Dyssynergic Defecation (or…when the poop just can’t get out)

Great photo, right? Click on it to link to a wonderful article by my colleague and friend, Jenna Sires, written for the amazing group ShareMayFlowers, “Are you pooping properly?”

I’ll admit it… I like treating pooping problems. I know that grosses some people out, but it’s true. I think it’s because bowel problems really really impact people’s lives. I mean, pooping is a super basic human activity–so when it’s not working the way it should, it’s really awful.

I have recently had quite a few patients who are having difficulty evacuating their bowels. Now, there are multiple reasons why this could occur (I know, I’ve written about constipation a lot already, see here for evidence)–but today, we’re going to chat about one in particular, dyssynergic defecation or sphinctor dyssynergia.

What exactly is dyssynergic defecation? 

Basically, your pelvic floor muscles work with your colon reflexively. When your colon is contracting to push the poop out, and you are sitting on the toilet ready to empty your bowels, the muscles should relax and open to allow this to occur.  Sometimes, this relationship becomes dysfunctional, and basically, you think you are pushing and relaxing the sphinctor muscles, but instead, the muscles are contracting and closing the sphinctor. I know what you’re thinking– Jessica, I would know if I were actually contracting my muscles instead of relaxing them while I poop. But, no, you wouldn’t. In fact, many patients are shocked when I show them the actual coordination of their muscles.

Click on the image to go to the blog post I pulled the image from. Great info from a supporter of squatty potty 🙂

Typically, incoordination of the pelvic floor muscles is paired with poor coordination of the abdominal muscles, and often impaired sensation of the rectum. Dyssynergic Defecation is diagnosed typically by an anorectal examination, and anorectal manometry/defecography testing (like this, with an MRI, or by assessing muscle activity with EMG while the person attempts to expel a balloon, or other testing options)

Why does it happen? 

Dyssynergic defecation is very common in people who have constipation. In fact, this review suggested that close to 40% of people with constipation have this incoordination pattern. There are several factors that can contribute to dyssynergic defecation. This review estimated that close to 30% of adults with dyssynergic defecation patterns had constipation as children, and found that 46% had frequent straining to empty hard stool. But there are other factors that can contribute as well, such as:

  • pregnancy
  • traumatic injury
  • low back pain
  • history of sexual abuse/trauma
  • poor behavioral habits related to bowel health
  • nothing (like many other things, we sometimes just don’t know why it happens)

What are the signs and symptoms? 

As we discussed previously, dyssynergic defecation is extremely common amongst those struggling with constipation (typically meaning < 3 BMs per week, as well as symptoms of abdominal discomfort, bloating, and/or difficulty emptying bowels). This article looked at the most common reported symptoms of those with dyssynergic defecation, and found that many experienced the following:

  • Excessive straining to have a bowel movement
  • Feeling of incomplete evacuation after a bowel movement
  • Abdominal bloating
  • Frequent hard stools
  • Frequently utilizing digital maneuvers to empty stool (this means, using a finger to either help pull stool out of the rectum, or using a finger to press inside the vagina to help empty)

What can you do about it? 

The great news is that men and women (and kids too!!) with a dyssynergic defecation pattern can respond very well to conservative treatment! Pelvic physical therapists are typically the providers of choice when it comes to helping people with these problems, and work closely with GI and Colorectal Physicians to help these men and women. Treatment typically involves a few different components:

1. Developing amazing bowel habits. You know that has to be first on my list. If your bowel habits are not stellar, we can try to help your muscles all we want, but you will still have difficulties emptying. So, first things first, we need to make sure your dietary habits rock, you have a great bowel routine, and you know how to sit on the toilet in the most optimal way. Wondering what that toilet position is? Check out this sort of funny, mostly weird video by my favorite potty comedians and stool developers (pun intended), Squatty Potty.

2. Surface EMG Biofeedback training to improve muscle coordination: Biofeedback training uses surface electrodes placed at the anal sphinctor muscles and the abdominal muscles to identify the type of pattern a person uses to expel a bowel movement. Once we identify the pattern you currently use, we can work together to improve the pattern so that your sphinctor muscles relax when you generate abdominal pressure to empty your bowels. Seems pretty basic, right? But the right biofeedback training can make a HUGE difference–and the current research really supports this treatment for anyone with this proble4m. (See this article, this one, that one, and this one!)

