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

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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.

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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 problem. (See this article, this one, that one, and this one!)

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

You don’t have to just deal with your bowel problems! CLICK HERE to schedule a virtual consultation with our team today to start feeling better!

135 thoughts on “Dyssynergic Defecation (or…when the poop just can’t get out)

  1. Hi Jessica…Can pelvic muscles uncoordination occur at the end of bowel movement? Its like at the beginning, the bowel movement is normal..but at the end i feel that i m not done yet and no matter how hard i strain…it doesnt come out. Many times i feel that i m not done yet..but later its just gas that is stuck there…and that too doesnt come out. I drink 2 litres of water in a day..also intake of fibre is proper in the form of fruits and vegetables.
    Thank you
    Dharmesh

    1. Hi Dharmesh! Absolutely, this can happen. I see this as a common complaint. The muscles basically don’t like staying open, so they’ll close and people will feel incomplete evacuation of the stool or difficulty with gas. If you haven’t, I would recommend seeing a pelvic PT for evaluation to see if they could help you! All the best in your healing!

  2. Hey Jessica!

    Great article I feel like your description of this checks off all of the symptoms that I have. My colonoscopy was clear minus some internal hemorrhoids that I always thought was causing me to have to push and strain so hard to have a bowel movement. But now I feel like those are a result and not the cause.

    Would the severity of this condition possibly get worse as the day goes on? I am able to have 1 super easy bowel movement in the morning but as the day goes on I constantly feel like I need to go but am unable to. I spend so much time on the toilet and it is having a huge negative impact on my life. Could this also cause narrow, pencil thin stools? All the doctors I’ve seen seem to believe I have tenesmus, but have only recommended I take more fiber. Unfortunately this makes me feel worse and have to strain even harder to have a bowel movement. If you have any advice or know of any doctor in the Washington DC area that would be great. I’ve been suffering through this for years and I am desperate for some relief. Thanks again!

    1. Hi Brendan, I’m sorry you’re dealing with this! We actually see this pattern of worsening symptoms as the day progresses very frequently. As the muscles become irritated and contract more, this leads to increased tensioning, which can cause very narrow stools. I think seeing a pelvic floor PT could be a good place to start. In the DC area, I frequently refer to Pany Nazari and Lauren Trosch. They’re both excellent clinicians! All the best, Jessica

  3. I absolutely enjoyed reading this article and found it very informative. Mega props to those responsible for the squatty potty video too. Thank you so much for this article!

  4. Hi Dharmesh! I read you comment I have the same problem Mnay times it takes a long time ,
    Sometimes it takes an hour or more just to get things moving ,,,,,,,,It goes lower and lower ,ito the rectum ,,Sometime I am able to go a bit but it’s always incomplete ,,,,and it is very painful ,,Even when I add force ,,and push it will not come out ,,,,I know I should not sit there for such a long time ,But the urge to go is so overcoming that I cannot get myself to get off the toilet ,,Sometime if I just sit there and strain for a while ,I can get out a little more but again always incomplete ,,I have gone to a least ,7 rectal surgeon as well a a couple of gastro doctors ,,and they all give me different sugestions ,,,,The suggest colace ,mirilax ,metamucil ,senna you name it Nothing works ,,,,I tried to change my diet or add a lot of water also but ,,that does not help much either ,,,

    Looking deparately for an answer for this problem This is painful and has been going on for at least 7 to 8 years

    Very hard to live with this condition ,I always feel like I have to go to the bathroom ,,and it is hard to live with this problem ,,,,,,,Anyone have alternative answers ,,None of the doctors have an good solution ,,,,

    Yours truly
    Sandy

    ,,

    1. Hi Sandy, I’m so sorry you’re struggling. Have you worked with a pelvic floor PT yet? That could be very useful to get a different perspective on your condition. Happy to help make a recommendation for you! All the best, Jessica

  5. Can this occur suddenly instead of gradually, as well as at a relatively young age (I’m still in my teens)? I remember that about three years ago I was abruptly unable to defecate without strain, and thus have been to many doctors, resulting in a colonoscopy as well as an MRI. Everything was proclaimed to be in good health, and it was declared that my inability was merely psychosomatic. Though even after three whole years, the problem persists.

    1. Hi JD- First, I’m so sorry for this delay in responding! Bowel problems in children and teens is also very common. I would really encourage you to see a different physician, perhaps a pediatric GI specialist (if you’re under 18) or a Colorectal specialist (if you’re over 18) to evaluate you. They can perform anorectal manometry for you which will identify dyssynergia. Option 2 would be to seek out a pelvic floor physical therapist who can evaluate this for you in clinic and help you figure this out. If you are under 18, I would really recommend sharing this article with your parents to help them potentially understand what is going on and support you in your journey. Sorry again for the delayed response! Best of luck in your healing! ~ Jessica

  6. Hello Jessica; I am a clinical psychologist working in Sarasota, Florida. I have been treating a 15 year old male who is often ostracized at school due to recurrent fecal odor and the soiling of himself (even during class). Most people had expressed concerns related to potential past issues of abuse, his current familial problems and his suppressed feelings of anger. Reading your blog presents an alternate hypothesis. have you had and/or treated teenagers with this type of problem? How common might this problem be for adolescents? Thank you for your efforts. I look forward to your repsonse(s).

