The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) on the diagnosis and management of obstructed defecation syndrome (ODS), with the purpose of guiding physicians in the selection of the most appropriate treatment option. A panel of experts was appointed by the Board of the SIUCP to develop key questions addressing the main topics related to the management of ODS and to perform an accurate literature search for each topic, in order to provide evidence-based answers and to summarize them in structured statements. All clinical questions were discussed by the expert panel over multiple rounds using the Delphi approach, and consensus among the experts was achieved for each statement. The questions were formulated according to PICO (patients, intervention, comparison, outcome) criteria, and the statements were developed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. In patients with ODS refractory to first-line medical therapy, rehabilitation may be considered as a therapeutic option, particularly in cases of dyssynergic defecation, whereas a surgical approach may be indicated in patients with a high symptom score and an Oxford prolapse grade system score ≥3 on defecography (using magnetic resonance imaging or another modality). Surgical options include stapled transanal rectal resection and ventral mesh rectopexy, eventually combined, respectively, with pelvic organ prolapse suspension and sacrocolpopexy in the presence of multicompartment pelvic prolapse. A transverse perineal support procedure may be considered in the presence of excessive perineal descent. In patients with recurrent symptoms after surgery, transanal irrigation may represent a useful therapeutic option.
Citations
Citations to this article as recorded by
Tailoring surgery for obstructed defecation and its evolution into ineffective defecation: a new staging of the syndrome and a site-specific decision algorithm Adolfo Renzi Annals of Coloproctology.2026; 42(3): 372. CrossRef
Purpose To evaluate the safety and long-term efficacy of stapled transanal rectal resection (STARR) combined with the transverse perineal support (TPS) procedure in the surgical treatment of obstructed defecation syndrome (ODS) associated with internal rectal prolapse and excessive perineal descent (PD).
Methods This multicenter observational case-control study involved 7 European centers. During the initial study period, patients underwent STARR alone (group 1), while in the subsequent period, patients received STARR combined with TPS (group 2). All patients were followed clinically at 6, 12, 36, and 60 months, and were offered radiological evaluation between 3 and 5 years postoperatively.
Results The median postoperative ODS score was similar between groups at 6 months (6 [range, 2–15] vs. 5 [range, 2–13]; P=0.16, Mann-Whitney U-test), but at 36 months, it was significantly lower in group 2 compared to group 1 (11 [range, 5–16] vs. 5 [range, 2–15]; P<0.001, Mann-Whitney U-test), with stable results maintained through 5 years. The success rate followed a similar trend. Postoperative maximum PD during straining remained unchanged in group 1, whereas it significantly decreased compared to preoperative values in group 2.
Conclusion The addition of TPS to STARR in the surgical treatment of ODS associated with internal rectal prolapse and excessive PD appears to significantly improve long-term success rates and correct descending perineum.
Citations
Citations to this article as recorded by
Laparoscopic Resection Rectopexy with Transanal Specimen Extraction for Complete Rectal Prolapse: Retrospective Cohort Study of Functional Outcomes Mustafa Ates, Sami Akbulut, Emrah Sahin, Kemal Baris Sarici, Ertugrul Karabulut, Mukadder Sanli Journal of Clinical Medicine.2026; 15(2): 718. CrossRef
Beyond stapled transanal rectal resection vs ventral rectopexy dichotomy: Toward a phenotype-guided surgical paradigm for obstructed defecation syndrome Michele Schiano di Visconte, Sonia Sarnari World Journal of Gastrointestinal Surgery.2026;[Epub] CrossRef
The Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of obstructed and ineffective defecation syndrome Adolfo Renzi, Luigi Brusciano, Pasquale Talento, Luigi Marano, Francesca Iacobellis, Antonio Vallo, Giovanna Frezza, Maurizio Grillo, Alessio Palumbo, Elisa Palladino, Benedetto Neola, Fabrizio Foroni, Michele Lanza, Massimo Antropoli, Carmine Antropoli, Annals of Coloproctology.2026; 42(2): 151. CrossRef
Early outcomes of transverse perineal support in obstructed defecation syndrome with pathological perineal descent; a prospective cohort study Haitham M. Azmy Basiouny, Ali Ahmed Shafik, Mohamed Yehia Elbarmelgi, Osama Refaie, Mohamed Tamer, Mahmoud Adel Abu Alwafa, Ahmed Mohamed Abdelaal BMC Surgery.2026;[Epub] CrossRef
Tailoring surgery for obstructed defecation and its evolution into ineffective defecation: a new staging of the syndrome and a site-specific decision algorithm Adolfo Renzi Annals of Coloproctology.2026; 42(3): 372. CrossRef
Purpose This study was conducted to evaluate the validity of a new imaging-guided, anatomy-based classification of anorectal fistulas in defining disease severity and predicting surgical outcomes.