Click on this picture to go to the open access article I pulled this from. Basically, this shows that after biofeedback, the person was able to still generate the right pressure, but the anal muscles relaxed and opened rather than contracting.

3. Making sure your pelvic floor muscles are strong, FLEXIBLE, and well-coordinated. So, we’ve talked in detail about the pelvic floor muscles on this blog. Remember, we all want muscles that can contract AND relax. And, for dyssynergic defecation patterns, the relaxation component is extremely important! Often times, people who have difficulty relaxing their muscles to have a bowel movement tend to have tender, overactive pelvic floor muscles to begin with. So, treatment will also focus on improving awareness of the pelvic floor muscles, learning to relax the muscles (dropping and lengthening them), and often will include some manual therapy (yes, internal vaginal or rectal) to help reduce the tenderness and improve the mobility of the muscles.

4. Balloon retraining. People love hearing about this one… but it really is an awesome and effective treatment for so many men and women!! (Research supports it also– see here and here!) This treatment basically uses a small balloon that is attached to a catheter and is inserted into the rectum, and slowly inflated. Often times, people with dyssynergic defecation patterns have decreased sensitivity in the rectum, so they will not feel the presence of stool (or a balloon!) in the rectum when they typically should. Based on what we find initially, we can use the balloon to improve the sensation in the rectum. We can also use a slightly filled balloon to work on proper expelling techniques. I know what you’re thinking, Wow Jessica, this sounds like a super fun and awesome treatment. I know, but honestly, it’s very very helpful for people who need it!

Now, this just scratches the surface in terms of what all we pelvic PTs do to help with dyssynergic defecation. But, I wanted to get the conversation started! This tends to be a topic many people don’t talk about… in fact, I have had men and women travel SO far just to get the initial diagnosis! And, I need that to stop… hence this blog post today. Lastly, if you are having problems with constipation and think you may have this problem– Go see a GI/Colorectal Physician! Honestly, make an appointment today! And, contact your local pelvic PT. If you live in Atlanta or the surrounding area, give me a call! It’s time to get your bowels back in order (or even in order for the first time!).

I always look forward to hearing from you! So please, ask any questions or make any comments below!!

~ Jessica

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24 responses to “Dyssynergic Defecation (or…when the poop just can’t get out)

  1. Hi Jessica
    I find it very interesting working with this population of patients. I treat pelvic floor dysfunctions as well and find that when I treat kids with encopresis, its hard to try the balloon test or even to do simple sEMG with them. They don’t feel comfortable and its hard to get a great reading on them. Please advise. My question is the MD sent this child who is 5 and I really don’t think is appropriate for the biofeedback retraining but nevertheless to appease the MD I have treated her and her bowel movements have gotten better just with exercise, diet modification and toileting positioning. She is still having difficulty with FI when sleeping and sometimes when at school but she has gotten much better after seeing her 7 times. I am however having a huge issue with biofeedback, she does not like this but I think it may be the only thing left that we can use to assist with proper evacuation. I don’t have a balloon to try the balloon test nor have I been trained to use the balloon test on kids. Do you recommend that? I would love to know your thoughts.
    KH

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    • Hi Katrina, Thanks for commenting! I avoid all internal/invasive treatments in children, so do not typically use sensory retraining with the balloon for them. I think it is difficult for children to fully understand these treatments, and frankly, I have treated adults who were traumatized by medical tests as children and prefer not to be associated with trauma for anyone :). That being said, I do think SEMG utilizing surface electrodes can be a very effective treatment to improve defecation patterns in children. I try to normalize it as much as possible and tell the child that we’re using stickers to “play a video game with their bottom.” If the child is shy, I generally will instruct the parent on where to place the electrodes and then the child will be fully clothed for the treatment. We use animated games and templates and practice “snake breathing” and “big belly breathing” to help the kids learn how to use the right defecatory pattern. Have you tried doing it that way? I hope that is helpful… I receive referrals regularly for children with constipation and this is typically what I utilize. I’ve written a few posts on kids specifically (https://jessicarealept.com/category/pediatric-pelvic-floor-pt/). Please feel free to e-mail me directly at jessica@onetherapy.com if you have additional questions to help this little one, and I can probably help once I get some more information (just don’t want to post any specific patient info on the blog!). Thanks! ~ Jessica

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  2. Annette Sison-Estrada, PT

    Thank you so much for all your great blogs & articles, Jessica!
    I always look forward reading all of them as they come in my inbox.
    Working in a rural setting as the only pelvix floor PT, your clinical pearls that you have been sharing has been helping me alot & I don’t feel so lost being by myself. More Power to you and keep up all these awesome blogs & articles!
    God Bless.

