| BackgroudChronic constipation has a high prevalence of 15% worldwide and has a serious impact on people’s lives,as well as a huge economic burden on public health.Outlet obstruction constipation is the main type of chronic constipation,accounting for approximately 60%.Its etiology and pathogenesis are relatively complex and its clinical manifestations vary greatly between individuals,making it a major problem for patients and specialists.In the literature,gender,age,diet,fluid intake and fertility are thought to be associated with the development of outlet obstructive constipation,but studies on the severity of symptoms and factors affecting quality of life in patients with outlet obstructive constipation are rare.The assessment of the severity of symptoms and the factors influencing them in patients with outlet obstruction constipation is of great importance in the choice of treatment options and deserves further study.Internal rectal prolapse is the main type of outlet obstruction constipation and is treated conservatively or surgically.Surgical treatment includes different approaches such as trans-abdominal and trans-perineal,which are more controversial and less effective.Therefore,the comprehensive conservative treatment,including pelvic floor exercises,dietary modification,bowel habit modification and medication,is in fact the first choice for almost all patients with outlet obstruction constipation.However,few studies have been reported on the efficacy of comprehensive conservative treatment,and it is important to assess the efficacy of comprehensive conservative treatment in order to determine the treatment strategy and surgical guidelines for patients with outlet obstruction constipation.Objective1.To analyze the factors affecting the severity of clinical symptoms and quality of life of patients with outlet obstruction constipation,and to provide reference for more targeted prevention and treatment of outlet obstruction constipation.2.To observe the efficacy of comprehensive conservative treatment on patients with outlet obstruction constipation mainly with internal rectal prolapse,to evaluate the feasibility,safety and effectiveness of comprehensive conservative treatment,and to provide a more systematic,standardized and effective plan for comprehensive conservative treatment.Methods1.General clinical information and ancillary findings of patients with outlet obstructive constipation attending the Daping Hospital from July 2021 to January 2023 were collected continuously by means of a cross-sectional survey in the form of a questionnaire.These included age,gender,occupation,height,weight,dietary habits,water intake,exercise,smoking history,alcohol history,defecation pattern and habits,mode of delivery,number of deliveries,menopausal status,history of abdominopelvic and anorectal diseases and surgery,duration of illness,Self-Assessment Scale(SAS)for anxiety,complaints and results of defecography and anorectal manometry.Patients’ symptom severity was assessed by the Wexner Constipation Score and the Obstructive Defecation Syndrome(ODS)score,and their quality of life was assessed by the Patient Assessment of Constipation-Quality of Life Score(PAC-QOL),with higher scores representing more severe symptoms and lower quality of life.Factors influencing the severity of symptoms and quality of life in patients with outlet obstruction constipation were analysed by univariate and multifactorial regression.2.Patients with outlet obstructive constipation with predominantly internal rectal prolapse attending the Daping Hospital from July 2021 to October 2022 were included by a pre-and post-treatment self-control method.The patients were treated with comprehensive conservative treatment for 2 months,including the anal sphincter exercises at knee-chest position,probiotics and dietary fibre,dietary advice and psychological counselling,and the overall improvement was observed.The changes in Wexner constipation score,ODS score and PAC-QOL score were compared before and after treatment to assess the safety,efficacy and feasibility of comprehensive conservative treatment for patients with outlet obstruction constipation.Rusults1.The final 404 patients with outlet obstruction type constipation were included in a cross-sectional survey study of factors influencing constipation severity and quality of life,and the results of multiple linear regression analysis showed that:(1)Drinking less than 1000 ml of water per day(β=0.083,P=0.046),low intake of vegetables and fruits [<300 g of vegetables/day or <200 g of fruits/day,(β=0.108,P=0.011)],thinness [BMI <18.5 kg/m2,(β= 0.080,P=0.026)],squatting stools(β=0.097,P= 0.009),laxative use [>2 times/week and >2 months,(β=0.203,P<0.001)],SAS score(β=0.186,P<0.001),number of deliveries(β=0.095,P=0.015),duration of disease >10 years(β=0.313,P<0.001),and comorbid perianal disease(β=0.087,P=0.021)were independent risk factors for Wexner’s constipation score,all with statistically significant differences.