1. Freeman A et al. Fecal incontinence and pelvic floor dysfunction in women: a review. Gastroenterol Clin North Am. 2016 Jun;45(2):217-37. [PMID: 27261895]
  2. Rao SS et al. Diagnosis and treatment of dyssynergic defecation. J Neurogastroenterol Motil. 2016 Jul 30;22(3):423-35. [PMID: 27270989]
  3. Paquette IM et al. The American Society of Colon and Rectal Surgeons' Clinical Practice Guideline for the Evaluation and Management of Constipation. Dis Colon Rectum. 2016 Jun;59(6):479-92. [PMID: 27145304]
  4. Mulholland MW. Greenfield's Surgery: Scientific Principles and Practice. 6th ed. Philadelphia: Wolters Kluwer; 2017.
  5. Cameron JL. Current Surgical Therapy: Expert Consult - Online and Print. 11th ed. Philadelphia: Elsevier Saunders; 2013.
  6. Paquette IM et al. The American Society of Colon and Rectal Surgeons' Clinical Practice Guideline for the Treatment of Fecal Incontinence. Dis Colon Rectum. 2015 Jul;58(7):623-36. [PMID: 26200676]
  7. Varma M et al. Practice parameters for the management of rectal prolapse. Dis Colon Rectum. 2011 Nov;54(11):1339-46. [PMID: 21979176]

Image Sources

  1. Slide 1:
  2. Slide 6: (top) (Bottom right);
  3. Slide 7:
  4. Slide 8:
  5. Slide 9: staff. "Blausen gallery 2014". Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762

Contributor Information


Robert Kucejko, MD
General Surgery Resident
Drexel University College of Medicine
Philadelphia, PA

Disclosure: Robert Kucejko, MD, has disclosed no relevant financial relationships.

Alexander Crean, MD
General Surgery Resident
Drexel University College of Medicine
Philadelphia, PA

Disclosure: Alexander Crean, MD, has disclosed no relevant financial relationships.

Edward Fazendin, MD
General Surgery Resident
Drexel University College of Medicine
Philadelphia, PA

Disclosure: Edward Fazendin, MD, has disclosed no relevant financial relationships.

David E Stein, MD
Associate Professor of Surgery
Chief, Division of Colorectal Surgery
Drexel University College of Medicine
Philadelphia, PA

Disclosure: David E Stein, MD, has disclosed no relevant financial relationships.


Close<< Medscape

Disorders of Defecation: Too Little, Too Much

Robert Kucejko, MD; Alexander Crean, MD; Edward Fazendin, MD; David E Stein, MD  |  February 22, 2017

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Slide 1

The pelvic floor contains a number of muscles that regulate defecation. Disorders of the pelvic floor include the following:

  • Stretching or weakness in the muscles (rectal prolapse)
  • Anatomic defects of the rectum passing through the muscles (rectocele)
  • Failure of the muscles to relax (anismus, or dyssynergic defecation)
  • Muscle spasms (levator syndrome)

Prior trauma to the area can also damage the muscles of the pelvic floor and the surrounding structures. These disorders can often present with either constipation or fecal incontinence, and accurate diagnosis may require advanced testing by a specialist.[1,2]

Image courtesy of Wikimedia Commons.

Slide 2

Constipation is the dysfunction of colonic motility in the defecation process. It is one of the most common gastrointestinal (GI) complaints in the physicians' office, with a prevalence as high as 30% in select populations, and it can have a substantial impact on quality of life. Each year, this typically benign condition accounts for well over $1 billion worth of over-the-counter medications. According to the Rome III criteria, constipation is diagnosed when two or more of the following symptoms are present:

  • Straining during ≥25% of defecations
  • Lumpy or hard stools in ≥25% of defecations
  • Feeling of incomplete evacuation in ≥25% of defecations
  • Feeling of obstruction or blockage to defecation in ≥25% of defecations
  • Having fewer than three unassisted bowel movements a week
  • Relying on manual maneuvers such as digital stimulation to promote defecation ≥25% of the time

Image by Sam Shlomo Spaeth for Medscape.

Slide 3

An 84-year-old woman comes to the office with a complaint of mild, persistent abdominal pain for the past 6 months. She denies experiencing any rectal bleeding and is up to date on her screening colonoscopies. She takes medication for hypertension and hyperlipidemia but has had no recent changes in her health. Her abdomen is soft, with minimal diffuse tenderness to deep palpation. You decide to order an abdominal radiograph (shown).