Methods This multicenter, retrospective cohort study analyzed data from patients with perianal fistulas who underwent surgery between 2017 and 2023. All patients underwent preoperative 3-dimensional endoanal ultrasound, with adjunctive magnetic resonance imaging performed if ultrasound indicated a complex fistula. Imaging examinations were retrospectively evaluated to categorize fistulas according to the Garg classification and the newly proposed classification system. The new classification included 6 severity grades based on the characteristics of the primary tract: submucosal, intersphincteric, low transsphincteric, high transsphincteric, multiple, and suprasphincteric/extrasphincteric. Each grade was further subdivided into 3 subtypes (A, B, C) based on the extension of secondary tracts.
Results When compared with the new classification, the Garg classification demonstrated a slightly lower ability to predict the feasibility of fistulotomy in simple fistulas (94.2% vs 99.1%; Fisher exact test, P=0.006). A strong positive correlation was found between the surgery failure rate and the severity grade of the new classification (Spearman rho, 0.90; P<0.001), whereas the Garg classification showed a nonsignificant positive correlation with surgical failure rate (Spearman rho, 0.90; P=0.08).
Conclusion The new imaging-guided, anatomy-based classification of anorectal fistulas demonstrates high accuracy in defining disease severity. It represents a valuable tool for preoperative grading of anal fistulas, standardizing the reporting of diagnostic imaging, and improving the communication of findings among healthcare professionals.
Citations
Citations to this article as recorded by
Comparison of the proposed new classification of anal fistulas with the Garg classification Pankaj Garg, Nicola Clemente, Kaushik Bhattacharya, Sattyadeep Garg Annals of Coloproctology.2026; 42(1): 145. CrossRef
Histological architecture of the intersphincteric region of the anal canal: implications for the anatomical basis of anal fistula pathways Satoru Muro, Yasuo Nakajima, Akimoto Nimura, Keiichi Akita International Journal of Colorectal Disease.2026;[Epub] CrossRef
Purpose Postoperative pain is a major concern for patients undergoing ultrasound scalpel-assisted hemorrhoidectomy, potentially exacerbated by delayed wound healing. This study aimed to evaluate the impact of an intimate cleansing gel containing chlorhexidine, hyaluronic acid, and other anti-inflammatory agents (Antroclean Fisioderm) on postoperative pain, itching, and wound healing in patients who had undergone this procedure.
Methods This multicenter observational case-control study involved a cohort of consecutive adult patients who underwent hemorrhoidectomy using an ultrasound device. The study compared 2 different postoperative wound management strategies over 1 month after surgery: washing with warm water twice per day (control group) versus a 2-minute topical application of intimate cleansing gel (Antroclean Fisioderm) followed by a warm water wash (intervention group).
Results The median postoperative pain score was significantly lower in the intervention group than in the control group at each follow-up point (P<0.01). The percentage of patients reporting anal itching was also significantly lower in the intervention group than in the control group at each follow-up point (P<0.01). All patients in the intervention group achieved complete wound healing 4 weeks after surgery, compared to 88 (82%) in the control group (P<0.01). No adverse events were reported.
Conclusion The topical application of intimate cleansing gel (Antroclean Fisioderm) twice daily for 1 month following ultrasound scalpel-assisted hemorrhoidectomy appears to be associated with faster healing, reduced pain, decreased itching, and improved quality of life, without any adverse effects. Further larger and prospective randomized trials are recommended to confirm these findings.
