What is the treatment for a rectal seal causing constipation?

Treatment of Rectal Seal Causing Constipation

For a rectal seal (rectocele or rectal outlet obstruction) causing constipation, begin with conservative management including osmotic laxatives (polyethylene glycol 17g daily), positioning aids during defecation, and pelvic floor biofeedback therapy—which is the treatment of choice for defecatory disorders and improves symptoms in over 70% of patients. 1

Initial Conservative Management

First-line therapy should focus on non-surgical interventions:

• Discontinue all medications that can cause constipation when feasible before further evaluation 2, 1
• Ensure privacy and comfort for normal defecation, use positioning aids like footstools to assist gravity, and increase fluid intake and physical activity within patient limits 2, 1
• Educate patients to attempt defecation at least twice daily, preferably 30 minutes after meals, straining no more than 5 minutes 2, 1
• Start with osmotic laxatives (polyethylene glycol 17g daily, lactulose, or magnesium salts) OR stimulant laxatives (senna, bisacodyl, glycerol suppositories) as first-line pharmacologic therapy 2, 1, 3

Diagnostic Evaluation

Before proceeding to advanced therapies, proper assessment is essential:

• Conduct a careful digital rectal examination including assessment of pelvic floor motion during simulated evacuation before referral for anorectal manometry 2, 1
• A normal digital rectal examination does NOT exclude defecatory disorders 2, 1
• Perform anorectal testing only in patients who do not respond to the initial therapeutic trial 1
• Consider defecography to document that the rectocele significantly impairs rectal evacuation 4

Biofeedback Therapy - The Preferred Treatment

Pelvic floor retraining by biofeedback therapy rather than laxatives is the treatment of choice for defecatory disorders caused by rectal outlet obstruction:

• Biofeedback therapy improves symptoms in more than 70% of patients with defecatory disorders 1
• This approach incorporates simulated defecation training and incurs no risk 4
• Benefits 60% to 80% of patients with pelvic floor dyssynergia 4
• Should be attempted before considering surgical options 5, 6

Surgical Considerations

Surgery should only be considered after failure of conservative therapy and only in specific circumstances:

• Surgery is indicated only after failure of an aggressive, prolonged trial of laxatives, fiber, and biofeedback therapy 1
• Rectocele correction may be considered if it can be definitively established that it is a cause of defecation disorder and only after conservative measures have failed 6
• Must exclude coexistent upper gastrointestinal motility disorders and other defecatory disorders before surgery 1
• Surgical division of the puborectalis muscle is risky and unproven 4

Critical Pitfalls to Avoid

• Do not skip biofeedback therapy in patients with defecatory disorders—it is more effective than laxatives 1
• Do not proceed to surgery without excluding other defecatory disorders and upper GI motility disorders 1
• Do not use bulk laxatives in non-ambulatory patients with low fluid intake 2
• Avoid operating on rectoceles unless it can be definitively established that vaginal pressure on the rectocele significantly improves rectal evacuation 4