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  3. Pingback: Your bladder and bowels need a diary. | Jessica Reale, PT, DPT, WCS

  4. Hi I was wondering if you know of a doctor or pelvic floor therapist in Utah (near Salt Lake City or the Univ of Utah) who could help me with dyssinergic defecation? thx!

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    • Hi Kristyn,

      I do not know anyone directly in Salt Lake City, however, I did find Innes Schwemmer, PT, DPT, WCS located at the University of Utah in SLC. Her office number is (801) 587-7005. Hopefully she can help you! Best of luck in your recovery!
      ~ Jessica

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  5. I am a 69 year old female losing weight rapidly. I ended up with a nurse for enemas and now laxative dependent. I had one hemorrhoids banded off but still lots of pain. I’ve been through testing and dome physical therapy they has not worked. Even when I could have a bm, nothing would happen without straining. Dr put me on Linzess….did not work. No digest easily so have urge to defecate usually twice a day but cannot because of the dyssynergia. I am so scared. I cannot give myself enemy’s because I have rods in my back so I cannot reach. How can I make it to Therspy when I need to defecate but cannot (anxious, constant pressure rectum snd stomach to defecate but cannot). Laxatives do not always work…off and on. I can’t eat. I have heart rhythm issues and now worried I won’t pass to have surgery. All of this is taking so long and keep losing weight.

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    • Hi Linda,
      I’m so sorry you are going through this– I can’t imagine how difficult it has been for you! Tell me more about the physical therapy… what sort of treatments were done? Did you have internal vaginal/rectal examinations or treatment? Did the PT use SEMG biofeedback with you? Balloon retraining? What sort of exercises did you do? One thing to remember is that physical therapy is going to differ based on the clinician you see. If you did not have good results with one, that does not mean you won’t have good results with another. It may be worth going to get a second opinion and working with someone who can help you manage all aspects of the problem (musculoskeletal, dietary, behavioral, etc), working in collaboration with your medical team. Where are you located? If you let me know, I can help you find someone near you! Wish you all the best in your recovery! ~ Jessica

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      • Thank you for your quick response. I quit therapy to have a nurse. Medicare will not pay for PT outside home health and home health does not offer the pfd PT. I’m not sure what to do.,I’m very weak and have to use laxatives that make me feel awful whether they work or not. Everything is so drawn out eg tests then the wait for results. I did not get to the biofeedback yet because I had to have a nurse. I’m not sure if you have any prescription or otc meds. I read a lot and apparently meds are not successful with this. My Drs are not sure what to do. I need to stay strong to pass a stress test and have surgery but it’s getting more and more difficult. My stomach is a mess. There only seems to be a sense of urgency in my mind. My family really doesn’t want to hear it.?they love me but are not caretakers nor doctors. I take one pain pill a day but no more as they helped get me this way. If I had a lot of weight on me I would not be as fearful although not being able defecate is horrible. It would be better if I had slow transit but my system digests normally. I appreciate you talking with me as I feel I have no one to just listen. I understand though. Who wants to talk about how someone can’t poop. lol If I get better, I am going to help people with pfd. Even if it is just to listen and make them comfortable. I have a wonderful family but like I said they are not caretakers in the medical sense. Also, perhaps I can find a delivery service that cooks up healthy foods. (I have a difficult time with fiber and I also fear eating much because so can’t get it out.) Another issue is just about every medicine has a constipation side effect. Three I need: heart, pain, and anti anxiety plus the health drinks like Ensure causes constipation. I have other disabilities they add to this. I am a mess but sometimes I can joke about it.

        I tend to write novels as I feel like I do not have a life or the life I once had. I know there are so many worse off than myself. I am in pain all day but not cancer pain. I should count my blessings. I hope others do not see this.

        Again, thank you. Your article is awesome. I passed it onto my daughter bc the video was hilarious! She has a little more knowledge now because of your article.