Citations
Citations to this article as recorded by
Comparing Outcomes of Conventional Hemorrhoidectomy With Hemorrhoidectomy Using the Harmonic Scalpel Gautham Vignesh, Ludia John, Sai Sravani Sure, Narayanan Cunnigaiper Cureus.2026;[Epub] CrossRef
Enhancing Proctological Outcomes: The Role of Hyaluronic Acid in Hemorrhoid Care – An Innovative Adjunct to Surgery Riddhi Upadhyay, Akshat Vadaliya, Haryax V. Pathak, Soham Upadhyay Journal of Coloproctology.2025; 45(03): 001. CrossRef
The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colon-Proctologia, SIUCP) on the diagnosis and management of hemorrhoidal disease, with the goal of guiding physicians in the choice of the best treatment option. A panel of experts was charged by the Board of the SIUCP to develop key questions on the main topics related to the management of hemorrhoidal disease and to perform an accurate and comprehensive literature search on each topic, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in multiple rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to PICO (patients, intervention, comparison, and outcomes) criteria, and the statements were developed adopting the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. In cases of grade 1 hemorrhoidal prolapse, outpatient procedures including hemorrhoidal laser procedure and sclerotherapy may be considered the preferred surgical options. For grade 2 prolapse, nonexcisional procedures including outpatient treatments, hemorrhoidal artery ligation and mucopexy, laser hemorrhoidoplasty, the Rafaelo procedure, and stapled hemorrhoidopexy may represent the first-line treatment options, whereas excisional surgery may be considered in selected cases. In cases of grades 3 and 4, stapled hemorrhoidopexy and hemorrhoidectomy may represent the most effective procedures, even if, in the expert panel opinion, stapled hemorrhoidopexy represents the gold-standard treatment for grade 3 hemorrhoidal prolapse.
Citations
Citations to this article as recorded by
Operative versus nonoperative treatment of thrombosed external hemorrhoids: a systematic review and meta-analysis Marcelo Albuquerque Barbosa Martins, Luiz Felipe Costa de Almeida, Anelise Poluboiarinov Cappellaro, Luís Fernando Rosati Rocha, Rachid Eduardo Noleto da Nobrega Oliveira Updates in Surgery.2026; 78(1): 169. CrossRef
Laser Hemorrhoidoplasty for Grade III Hemorrhoidal Disease: Safety and Efficacy in a Brazilian Multicenter Retrospective Cohort Study Fabrício Doin Paz de Oliveira, Bruno Lorenzo Scolaro, Ana Carolina Buffara Blitzkow, Sonia Cristina Cordero Time, Alline Maciel Pinheiro Borges, Thais Alencar Pinto dos Santos, Alfadl Abdulfattah, Elisa Treptow Marques Lemos, Glicia Estevam de Abreu Photobiomodulation, Photomedicine, and Laser Surgery.2026;[Epub] CrossRef
Comparative Effectiveness of Lidocaine- Versus Nifedipine-Based Multimodal Conservative Regimens for Acute Hemorrhoidal Disease Michele Schiano di Visconte, Sonia Sarnari, Angelo Guttadauro, Marco Chiarelli, Umberto Favetta Journal of Clinical Gastroenterology.2026;[Epub] CrossRef
Determinants influencing decision-making for operative and perioperative management of grade III and IV hemorrhoidal disease: secondary analysis of a multicenter nationwide prospective cohort study Metin Kement, Orhan Ali̇moğlu, Hakan Baysal, Salih Tosun, Atif Tekin, Ilker Sucullu, Osman Ci̇vi̇l, Nevi̇n Sakoğlu, Naci̇ye Çi̇ğdem Arslan, Ci̇had Tatar, Rozan Kaya, Ali̇ Emre Nayci, Taygun Gülşen, Serhat Meri̇c, Farid Mohamad Hamad, Ahmed Salhat, Ni̇hat Langenbeck's Archives of Surgery.2026;[Epub] CrossRef
The Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of obstructed and ineffective defecation syndrome Adolfo Renzi, Luigi Brusciano, Pasquale Talento, Luigi Marano, Francesca Iacobellis, Antonio Vallo, Giovanna Frezza, Maurizio Grillo, Alessio Palumbo, Elisa Palladino, Benedetto Neola, Fabrizio Foroni, Michele Lanza, Massimo Antropoli, Carmine Antropoli, Annals of Coloproctology.2026; 42(2): 151. CrossRef
