessed as general satisfaction and reduction of frequency of ODS symptoms. Among 545 patients, 358 (65.68%) have registered a considerable improvement, while 187 (34.3%) not. We consider this a good result, based on fact that 89% of them had only conservative measures and only 9.4% escalated to surgery.

As ODS is characterised by a variety of symptoms, using a combination of conservative treatments might be the best choice to achieve satisfactory improvement. Use of standardized questionnaires to assess baseline patients’ symptoms is important to understand possible overlap with anal incontinence symptoms and understand how compromise is patients’ quality of life, even if in our experience this is not used for change treatments’ plans.
The majority of patients has achieved good results only with conservative treatment which should be tried as first line. In our cohort of patients, pelvic floor investigations were performed to a large number of patients to assess possible pelvic organ prolapse and to understand anal sphincter function. More recently we have decided to use them only for patients failing first line strategy, before considering their suitability for surgery. 
From this review only 9.4% of patients’ required surgical intervention to correct anatomical abnormalities related to symptoms. This highlights the important role that conservative treatment plays in ODS, while surgery should be considered as the option of last resort, due to possible complications and limited benefits, with the exception of correcting possible associated pelvic organ prolapse.

Obstructive defaecation syndrome includes a wide range of symptoms, and may overlap with anal incontinence and pelvic organ prolapse. An accurate assessment at presentation is fundamental to structure a tailored conservative treatment for individual patients. Conservative treatment is the primary and most successful option for patients with ODS, while surgery should be reserved only for patients’ with associated pelvic organ prolapse who haven’t achieved satisfactory improvement.

Bocchini R, Chiarioni G, Corazziari E, Pucciani F, Torresan F, Alduini P, Bassotti G, Battaglia E, Ferrarini F, Galeazzi F, Londoni C, Rossitti P, Usai Satta P, Iona L, Marchi S, Milazzo G, Altomare DF, Barbera R, Bove A, Calcara C, D'Alba L, De Bona M, Goffredo F, Manfredi G, Naldini G, Neri MC, Turco L, La Torre F, D'Urso AP, Berni I, Balestri MA, Busin N, Boemo C, Bellini M. (2019) Pelvic floor rehabilitation for defecation disorders. Tech Coloproctol. Feb;23(2):101-115.
Bharucha AE, Wald A, Enck P, Rao S. (2006) Functional anorectal disorders. Gastroenterology. 130. p.1510-18.
Cavallaro PM, Staller K, Savitt LR, Milch H, Kennedy K, Weinstein MM, Ricciardi R, Bordeianou LG(2019) The Contributions of Internal Intussusception, Irritable Bowel Syndrome, and Pelvic Floor Dyssynergia to Obstructed Defecation Syndrome.  Dis Colon Rectum. Jan;62(1):56-62.