There are three groups of patients with constipating symptoms; those with obstructed defecation, slow transit constipation, or both. The treatment of obstructed defecation (pelvic outlet obstruction) is often challenging because the underlying disorders are diverse with a wide range of and clinical symptoms. The underlying anatomical and pathophysiological changes in patients with obstructed defecation are complex and often poorly understood. As a consequence, many medical, surgical, and behavioral approaches have been described, with no single panacea. For successful outcomes, preoperative physiologic testing is mandatory to differentiate between obstructed defecation caused by pelvic outlet obstruction and slow transit constipation. Obstructed defecatory disorders can distress patients both socially and psychologically and greatly impair their quality of life. For the great majority of patients, dietary adjustment with an increased fiber and liquid supplement can resolve the symptoms. The surgical approach depends upon the etiology, severity of symptoms, and operative risks. In a small group of patients with a rectocele or a third degree sigmoidocele, surgical intervention yields a high success rate. Division or resection of the puborectalis muscle is not recommended. In patients with a mixed pattern of slow transit colon and pelvic outlet obstruction, surgical intervention alone is often not successful; these patients can experience better outcomes by conservative treatment of pelvic outlet obstruction, followed by a colectomy. Stapled transanal rectal resection has recently become a recommended surgical procedure for obstructed defecation syndrome. One problem when using a transanal stapling device for rectal surgery is the potential damage to the structures located in front of the anterior rectal wall. The laparoscopic approach can shorten the hospital stay with good outcomes and is well tolerated in elderly patients with rectal prolapse. Despite the progress in modern surgery, the choice of the surgical procedure of pelvic outlet obstruction is still controversial. Preoperative counseling of all patients undergoing surgery is of extreme importance, in particular to explain the evolving nature of pelvic floor dysfunction and the possible need for further reconstructive surgery. To identify patients who will benefit from surgery for obstructed defecation, a careful selection of candidate patients remains the crucial issue in the diagnostic assessment. Surgical intervention should be limited only to the patients with identifiable, surgically correctable causes of outlet obstruction. This review gives an overview of surgical treatment options in patients with obstructed defecation.