title: A prospective evaluation of occult disorders in obstructed defecation using the 'iceberg diagram'.
abstract: OBJECTIVE
  Surgical treatment of constipation and obstructed defecation (OD) carries frequent recurrences, as OD is an 'iceberg syndrome' characterized by 'underwater rocks' or occult diseases which may affect the outcome of surgery. The aim of this study was to evaluate occult disorders in order to alert the clinician of these and minimize failures.
  
  
  METHODS
  One hundred consecutive constipated patients with OD symptoms, 81 female patients, median age 52 years, underwent perineal examination, proctoscopy, anorectal manometry, and anal/vaginal ultrasound. Anorectal physiology and imaging tests were also carried out when indicated, as well as psychological and urogynaecological consultation. Symptoms were graded using a modified 1-20 constipation score. Both evident (e.g. rectocele) and occult (e.g. anismus) diseases were prospectively evaluated using a novel 'iceberg diagram'. The type of treatment, whether conservative or surgical, was also recorded.
  
  
  RESULTS
  Fifty-four (54%) patients had both mucosal prolapse and rectocele. All patients had at least two occult OD-related diseases, 66 patients had at least three: anxiety-depression, anismus and rectal hyposensation were the most frequent (66%, 44% and 33% respectively). The median constipation score was 11 (range 2-20), the median number of 'occult disorders' was 5 (range 2-8). Conservative treatment was carried out in most patients. Surgery was carried out in 14 (14%) patients.
  
  
  CONCLUSIONS
  The novel 'iceberg diagram' allowed the adequate evaluation of OD-related occult diseases and better selection of patients for treatment. Most were managed conservatively, and only a minority were treated by surgery.
authors.affiliation: Coloproctology Units, Villa Flaminia, Rome, Italy. ucpclub@virgilio.it
authors.forename: M
authors.initials: M
authors.lastname: Pescatori
authors.forename: M
authors.initials: M
authors.lastname: Spyrou
authors.forename: A
authors.initials: A
authors.lastname: Pulvirenti d'Urso
mesh_terms: D000328:Adult; D000368:Aged; D001008:Anxiety Disorders / Q000150:complications* / Q000601:surgery; D003248:Constipation / Q000209:etiology* / Q000503:physiopathology / Q000601:surgery; D019841:Defecography; D005244:Fecal Impaction / Q000209:etiology* / Q000503:physiopathology / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D008365:Manometry; D008875:Middle Aged; D018579:Patient Selection; D011446:Prospective Studies; D012005:Rectal Prolapse / Q000150:complications* / Q000601:surgery; D020047:Rectocele / Q000150:complications* / Q000601:surgery; D012720:Severity of Illness Index