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      • Hi Linda,

        Sorry for my slow response this time! Sounds like a difficult place to be with currently being on home health, and the many difficulties you are having! As soon as your able to leave the house, I really would encourage you to see a pelvic physical therapist to further evaluate you and recommend a treatment plan. Although there are many nurses educated in pelvic floor dysfunction, a physical therapist will offer a different skill set, and evaluate you in a different way, which may be a key piece in your recovery journey. I hope you will be able to leave the house soon, and wish you all the best in your recovery! Please feel free to be in touch if you need anything in the future! ~ Jessica

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  6. My 12 year old son was just diagnosed with this. He has been having stomach aches for months and we have tried all sorts of testing. A pediatric GI specialist just recommend the bio-feedback training. My question is how does anxiety play into dyssynergic defecation? Can it cause it or does having dyssynergic defecation cause anxiety? I am seeing anxiety and depression symptoms in my son as well. Any advice or suggestions would be most helpful.

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    • Hi Ricki,

      Anxiety can often be connected to toiletting problems in children, especially if the child has anxiety related to being on the toilet (or a fear of defecation, which I have seen happen after a painful bowel movement). If you think it may be a factor for your son, it could be worth mentioning it to your GI or pelvic PT, and getting a referral to a good child psychologist who could help!

      I hope your son is able to get things moving soon! Wish you all the best!

      Jessica

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  7. Hi Jessica! Help! I’m 8 weeks postpartum (second child) and had a third degree tear over a previous 3rd degree episiotomy (YIKES). I am already slated to see a Pelvic Floor physiotherapist, but in the mean time, I have a question about using glycerin suppositories. They work so well to help evacuate, but I feel like I can’t accomplish a difficult bm without. What is more harmful, using suppositories semi regular or having to strain to poop?

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    • Hi Anna, sorry for my delayed response! Ideally, we want to avoid straining as much as we can to protect the pelvic floor. If your doctor has recommended suppositories, you could continue that until your pelvic PT helps you develop other strategies to empty your bowels. There are so many natural methods to get the bowels moving comfortably. Hope pelvic PT is going well! All my best, Jessica

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  8. Hi! I am struggling with pelvic floor dyssynergia. I have gotten the colonoscopy and anorectal manometry, this led to PT and biofeedback. I have been going to PT now for months and I’m still not getting better. My GI has me on laxatives which leaves me in the bathroom for hours everyday. However, without them, I’m lucky if anything comes out at all. Biofeedback showed a 50 when resting! This was just last week. So then I decided to try a chiropractor, maybe that’s where the miscommunication was coming from.. After the chiropractor, I now register at a 20 when resting. So that was a huge improvement, yet I’m still having the same issues. I’m still in this bathroom hours straight everyday, sometimes up to 5+ hours. Not being able to defecate fully and properly has completely changed my life for the worse. I’ve been out of work since December, searching for my cause or causes. I’ve been going to a therapist for months now as well, seeking out mental heath, thought maybe that was the issue. I was abused growing up physically, mentally and sexually. I have had many traumas throughout my life. I just don’t know anymore and I need any help I can get. I’m really starting to think there is something else wrong that none of my many doctors along the way were able to catch. What do you do when the biofeedback doesn’t work, when chiropractic doesn’t work, when mental therapy doesn’t work, super healthy diet doesn’t work, exercise doesn’t work, pills don’t work, squatting to lengthen the muscles don’t work, proper sleep schedule doesn’t work. yoga exercises doesn’t work. The only other things I can think of now is acupuncture and hypnotism. Is that really where going to medical professionals is leading me now? It’s either that, or I scrap my team of doctors and start over building a new team? I’m only 36 years old, what is wrong with me? I live in northern NJ, I’m considering going to NY since they have better doctors, or so I’ve been told. That would dramatically change how much this all costs and the efforts of traveling. I already have to travel very far just to get to PT, sometimes up to 2 hours to get home, stuck in traffic right after getting internal work done. I just don’t know anymore and neither do my doctors. My GI admitted last visit that there’s got to be something else because I’m not responding to the treatments in anyway that was expected. Any help would be appreciated. It feels like my life is ending and no matter how much money I spend or how many doctors work my case, I’m barely on any road to recovery. Thank you for your time and for reading this.