    1. Brad, I’m so sorry for missing your comment and not responding!! I actually have treated children and teens with difficulties like this. One of the common problems (different from this one) for kids is constipation with encopresis and fecal soiling. What happens in that case is that the stool backs up in his rectum, stretches it significantly, then looser less digested stool seeps around the stool leading to accidents that he doesn’t feel nor notice. It’s a major problem. If he hasn’t been evaluated by a pediatric GI provider, I would strongly recommend that. They can quickly find out if this is the case. Dyssynergia, if this is the problem, can also be easily diagnosed with anorectal manometry. I hope this is helpful, and again, apologize for the delay. Feel free to e-mail me at jessica@southernpelvichealth.com if you’d like to discuss further! ~ Jessica

  7. Hi Laura, I am 13 and I get constipated often.
    When I overcome this, i poop for about 2 days normally, one day a little, then the next a tiny bit.
    I think I may have this because on the day I poop a little, the stool is soft, but it doesn’t come out no matter how much i push.
    I poop normally without this pelvic floor thing, but on the 4th day, it just doesnt all come out.
    What do I do?

    1. Hi Hannah, I’m so sorry you’re dealing with this! Pooping problems are so hard to deal with. If you’re 13 years old, please talk to your parents about this, and tell them you want to see a doctor to be evaluated. Constipation problems in teens is a little different than adults, so doctors who know about kids (in this case, a pediatric GI doctor) are the best ones to see! ~ Jessica

  8. Hi what I am reading from you and the comments sounds like me. I start the day with a poop and by the end of the day I need another but I just cannot push it out. Change me position will be the first thing. I am seeing a specialist soon, so hopefully I can get some direction with this. Over time it is getting worse.

    1. Sorry for the delayed response. I hope you’re able to see a good provider to help you with this! I’m happy to help offer some guidance if you need it! ~ Jessica

    1. Yes! Lots of great PTs in NYC. Amy Stein’s group, Beyond Basics Physical Therapy is great. I also really like Stacey Futterman’s group 5 Point PT and Kara & Erika’s group, Solstice PT. All amazing clinicians and great practices! Good luck in your healing journey (and sorry for the delay!!) ~ Jessica

  9. Hi jess,

    my problems started about 2 week ago coincidently on the back of a 50 mile bike ride I went on, I’m not an avid cyclist but due to the current goings on in the world I have taken up riding recently. after the ride I suffered with bad saddle sourness and pain in the number 2 area which subsided a day or 2 later, since then I have managed to go every day but the natural urge that you get when its time to go seems to have disappeared and I’m finding I have to go and sit on the toilet and force a bowel movement rather than a naturally occurring one, my question today is could there have been potential nerve damage from the saddle that can impact on the pelvic floor and related nerves to the contracting muscles?

    1. This sounds nerve related to me, and perhaps muscles involved as well. I would encourage you to see a pelvic floor PT locally for evaluation to get a closer look at what is going on and help you get this improved! Best of luck in your healing journey! ~ Jessica

  10. Hi Jess,
    I am 26 years old, constipated almost everyday and have been suffering from severe haemorrhoids and fissures for the past 3 months. A doctor put me on laxatives for this entire 3 months period to make sure my stool remains soft and the fissures heal. It has healed 80% now, but the fissure and haemorrhoids have reached a point where no medicine/ointment is working on them. Also because of the extreme pain that I experienced everyday for the past 3 months, I have now gotten used to a very weird habit. I get this urge to poop after which I can feel the poop inside my anus, but I can’t get it out on my own even if I’m squatting properly.
    Now since I cannot strain at all because of the fissure and haemorrhoids, I have to use a rectal douche to push about 30 ml of water inside my anus, following which the stool comes out along with the water immediately. This makes me feel like I’ve lost my natural ability to use my anus muscles to poop and it stresses me out too much. I am from India and no doctor here is able to understand my situation. They simply keep giving me laxatives and ointments to heal the fissure, which is also not working. I am really frustrated, depressed and hopeless since the last 3 months. It has affected my daily activities and mood very badly and any help from you would be really appreciated even if it means consulting you virtually.
    PS: Right now my diet is good with a lot of fibrous vegetables and fruits and at least 4 litres of water each day. Avoiding spicy food for now because of the fissures.

  11. I have had problems with bowel movements for 22 years – possibly more. 10 years ago, I had a rectocille repair and now it’s as if there’s a holding area down there and I have to push the back of my vagina to get the feces to come out. Have you heard of this? Any recommendations in the greater Nashville area? Preferably north of Nashville. Thanks

    1. Hi Joyce! I’m sorry you’re dealing with this Pushing at the back of the vagina to empty is common, especially for people who have rectoceles. Seeing a pelvic PT would definitely be helpful. I don’t know anyone personally in Nashville but did find Archer Physical Therapy, and they seem knowledgeable. Check out the options at pelvicrehab.com and see what you think.

  12. Hello, can you help me? I live in NYC and having what may be dyssynergic defecation issues. I just had a colonoscopy that showed nothing serious, just a redundant colon/tortuous colon, whatever that is. But having real problems affecting my quality of life. I am wondering if this may also be caused by the SSRI I take, Celexa. Would Amy Stein’s group, Stacey Futterman or Solstice PT be able to help? Terrible.

    1. Hi Karl! Happy to help. Celexa does have constipation as a side effect, so this could be a part of it. All 3 PT clinics you mentioned are great. Have you seen anyone yet? One of my PTs is also licensed in New York, and she’d be happy to see you via telehealth if you’d like. Feel free to email me- jessica@southernpelvichealth.com

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