Which of the following is not associated with an increased risk of constipation?

  1. Mental health conditions
  2. Nonwhite race
  3. Age >65 years
  4. Male sex
  5. Lower socioeconomic status

Image courtesy of David E Stein, MD.

Slide 4

Answer: D. Male sex.

Women are at higher risk for constipation than men are.[3] The causes of constipation are diverse and often multifactorial. Potential exacerbating factors include diet, dehydration, metabolic disorders, and neurologic diseases, as well as psychosocial issues. Multiple classes of medications can cause constipation, including opioids, antidepressants, anticholinergics, calcium-channel blockers, and calcium supplements. Initial management consists of medication review in conjunction with changes in diet (eg, increasing fiber and fluid intake). These conservative measures have a high success rate in patients without underlying pathology. In cases where they prove ineffective, referral to a specialist for further workup is warranted. The computed tomography (CT) scan in the slide shows a large stool burden in the transverse colon of a patient with constipation.

Image courtesy of David E Stein, MD.

Slide 5

A 54-year-old woman with a history of three vaginal deliveries presents with complaints of chronic constipation and a sensation of incomplete emptying of stool from her rectum. She also reports episodes of multiple small bowel movements in a short period. You are concerned about pelvic floor dysfunction as the possible cause of her constipation.

Which of the following is not an appropriate test to include in the workup of this patient?

  1. Colonoscopy
  2. Anal and perineal manometry
  3. Defecography
  4. History and physical examination
  5. Positron emission tomography (PET)/CT

Image courtesy of David E Stein, MD.

Slide 6

Answer: E. Positron emission tomography (PET)/CT.

All of these measures except PET/CT are standard components to be considered in the workup of pelvic floor dysfunction. Pelvic floor dysfunction gives rise to a wide range of patient presentations that can include problems with urination, disordered defecation, and chronic pain. The first step in the evaluation consists of a thorough but focused history and physical examination. After initial evaluation, consultation with a GI, colorectal, or urologic specialist is advised to guide further management and testing. Magnetic resonance imaging (MRI) of the pelvis (see slide 5) is helpful for evaluating the pelvic floor musculature and can identify anatomic lesions responsible for a patient's symptoms. Anorectal manometry (shown) can provide information about the functioning of the pelvic floor muscles.[4]

Images courtesy of David E Stein, MD (left) / Wikimedia Commons (top) / Medscape (bottom right).

Slide 7

A 65-year-old woman with a history of chronic constipation and previous obstetric trauma presents with worsening constipation and the sensation of vaginal fullness with bowel movements. She also reports that she feels unable to empty her rectum with bowel movements. After a bimanual pelvic examination, rectocele is the suspected diagnosis.

Which of the following is the ideal imaging examination to evaluate for rectocele?

  1. Abdominal radiography
  2. Abdominopelvic CT
  3. Defecography
  4. Pelvic MRI
  5. Endoanal ultrasonography (EAUS)

Image courtesy of Medscape.

Slide 8

Answer: C. Defecography.

Rectocele is the bulging of the rectum into the posterior wall of the vagina, which is thought to be caused by weakened pelvic floor muscle and a thinning rectovaginal septum. When this condition is suspected, defecography is the imaging modality of choice. As many as 40% of patients with rectoceles may be asymptomatic. Treatment should be pursued only if patients are having significant symptoms that affect their quality of life. Medical therapy includes fiber supplementation, stool softeners and biofeedback. Surgical therapy (shown) should be reserved for patients who continue to experience severe symptoms despite optimal medical therapy.[5]

Image courtesy of Medscape.

Slide 9

A 45-year-old woman who underwent episiotomy to assist vaginal childbirth in the previous year presents with complaints of fecal incontinence. She has multiple episodes of incontinence each day and states that she feels unable to hold stool in her rectum when she has the urge to defecate.

After a thorough history and physical examination, which of the following tests would be most helpful in evaluating this patient's anal sphincter anatomy?

  1. EAUS
  2. Abdominopelvic CT
  3. Anal manometry
  4. Pelvic MRI
  5. Abdominal radiography

Image courtesy of Wikimedia Commons / staff.