(2)Drinking less than 1000 ml of water per day(β=0.105,P=0.008),low intake of vegetables and fruits [<300 g of vegetables/day or <200 g of fruits/day,(β=0.119,P=0.003)],thinness [BMI <18.5 kg/m2,(β=0.089,P=0.008)],history of smoking [>5 cigarettes/day for >6 months(β=0.130,P=0.002)],laxative use [>2 times/week and >2 months,(β=0.275,P<0.001)],SAS score(β=0.227,P<0.001),number of deliveries(β=0.113,P=0.012),duration of disease >10 years(β=0.239,P<0.001),comorbid perianal disease(β=0.071,P=0.044)were independent risk factors for ODS scores,all with statistically significant differences.(3)Drinking less than 1000 ml of water per day(β=0.113,P=0.007),low intake of vegetables and fruits [<300 g of vegetables/day or <200 g of fruits/day,(β=0.123,P=0.004)],thinness [BMI <18.5 kg/m2,(β=0.099,P=0.006)],squatting stools(β=0.136,P< 0.001),laxative use [>2 times/week and >2 months,(β=0.198,P<0.001)],SAS score(β=0.389,P<0.001),duration of disease >10 years(β=0.159,P<0.001),and comorbid perianal disease(β=0.082,P=0.028)were independent risk factors for PAC-QOL score,all with statistically significant differences.2.Among 404 patients with outlet obstruction constipation,367 completed defecography and 146 completed 3D high-resolution anorectal manometry.The results of the univariate analysis showed that the higher the grade of endorectal prolapse,the higher the patients’ Wexner constipation score(r=0.123,P=0.021),ODS score(r=0.149,P=0.007)and PAC-QOL score(r=0.142,P=0.010),the difference was statistically significant;patients with a duration of anal contraction less than or equal to 30 seconds had a higher ODS score than those with a duration of contraction greater than 30 seconds [13.0(9.0,17.3)vs 11.5(6.0,14.0),P<0.001],the difference was statistically significant.3.After 2 months of comprehensive conservative treatment,among the 59 patients with outlet obstruction constipation with mainly internal rectal prolapse who completed the treatment and follow-up,there was complete improvement in 2 cases,significant improvement in 6 cases,partial improvement in 43 cases and no improvement in 8 cases,totaling 51 cases with effective treatment and 8 cases with ineffective treatment,with an effective rate of 86.4%.The Wexner constipation scores were significantly lower after treatment(pre vs post: 11.8±4.6 vs 9.6±4.2,P<0.001),with frequency of defecation,difficulty in defecation,incomplete defecation,time to defecation and defecation failure scores all lower than pre-treatment,with statistically significant differences(all P<0.05).ODS scores were significantly lower after treatment(pre vs post: 11.2±5.6 vs.7.6±4.6,P<0.001),with lower scores for time to defecation,number of bowel movements per day,and effort to defecate than before treatment,with statistically significant differences(all P<0.05);PAC-QOL scores were significantly lower after treatment(pre vs post: 48.9±20.1 vs.35.3±19.4,P<0.001).The PAC-QOL scores were significantly lower after treatment(pre vs post: 48.9±20.1 vs.35.3±19.4,P<0.001)and the scores on all dimensions(physical discomfort,psychological discomfort,worry and anxiety,satisfaction)were lower than before treatment,with statistically significant differences(all P<0.05).Conclusion1.The severity of clinical symptoms and quality of life in patients with outlet obstruction constipation are influenced by a number of factors,including drinking less than 1000 ml of water per day,low intake of vegetables and fruits,anxiety,thinness,use of laxatives,duration of disease >10 years,squatting,and the presence of a combination of Perianal disease was an independent risk factor for symptom severity and quality of life,and the number of deliveries and history of smoking were independent risk factors for symptom severity.2.The higher the grade of internal rectal prolapse,the more severe the constipation and the lower the quality of life;patients with abnormal duration of voluntary contraction of the anal canal have more severe symptoms of constipation.3.Systematic and standardized comprehensive conservative treatment is safe,effective,and feasible in improving the symptoms of bowel obstruction and improving the quality of life in patients with outlet obstruction constipation due to internal rectal prolapse. |
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