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    • Hi William,
      First, I apologize for my slow response. I am so sorry you’ve been struggling with this for so long! It sounds like you have tried many different treatments, but are still having a lot of trouble. Tell me a little bit more about what PT has included for you. Has it only been biofeedback or has it included internal rectal examination and evaluation? Have you worked with a functional medicine doctor at all to look more at your gut health, gut bacteria and nutrition? I’m happy to help you as much as I can, but just need a little more info. Feel free to email me at jessica@onetherapy.com and we can chat more. All my best, Jessica

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  9. I have had pelvic-floor dysfunction for many years, but am recently having trouble initiating bowel movements and then passing stool. I started PT two weeks ago, and the therapist is doing inter-vaginal muscle treatment. Is this appropriate, given that my issues seem to be more related to the rectum? My tailbone is often sore and I have lower-back pain. For women, can treatment happen either in the vagina OR the rectum, or should we really be focusing more on the latter? Many thanks.

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    • Hi Jacquie! Great question. The pelvic floor muscles actually run around the openings of the urethra, vagina and rectum, so yes, the pelvic floor can be treated vaginally when someone is having bowel problems. That being said, I have found that many patients who have difficulty with defecation benefit from specifically being treated intrarectally. The puborectalis muscle which hooks around the rectum can only be accessed rectally and is often a big player in situations where someone is having difficulty passing stool. Sometimes, however, if all of the muscles are very sensitive, patients may tolerate vaginal treatment more comfortably than rectal treatment– so it can be a good starting point. It’s difficult for me to say in your specific situation, having not examined you myself. I would ask your PT specifically about your situation (basically, ask her just what you asked me!), then go from there. If you have additional questions after that conversation, feel free to be in touch! Best of luck in your recovery! ~Jessica

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  10. I was molested at the young age of 3 , I have had trouble with evacuation since young , My daughter ripped the wall between my rectum, and Vagina when she was born, I have strained so hard that I ended up with a 3 rectocele , and had surgery for it . Now my feces comes out flat on one side ( when I can get it out ..) I have problems with taking stool softeners, and things for constipation, as my heart races ,and my face turns red and my abdomen hurts . So I buy enemas ,dump them out and use nothing but water in it. and sometimes I even have trouble getting the little end on the enema bottle into my rectum.until I put the tip of my finger into my rectum, and push it open. My feces is not hard , but it comes out in small pieces . My dr. had a balloon test done, and I failed it . I could not push the balloon out , Then he had an X ray done and it showed my intestinal track was full, but then he had me swallow little round markers and Xrays taken every other day for 3 times . I had 3-7 bowel movements a day while the markers were in me , but they stopped when the makers were out of my body. He said I should just take laxatives for the rest of my life . Another doctor , did a barium enema , but they had trouble getting the end of the hose into my rectum, so he said my muscles were cramping and ordered a tins unit for me to use , It did not help. This is heart breaking for me . I am 66 years old , and not getting younger . I really want some answers , and my Dr.’s seem to just give up .I want so bad to get this problem fixed before I get older , I have worked in Nursing homes ,and have seen the horrors of problems like these . After reading what you have written, I am hopeful that if I can find a colorectal Dr. around where I live ,that I have hope .. Thank you .. Jeanette

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    • Oh Jeanette, I’m so sorry you have gone through all of this!! I’m glad my article was helpful for you, and I truly help you find relief soon! Please let me know if there is anything I can do to support you! ~Jessica

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  11. Hi,
    I have a question. I more recently have been having troubles with my bowel movements. It is not constipation just straining hard to produce. I have gone from one bowel movement a day to 3 a week, and I feel bloated. When I do have a bowel movement I am feeling like they are not complete. When I need to pass gas I feel like it is getting trapped and not able to get out or I am straining to let them out to. I think it may be because for a while, when I had to use the bathroom at work, I started to “help” my bowel movements finish quicker by pushing back against the space right in front of my anus. Could my “helping” my bowel movements caused my difficulties?

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    • Hi Toni, It’s difficult really to say without examining you. I’m wondering if you “helping” to get the stool out was masking a problem that was there (meaning, perhaps your muscles weren’t opening the way that they should). If you haven’t already, I would encourage you to see someone to be evaluated comprehensively so they can help you see what is going on and figure out the next step to help you get better. Wish you all the best for your recovery! ~Jessica

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