Slide 10

Answer: A. EAUS.

EAUS allows visualization of the internal and external anal sphincter muscles. The image in the slide shows that both sphincter muscles are incomplete at the superior aspect, a finding related to the obstetric trauma sustained by the patient. Whereas the internal anal sphincter is an involuntary muscle, the external anal sphincter is under voluntary control, giving the patient the sensation of holding stool in despite an urge to defecate. Fecal incontinence can be caused by anatomic injury to the sphincter muscles, as well as by functional defects that develop despite a normal anatomy.

Image courtesy of David E Stein, MD.

Slide 11

Fecal incontinence (accidental bowel leakage) in an adult can have devastating effects on quality of life, which can result in significant disability. Continence relies on a complex relation between pelvic floor muscles, neurologic function, rectal reservoir function, and stool consistency. The workup begins with a thorough history and physical examination. Risk factors for fecal incontinence include the following:

  • Pregnancy (multiparity, prolonged labor and instrument deliveries)
  • Chronic diarrhea
  • Diabetes mellitus
  • Previous anorectal surgical procedures
  • Urinary incontinence
  • Smoking
  • Obesity
  • Neurologic disease

Physical examination by a specialist would include a thorough external inspection, digital examination to assess sphincter tone, and anoscopy to inspect the anal canal. Clinical testing includes pelvic MRI, EAUS, anal manometry, and defecography.[6]

Image courtesy of David E Stein, MD.

Slide 12

Management of incontinence begins with dietary modification. Studies have shown that formal counseling regarding dietary habits, fluid management, bowel routines, and changes in medication can lead to improvement in 22-54% of patients with fecal incontinence. Medications used in this setting include antidiarrheal agents, tricyclic antidepressants, and opiates. When conservative measures fail or when obvious anatomic defects (eg, previous sphincter trauma) are present, surgical management (shown) may be indicated. Sphincteroplasty (sphincter repair) attempts to restore the integrity of the internal and external sphincters, as well as to provide resistance to stool passing through the anus. Sphincteroplasty for defects caused by pregnancy complications are associated with good-to-excellent results in as many as 85% of patients.

Image courtesy of David E Stein, MD.

Slide 13

A 65-year-old woman with a history of multiple vaginal childbirths and chronic constipation presents with a complaint of her "rectum falling out" (ie, rectal prolapse). She is able to push the prolapsed rectum back in. This is occurring more frequently and is associated with straining during bowel movements.

Which of the following is the most effective treatment for rectal prolapse?

  1. Biofeedback
  2. Fiber supplementation
  3. Abdominal operation
  4. Perineal operation
  5. Endoscopic therapy

Image courtesy of David E Stein, MD.

Slide 14

Answer: C. Abdominal operation.

Rectal prolapse (procidentia) is six times more common in women older than 50 years than it is in men. Although multiparity is commonly associated with this disease, one third of female patients are nulliparous. When rectal prolapse occurs in men, it is more likely to be a result of developmental delay or psychiatric comorbidities. It is common for patients to confuse rectal prolapse with prolapsing hemorrhoids. To identify rectal prolapse, after a thorough history is performed, it may be helpful to examine the patient while he or she is sitting or squatting, as well as to have the patient attempt to reproduce symptoms on the toilet. Diagnosis is aided by additional tests such as defecography, colonoscopy, and barium enema. Treatment of rectal prolapse is primarily surgical.[7] Operative repair via an abdominal approach is the most definitive treament (see the following slide).

Image courtesy of David E Stein, MD.

Slide 15

Medical comorbidities typically dictate which of the two primary surgical approaches is chosen. For healthier patients who are low-risk surgical candidates, an abdominal procedure (either open or laparoscopic) is performed. The abdominal approach has a recurrence rate four times lower than that of the perineal approach. The primary method of reducing recurrence is to affix the rectum to the retroperitoneal space (rectopexy). Removal of excess sigmoid colon can be helpful in patients with redundant colon or chronic constipation. If the patient cannot tolerate an abdominal operation, then a perineal rectosigmoidectomy (Altemeier procedure; shown) is performed. This procedure consists of a full-thickness resection of prolapsing or redundant rectum, followed by a transanal anastomosis.

Image courtesy of David E Stein, MD.

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