Disorders of Defecation
Satish S.C. Rao, MD, PhD, FRCP (LON)
Defecation is a coordinated process that involves
generation of sufficient propulsive forces in the abdomen and rectum together with relaxation of the
puborectalis and external anal sphincter. Likewise,
continence involves conscious retention of bowel
contents until stool or gas can be voluntarily eliminated in an appropriate fashion. A failure of these
processes leads to altered bowel function and disorders of defecation that are commonly encountered in
clinical practice. They include a diverse group of mal-adies that result in altered defecation. Among them
are functional disorders, such as dyssynergic defecation, and mechanical/structural disorders, such
as rectocele, solitary rectal ulcer syndrome (SRUS),
excessive perineal descent, and rectal prolapse. This
manual discusses 3 cases that illustrate the clinical
features and management approaches to dyssynergic defecation, SRUS, and fecal incontinence.
CASE PRESENTATION 1
Initial Presentation and History
A 26-year-old white woman with a 10-year
history of constipation presents to a gastro-
enterologist after referral from her primary care phy-
sician. She reports spontaneous bowel movements
once every 2 weeks, and often she has to induce
stools by using enemas or suppositories. Stooling
became progressively more difficult for her during
her teenage years, with infrequent bowel movements
and hard stools (type 1–2 on Bristol stool scale).
She also reports having to strain excessively during
bowel movements, and on average she spends 30
minutes in the bathroom. She denies experiencing
any perianal pain or bleeding or using manual ma-
neuvers to defecate, but she often feels a sense of
incomplete evacuation. She also describes intermit-
tent abdominal pain and bloating.
She has tried several over-the-counter laxatives,
including milk of magnesia, senna, and magnesium citrate. Most recently, she tried lubiprostone
and polyethylene glycol without improvement. Her
past medical history is significant for endometriosis, exploratory laparotomy, and 1 vaginal delivery.
There is no family history of colorectal cancer or
inflammatory bowel disease. She works as a truck
driver and does not use alcohol, illicit drugs, or
tobacco. There is no history of physical or sexual
abuse. Her current medications include lubiprostone 24 µg twice daily, polyethylene glycol 17 g
twice daily, and a birth control pill.
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