Management of obstructed defecation syndrome: 2026 European guideline update

Gastroenterology · General Surgery

Obstructed defecation syndrome (ODS) is a form of chronic defecatory dysfunction characterised by difficulty in evacuating stools despite the presence of an urge to defecate. Symptoms may include excessive straining, incomplete evacuation, a sensation of anorectal blockage, prolonged toilet visits, and the need for manual assistance. Both functional abnormalities, such as dyssynergic defecation, and structural abnormalities, including rectocele, internal rectal prolapse, and enterocele, may contribute to its development. The management of ODS remains challenging because of its multifactorial etiology and the frequent coexistence of pelvic floor disorders.[1]The 2026 ESCP/UEG/ESGAR/EAGEN/ESGENA/ESNM/ESPCG guideline update emphasises comprehensive clinical assessment, conservative management, multidisciplinary decision-making, and carefully selected surgical interventions to optimise treatment outcomes.Clinical assessment and diagnosisA detailed clinical history should be obtained, with particular attention to previous anorectal surgery, childbirth-related trauma, and other factors potentially contributing to defecatory dysfunction. Psychological factors, including anxiety, depression, psychological distress, and a history of sexual abuse, should also be considered during patient evaluationDigital rectal examination (DRE) may be performed to identify dyssynergic defecation. Symptom severity and treatment response can be objectively assessed using the obstructed defecation syndrome score and Cleveland chronic constipation score. Other validated disease-specific scoring systems may also be selected according to individual clinical characteristics and associated pelvic floor disorders. The Oxford classification may be used to grade prolapse severity and guide treatment selectionDiagnostic investigationsEvacuation proctography is recommended as the first-line radiological investigation for detecting functional and structural abnormalities associated with ODS. MR defecography and transperineal ultrasonography may be used as triage investigations, particularly in women with suspected multicompartmental prolapse. Endoanal ultrasonography, anorectal physiology testing, and colonic transit and morphological studies may also be considered to identify underlying functional or organic abnormalitiesEvacuation proctography and MR defecography can facilitate multidisciplinary treatment planning and help assess anatomical outcomes following surgery. However, radiological findings may not consistently correlate with symptom severity before or after surgery. Furthermore, the balloon expulsion test should not be regarded as a screening investigation, particularly when performed in the left lateral positionConservative managementConservative interventions are recommended as the initial treatment approach. A fibre-rich diet, increased fluid intake, and bulking laxatives may be prescribed to improve stool consistency and facilitate evacuationBiofeedback therapy should be considered before surgical intervention in patients with ODS and dyssynergic defecation who remain symptomatic despite dietary modification and laxative therapy. Botulinum toxin injection and bilateral posterior tibial nerve stimulation may also be considered, although supporting evidence remains limitedIn selected patients with persistent impaired rectal emptying despite optimisation of stool consistency and conservative treatment, additional emptying strategies may be introduced. These may include enemas and transanal irrigationIndications for surgical interventionSurgery may be considered when adequate symptom control has not been achieved through conservative and medical management. A stepwise treatment strategy, progressing from conservative interventions to medical treatment and subsequently to surgery, should be adopted following multidisciplinary pelvic floor assessment.Transabdominal surgical approaches: Ventral mesh rectopexy may be offered to patients with ODS associated with posterior pelvic floor anatomical dysfunction. Both laparoscopic and robotic approaches have demonstrated favorable anatomical correction. When both approaches are available, robotic ventral mesh rectopexy may be preferred because of its association with better functional outcomes, shorter hospitalisation, reduced intraoperative blood loss, and fewer postoperative complicationsResection rectopexy may be considered in patients with internal rectal prolapse. During ventral mesh rectopexy, absorbable sutures may be used for mesh fixation to reduce the risk of mesh erosion. The procedure may also be considered in selected patients with solitary rectal ulcers, with improved outcomes potentially being achieved when combined with a transanal approachIn patients with multicompartmental prolapse involving rectal prolapse, rectocele, or enterocele, ventral rectopexy may be combined with sacrocolpopexy to achieve favorable short- and long-term outcomesTransanal and transperineal approaches: Internal Delorme's procedure may be considered the preferred transanal approach, particularly in patients with impaired anal function or an increased risk of postoperative fecal incontinence. Postoperative biofeedback may subsequently be incorporated to improve functional outcomes. Transperineal or transvaginal repair may be performed in patients with symptomatic uncomplicated rectoceleStapled transanal rectal resection (STARR) and its modifications may be considered in patients with preserved anal sphincter function. However, the associated risks of complications and repeat interventions necessitate careful patient selection, comprehensive preoperative assessment, and adequate surgical expertiseSafety considerations and surgical outcomesPatients should be adequately counselled regarding the potential benefits and complications of mesh-based procedures. Individualised treatment planning and appropriate surgical expertise are essential.Potential predictors of unfavorable outcomes following STARR or ventral mesh rectopexy include small rectal diameter, reduced anal sphincter squeeze pressure, increased pelvic floor descent at rest, redundant colon, connective tissue disorders, and pre-existing constipation. Conversely, the radiological presence of an enterocele does not independently predict surgical failure or constitute an absolute contraindication to surgeryRedo surgery following ventral mesh rectopexy may be considered feasible and safe. However, reintervention for mesh erosion or chronic pelvic pain may carry substantial morbidity and may be associated with limited effectivenessConclusionThe 2026 European guideline update reinforces an individualised, multidisciplinary approach to ODS management. Conservative interventions, particularly dietary modification and biofeedback, remain central to initial treatment, while surgical procedures should be reserved for appropriately selected patients with persistent symptoms and identifiable anatomical abnormalities. Comprehensive diagnostic assessment, informed consent, and careful consideration of functional outcomes and procedural complications are essential for optimising treatment decisions and improving long-term patient care.[2]Reference(s):1. Singh JP, Assaie-Ardakany S, Aleissa MA, et al. Optimizing diagnosis in obstructed defecation syndrome: A review of imaging modalities. World J Radiol. 2025;17(7):107459. doi:10.4329/wjr.v17.i7.107459. https://pmc.ncbi.nlm.nih.gov/articles/PMC12308581/2. Gallo G, Goglia M, Kleijnen J, et al. European Guidelines on Multidisciplinary Management of Obstructed Defecation Syndrome-ESCP, UEG, ESGAR, EAGEN, ESGENA, ESNM and ESPCG. United European Gastroenterol J. 2026;14(9):e70303. doi:10.1002/ueg2.70303. https://onlinelibrary.wiley.com/doi/10.1002/ueg2.70303