**3. Surgical indication**

SDO can have many causes as already explained, one of them is the pudendal nerve injury and secondary pelvic floor denervation. One of the factors that can contribute to the development of fecal or urinary incontinence is denervation of the muscles such as puborectalis, pubococcygeus, and pelvic fascia [8, 9]. Some studies link decreased pudendal nerve function and incontinence in women [10]. In that sense, delivery-related pelvic floor trauma [9] can result in pelvic muscle or fascia trauma and pudendal nerve injury. There are electromyography and pudendal nerve conduction studies after childbirth showing denervation [11].

Other factors such as chronic straining at stool are related to pudendal nerve injury. This affection is being studied as it can have an association with genuine stress incontinence. Women with low urinary tract dysfunction have more chance of suffering from SDO symptoms, which makes think of benign joint hypermobility syndrome or other connective tissue disorders as an important factor [12].

Considered all the possible causes, surgical treatment in patients with obstructive defecation symptoms is indicated after having completed a conservative management, and this has not achieved control of the symptoms and, after it has been provided that there is an anatomical basis that justifies them.

In the specific case of patients with ODS, the origin could be a functional disorder, and we must demonstrate an anatomical cause through imaging that justifies the intervention. The surgical indications for a rectocele are normally a size longer than 3 cm [3], or a significant retention of the barium contrast within it, during defecography associated with important symptoms that affect quality of life, such as the need for frequent digitation to achieve defecation [13]. Prior to the indication for surgery, it is essential to inform the patient and determine the expectations that the patient has of the surgical treatment [14].
