to the vagina. in severe cases, during defecation peritoneal contents can protrude through into the vagina or rectum, or displace them. symptoms are variable, depending on the severity and the location of the herniation, and may include incomplete evacuation of the rectum, heavy sensation in the pelvis, and constipation. enterocoele may develop because of weakening pelvic floor, multiple pregnancies, hysterectomy, and long term chronic straining. sometimes people have a developmental condition where the rectovaginal septum fails to completely fuse, and they have a congenitally deep pouch of douglas. rectal hyposensitivity also termed "blunted rectum", rectal hyposensitivity is a relatively newly identified entity, defined as "elevation beyond the normal range in the perception of at least one of the sensory threshold volumes during anorectal manometry." there is blunted or reduced perception of distension of the rectum. conceptually there are two categories of rectal hyposensitivity: primary (dysfunction of the rectal afferent pathway, i.e. a true sensorimotor dysfunction), and hyposensitivity that is secondary to abnormal rectal structure (e.g. megarectum) or rectal biomechanical properties (e.g. rectal hypercompliance). it may be caused by generalized neuropathies such as diabetes mellitus, or by diseases which effect the central nervous system (the spinal cord or brain), such as multiple sclerosis, or parkinson’s disease. rectal hyposensitivity may also result from pelvic nerve injury (e.g. spinal trauma, pelvic surgery, anal surgery, hysterectomy or disc (l5-s1) surgery). people with a history of severe sexual/physical abuse may have rectal hyposensitivity, theorized to reflect altered central processing of rectal sensation in response to painful rectal stimuli. rectal hyposensitivity is frequently associated with ods, especially with dyssynergic defecation. it is detected in about 23% of people with constipation overall. psychological factors potential psychological factors which may contribute to ods are anxiety, depression, post-traumatic stress and sexual abuse. for example, one-third of females with ods and proctalgia have a history of sexual trauma during childhood or adolescence. patients with ods have a higher than normal level of psychiatric conditions, such as obsessive-compulsive disorder, phobia of stool, and eating disorders (such as anorexia nervosa or bulimia). many patients with ods will report initiating stressful life events that worsened their constipation. such life stressors include new job, divorce, financial problems, sexual abuse or assault. other neurological causes other neurological disorders may cause or contribute to ods, such as dementia, parkinson's disease, multiple sclerosis, hirschsprung disease, acute cerebrovascular accident, spinal lesion, or spinal injury. the rectoanal inhibitory reflex is inhibition of the internal anal sphincter. this reflex can be affected by hirschsprung disease, chagas disease, and hereditary myopathy of the internal anal sphincter. anal stenosis anal stenosis (also termed anal stricture) is narrowing of the anal canal. according to one report, 88% of cases develop after by hemorrhoidectomy. however, overall it is a rare complication of hemorrhoidectomy (less than 1.5%). removal of too much anoderm and hemorrhoidal rectal mucosa during this procedure causes scarring and progressive narrowing. other types of surgical procedure for recurrent anal fissures, abscesses and anal fistulae may cause anal stenosis. other causes include crohn’s disease, radiotherapy, removal of perianal skin lesions e.g. in paget disease or bowen disease, tuberculosis, actinomycosis, lymphogranuloma, anal and rectal cancers and developmental abnormalities of the anus. some authors describe a "muscular" type of anal stenosis (i.e. a functional disorder). functional anal stenosis disappears under anesthesia, whereas true anal stenosis does not. the main symptoms of anal stenosis are difficult evacuation of stool, narrow stools, painful defecation, need for self-digitation to achieve defecation, bleeding from anal tears, and constipation. diagnosis diagnosis is very challenging for clinicians, since most patients will simply complain of "constipation". as discussed previously, there are many possible causes of ods, which often may occur together in the same patient, and ods may co-exist with other conditions such as slow-transit constipation. as such, the first step in diagnosis is identification of organic causes of ods and to identify possible slow transit constipation. also, patients may be too embarrassed to discuss their exact problems, especially with regards symptoms like digitation. the two key features of obstructed defecation are: an inability to voluntarily evacuate rectal contents. normal colonic transit time, but delayed transit in the rectum and sigmoid colon. scoring systems scoring system are recommended in ods to assess the severity of symptoms, to enable measurement of treatment outcomes, and to enable comparison of different treatment modalities in research. the renzi ods score is a five-item questionnaire. it has been validated for diagnosis and grading of ods. the parameters are: excessive straining incomplete rectal evacuation use of enemas and/or laxatives vaginal-anal-perineal digitations (needing to press in the back wall of the vagina or on the perineum to aid defecation) abdominal discomfort and/or pain another validated instrument is the altomare ods score. there are 7 parameters, scored from 0-4: mean time spent at the toilet number of attempts to defaecate per day anal/vaginal digitation use of laxatives use of enemas incomplete/fragmented defaecation straining at defaecation stool consistency investigations there are many different investigations which are used in the diagnosis of ods. some authors state that multiple different diagnostic tests are required because of the coexistence of multiple causative factors. extensive anorectal sensory and motor physiological testing may help to identify subgroups of patients in whom surgery may be more successful. however, the financial costs of such testing is significant, and the investigations only change the management in about 23% of cases. also, performing a full range of physiological tests of defecation function may not distinguish the different subtypes of constipation (of which ods is only one). furthermore, such tests give frequent false-positive results in individuals without any symptoms. for example, some have suggested that anismus is an over-diagnosed condition, since the standard investigations or digital rectal examination and anorectal manometry were shown to cause paradoxical sphincter contraction in healthy controls, who did not have constipation or incontinence. due to the invasive and perhaps uncomfortable nature of these investigations, the pelvic floor musculature is thought to behave differently than under normal circumstances. therefore, paradoxical pelvic floor contraction is a common finding in healthy people as well as in people with chronic constipation and stool