Introduction: It was the aim of this prospective study to assess the coincidence of obstructed defecation in patients with hemorrhoidal disease.
Methods: Within a 16-months-period (August 1, 2004 to December 1, 2005) all patients with third- and fourth-degree hemorrhoidal disease scheduled for hemorrhoidal surgery were assessed preoperatively including a standardized history (Rome-II-criteria), a proctological examination with proctorectoscopy and an individualized pelvic floor assessment focussing on associated disorders of the pelvic floor and obstructed defecation. All data obtained were entered into a prospective PC database registry. Stapled hemorrhoidopexy was performed in a standardized technique using a 33-mmm-circular stapler device (PPH03).
Results: 102 patients with third- and fourth-degree hemorrhoidal prolapse were examined preoperatively in the proctological unit. In 86 patients (84%), typical hemorrhoidal symptoms (bleeding, pain, itching) were documented without any clinically relevant sign of obstructed defecation or pelvic floor dysfunction. In these patients, surgery was performed primarily (76 stapled hemorrhoidopexies, 10 conventional hemorrhoidectomies). Conversely, 16% of the patient collective (5 males, 11 females) showed symptoms of obstructed defecation. In these patients, a diagnostic pelvic floor work-up was performed (dynamic MRI of the pelvic floor: n = 9; defecography: n = 7; anal manometry: n = 16; anal endosonography: n = 8; pelvic floor EMG: n = 4; gynecologic examination: n = 2). Diagnostic assessment showed pelvic floor pathologies associated with hemorrhoidal disease in 11 of 16 patients (69%), whereas functional disorders (dyssynergia) were most frequent (n = 7). 3 female patients showed obstructive defacation syndrome (ODS) including rectoanal intussusception and anterior rectocele (n = 2) and descending perineum syndrome (DPS) with obstructed defecation caused by symptomatic sigmoidocele (n = 1). Consequently, therapeutic strategy was changed or modified in these 11 patients including biofeedback (n = 8), stapled transanal rectal resection (STARR, n = 2) instead of stapled hemorrhoidopexy, and, finally, resection-rectopexy (n = 1). In the other 5 patients, pelvic floor assessment did not show any additional pathology, and stapled hemorrhoidopexy was performed as a sole procedure.
Conclusion: Patients with obstructed defecation or pelvic floor dysfunction associated with hemorrhoidal disease are not uncommon and represent a 16% collective in the current series. The own results show that therapy is enriched or modified in 11 of 16 patients as initially planned. The potential coincidence with functional pelvic floor disorders and obstructed defecation in patients with hemorrhoidal disease scheduled for surgery should lead to diagnostic assessment in selected patients.