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Dys-synergic defaecation

What is dys-synergic defaecation?
Dys-synergic defaecation (DD) is a condition where a patient overstrains to start a bowel movement and has great difficulty completing the bowel movement. Many people with DD do not realize they have a problem until they present with complications from years of overstraining. These people overstrain because they are unable to coordinate the muscles that help a bowel movement. This disordered muscle contraction and relaxation leads to inability to pass normal stools through the anus. The pelvic floor and anal muscles are structurally normal in patients with DD.
DD is also known by many other names; anismus, obstructed defaecation, pelvic floor dys-synergia and puborectalis paradoxus syndrome. Most of these terms are interchangeable. Some of the more common presentations of patients with untreated DD are recurrent anal fissures, rectocoele and rectal prolapse.
How does it differ from constipation?
Patients with constipation have fewer than one bowel movement every 3 days while patients with dys-synergic defaecation (DD) are usually able to have regular bowel movement but have difficulty passing the bowel movement. Often patients with constipation and DD have similar symptoms, such as abdominal cramps and bloating, but treatment can be quite different.
How does dys-synergic defaecation present?
Many patients have symptoms of abdominal bloating and cramps relieved by bowel movement. However, the patient will usually have to sit or squat at the toilet for a very long time (as long as 30 minutes in some cases) and need to strain very hard before the stools can come out. Some say they strain until they break out in sweat. Once the stool starts coming through the anus, there is usually less difficulty completing the bowel movement.
Due to repeated straining, many complain of heaviness or pain around the anus after the bowel movement. Some feel a sense of incomplete emptying of the rectum even after straining for half an hour. Others feel a cramping pain deep in the pelvis, most likely from rectal wall spasm, due to the repeated abdominal straining.
As dys-synergic defaecation and constipation are not mutually exclusive, some patients with DD also have infrequent bowel movements and other constipation symptoms.
How is dys-synergic defaecation evaluated?
A detailed history with emphasis on bowel habit, diet and lifestyle is necessary. Clinical examination is aimed at detecting secondary problems arising from DD. A colonoscopy is best performed to exclude more sinister conditions such as colorectal cancer or polyps which take priority in treatment.
An anorectal manometry with or without rectal balloon expulsion test may give the necessary information to guide treatment. This test is a painless outpatient bedside test that takes about 30 minutes to administer. Electromyography of the anal sphincters help to detect anismus by studying the electrical activity of the anus using surface electrodes outside the anus connected to a computer.
A defaecating proctogram or dynamic MRI defaecogram may be useful when DD is strongly suspected but other tests are unclear on the diagnosis. These two tests simulate an actual act of bowel movement and gives real time information of what happens to the rectum, anus and pelvic floor muscles during bowel movement. The information provided helps pinpoint the areas of pelvic floor rehabilitation to focus on. It may also provide crucial information to determine whether surgery may be necessary in the treatment.
What are the treatments available for dys-synergic defaecation?
The mainstay of treatment of DD is anorectal biofeedback (pelvic floor rehabilitation physiotherapy with dietary and lifestyle modifications) with/without medication. Anorectal biofeedback aims to correct the problem of muscle coordination of the pelvic muscles as well as coping mechanisms for these patients with DD.
Surgery is reserved for patients who have developed structural abnormalities as a complication of long-standing DD such as rectocoele and rectal prolapse.
If you have feedback or would like to know more about treatment for these conditions, feel free to contact us or make an appointment.