Effects of modified Milligan-Morgan hemorrhoidectomy with acupuncture on postoperative wound healing and pain in mixed hemorrhoids Yong-Jiao Zhao, Qian-Yu Xu, Ying Shi, Wei-Na Guo World Journal of Gastrointestinal Surgery.2026;[Epub] CrossRef
Clinical evidence and rationale of topical nifedipine and lidocaine ointment in the treatment of anal fissure and hemorrhoidal disease Gaetano GALLO, Mario TROMPETTO Minerva Surgery.2025;[Epub] CrossRef
Milligan–Morgan hemorrhoidectomy combined with rubber band ligation and polidocanol foam sclerotherapy for the management of grade III/IV hemorrhoids: a retrospective study Qing Long, Yong Wen, Jun Li BMC Gastroenterology.2025;[Epub] CrossRef
Critical appraisal of transperineal Doppler ultrasound as a diagnostic tool for hemorrhoidal recurrence Michele Schiano di Visconte International Journal of Colorectal Disease.2025;[Epub] CrossRef
Validation of a novel imaging-guided and anatomy-based classification system for anorectal fistulas: a retrospective clinical evaluation study Antonio Brillantino, Francesca Iacobellis, Luigi Marano, Adolfo Renzi, Pasquale Talento, Luigi Brusciano, Claudio Gambardella, Umberto Favetta, Michele Schiano Di Visconte, Luigi Monaco, Maurizio Grillo, Mauro Natale Maglio, Fabrizio Foroni, Alessio Palum Annals of Coloproctology.2025; 41(3): 207. CrossRef
Acute thrombosis of hemorrhoidal nodes: conservative against surgical treatment A. Ya. Ilkanich, R. A. Kolomyts, Yu. S. Voronin Yakut Medical Journal.2025; (2): 40. CrossRef
Hämorrhoidalleiden und stadienabhängige Behandlung (inklusive Analprolaps) Oliver Schwandner Die Chirurgie.2025; 96(9): 709. CrossRef
Comparative efficacy of lidocaine- and nifedipine-based conservative therapies in acute hemorrhoidal disease: A retrospective cohort study Michele Schiano di Visconte The Surgeon.2025; 23(6): 406. CrossRef
Postoperative Perianal Abscess and Concomitant Anorectal Fistula: An Extremely Rare Complication After Emergency Transanal Hemorrhoidal Dearterialization With Mucopexy for Hemorrhoidal Disease Charito Chatzinikolaou, Konstantinos Perivoliotis, Amalia Moula, Kyriakos Psarianos, Alexios Stavrou, Ioannis Baloyiannis, George Rallis Case Reports in Surgery.2025;[Epub] CrossRef
Tissue selecting therapy stapler minimally invasive surgery to treat severe hemorrhoids Rong Huang, Minghu Fan, Hongwu Lin, Laibin Luo BMC Surgery.2025;[Epub] CrossRef
Transverse perineal support improves long-term outcomes in patients undergoing stapled transanal rectal resection for obstructed defecation syndrome: a multicenter observational case-control study Adolfo Renzi, Luigi Marano, Pasquale Talento, Luigi Brusciano, Angela Pezzolla, Domenico Izzo, Carmine Antropoli, Francesco D’Aniello, Giandomenico Di Sarno, Gianluca Minieri, Grazia Cantore, Gianmattia Terracciano, Domenico Barbato, Ludovico Docimo, Mass Annals of Coloproctology.2025; 41(4): 330. CrossRef
Hemorrhoidal Disease Jean H. Ashburn JAMA.2025; 334(17): 1541. CrossRef
From the Editor: Uniting expertise, a new era of global collaboration in coloproctology In Ja Park Annals of Coloproctology.2024; 40(4): 285. CrossRef
Lower pain, less itching, and faster healing after ultrasound scalpel-assisted hemorrhoidectomy using an intimate cleaner containing chlorhexidine, acid hyaluronic acid, and natural anti-inflammatories: a multicenter observational case-control study Antonio Brillantino, Luigi Marano, Maurizio Grillo, Alessio Palumbo, Fabrizio Foroni, Luciano Vicenzo, Alessio Antropoli, Michele Lanza, Maria Laura Sandoval Sotelo, Nicola Sangiuliano, Mauro Maglio, Rosanna Filosa, Lucia Abbatiello, Maria Preziosa Romano Annals of Coloproctology.2024; 40(6): 602. CrossRef