One of the most common complaints of patients seeing colorectal surgeons is constipation. The prevalence of chronic constipation in the United States varies from 2% to 34%.' Constipation is caused by several etiologies. Pelvic outlet obstruction (POO) is a common cause of constipation and is attributed to muscular dysfunction of the pelvic floor. The reported incidence of POO as a cause of constipation was reported as high as 50% at a tertiary referral center.2 Population studies have demonstrated the prevalence of POO in the elderly (age 65 years and older) as 20%.3 In a population study performed by Talley et al.,1 the prevalence of POO was 16.5% in females and 5.2% in males. In another study that compared age-related prevalence in the same community of patients, aged less than 60 to more than 65 years, there was an increasing prevalence of POO with increasing age.1,3
Multiple risk factors suspected to be associated with POO have been reviewed. One such risk factor is gender. Constipation in young and middle-aged adults is approximately three times more prevalent in women, and the prevalence increases in both genders with age.4 Nons-teroidal antiinflammatory drug usage has been shown to be associated with POO in some studies but not in others.1,3 Other factors such as aspirin, Tylenol, alcohol, and tobacco use, marriage and employment status, level of education, and depression have not borne out as significant risk factors for POO.1,3,5 Laxative and enema abuse have been associated with POO, but have not been shown to be significant. There are limited reports of other associated pelvic floor anomalies with POO. For example, Talley et al.1 reported up to a 28% incidence of proctalgia fugax in patients with POO.
Among patients with POO, there are several neuro-muscular-associated or etiologic syndromes, including: 1) nonrelaxing puborectalis syndrome, 2) rectocele, and 3) descending perineum syndrome. Nonrelaxing puborectalis syndrome occurs when there is failure of relaxation or paradoxical contraction of the puborectalis muscle at the time of defecatory effort. Paradoxical or nonrelaxation of the puborectalis muscle is the cause in 31% to 42% of patients with POO constipation.2,6 As a result of the chronic straining associated with this syndrome, many other associated disorders may develop including rectal prolapse and rectocele.
The descending perineum syndrome occurs as a result of either injury of the sacral or pudendal nerves or damage to the pelvic floor muscles. Most often, this injury occurs secondary to childbirth or chronic straining at stool. The descending perineum syndrome is frequently associated with constipation and, later, development of fecal incontinence. Its incidence increases with age and it is more common in women than men.7
A rectocele is defined as a herniation or protrusion of the anterior rectal wall into the vagina and is associated with pelvic laxity. Rectoceles are found in 1% of patients presenting to specialists with complaints of chronic con-stipation.2 They are very common and not often symptomatic, and so they are vastly underreported. Many rectoceles will remain asymptomatic until the fourth or fifth decade of life.8 The majority of patients with rectoce-les are multiparous and/or have chronic constipation with a history of straining.9 During vaginal delivery or chronic straining, damage to the rectovaginal septum, pelvic floor muscles, and the pudendal nerves may be related to recto-
cele development.9 Rectoceles are also associated with hysterectomies.9
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Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.