incontinence, and it may represent a non-specific finding or laboratory artifact related to untoward conditions during examination. they concluded that true anismus is actually rare. many of these tests assess simulated, rather than spontaneous, true defecation function. specific investigations which have been used in ods are: digital rectal exam anoscopy. colonoscopy. defecography. simultaneous pelvicography and colpocystodefecography (pccd) (defecography + voiding cystography, vaginal opacification and pelvicography). entero defecography. magnetic resonance imaging defecography. anorectal manometry. balloon expulsion test. transanal-vaginal ultrasound. dynamic perineal ultrasound. pudendal nerve motor latency test. psychological evaluation. gastrointestinal transit time (gitt) assay. anal surface electromyography. evacuation proctography evacuation proctography is the most common type of imaging used in the diagnosis of posterior pelvic floor disorders and ods. it is considered as the reference standard but it does not have perfect accuracy. the technique also uses ionising radiation and is embarrassing and invasive for patients. dyssynergic defecation dyssynergic defecation may be detected clinically, by digital rectal examination. non relaxation or paradoxical contraction of the puborectalis muscle at the anorectal junction can be felt when the patient performs a valsalva manoeuvre or evacuation. the diagnosis can be confirmed by anal electromyography, anorectal manometry, and/or defecography. "celes" it is difficult to tell peritoneocele, enterocele and sigmoidocele apart from rectocele without imaging. peritoneocele is the most difficult type of pelvic prolapse to detect by clinical examination. to improve visualization of peritoneocele during mr defecography, the patient should complete normal defecation and the rectal contrast material should be completely evacuated, because then the rectovaginal space widens and pushes the peritoneum and bowel loops inferiorly (lower). an enterocoele can be easily detected by a clinician during physical examination. using a bidigital technique (one finger in the anus and another in the vagina), the mass of the enterocele can be felt to "slip upwards" between the fingers when squeezing together. if the patient coughs during this procedure, it is easier to detect. treatment it is suggested that a multidisciplinary approach is the best way to treat ods. for example, a team composed of a gynecologist or urogynecologist, gastroenterologist and colorectal surgeon. the general goal of treatment is to improve defecation mechanics and stool texture. this will give marked improvement in quality of life for most patients with ods. conservative management versus surgery treatment may be conservative or surgical. the exact way of managing ods is controversial, with many authors now taking positions against surgery as a first line treatment for ods, while others state that surgery should be used as a last resort, not be used at all, or take a more pro-surgery position. treating ods can be extremely challenging and time-consuming. it is rare that ods is "cured" with one intervention or in a single setting. the underlying, original causes of ods are typically psychological, muscular and/or neurological. such causes require complex, long term treatment. some authors have suggested that surgically correctable anatomical disorders which are detected in ods patients may actually represent effects, rather than causes of ods. furthermore, the complexity of this condition means it takes a lot of time to understand it. however, both patients and surgeons prefer faster solutions like surgical procedures. it has been suggested that this is the reason why most, if not all surgical procedures are unsuccessful in the long term. in other words, the detectable anatomical defects can be restored surgically, but this does not mean that the function is also restored. others report that the outcomes of non-surgical methods have conflicting results, and their effects are not significant. most authors now recommend a combination of different conservative measures. if conservative fail to improve symptoms, management can be supported, where strictly indicated, with surgical procedures as a secondary treatment. this approach reflects the multifactorial nature of ods, where the exact approach to treatment is individualized to each patient. for example, in a patient with isolated dyssynergic defecation and no other anatomical defect, surgery is contraindicated, however where ods is caused by a neoplastic tumor or external prolapse, surgery is usually strongly indicated. some stress that it is important for clinicians to set realistic and honest goals with patients. overall it is reported that nearly 20% of patients need surgical treatment. surgery is said to be overused to treat ods, with more than 50% of patients undergoing the stapled transanal rectal resection (starr) procedure. there are many different surgical treatments which have been attempted to treat ods. some authors state that the vast number of reported surgical treatments that have been used for ods indicate that surgery is an unsuccessful treatment for ods. european consensus guidelines on management in 2021 a consensus regarding approach to treatment of ods was published. a panel of 31 surgeons from 12 european countries worked on the consensus. the members of the panel were all engaged in research and treatment of ods, and were considered expert in the field of pelvic floor functional disorders. they came to a consensus on about 50% of controversial issues surrounding management of ods, which enabled creation of a treatment algorithm. the algorithm was based around the condition of the function of the anal sphincter, the presence of dyssynergia and the presence of other abnormalities like rectocele, intussusception, etc. they unanimously agreed that surgery should be discouraged for pelvic floor dyssynergia, and instead that biofeedback/pelvic floor retraining was the first line treatment. when dyssynergia is present with major abnormalities like rectocele or rectal intussusception, biofeedback/pelvic floor retraining should be conducted before attempting surgery. for patients with rectal intussusception and a large rectocele or enterocele the experts all preferred laparoscopic (transabdominal) ventral rectopexy with non resorbable mesh, regardless of the function of the sphincter. especially in the case of poor sphincter function (e.g. some degree of fecal incontinence), they preferred to avoid transanal approach, because there is greater risk of further deterioration in continence function. in the event of failure of previous ventral rectopexy, the consensus was to repeat the same procedure again rather than carry out different procedures. for patients with large rectocele or enterocele only (i.e. no intussusception), there was no clear consensus about the best treatment. the experts did however agree that mesh should not be used for direct rectocele repair. conservative (non-surgical) some authors state that treatment of ods is