Dyssynergic Defecation - Symptoms, Causes and Treatment

Constipation is one of the most frequent gastrointestinal problems worldwide. Although it is not a disease itself, it is often a symptom of an underlying disorder affecting the digestive or nervous system. Among the different forms of chronic constipation, Dyssynergic Defecation (DD) stands out as a functional problem involving poor coordination of pelvic floor muscles during bowel movements.

Dyssynergic Defecation is both underdiagnosed and undertreated, primarily because people tend to dismiss constipation as a minor inconvenience rather than a complex, chronic issue. Understanding its causes, identifying the symptoms, and accessing effective therapies such as biofeedback can dramatically improve quality of life.

Constipation is defined by the infrequent or difficult passage of stool and affects up to 20–30% of the population, especially women and the elderly. According to standard clinical criteria, constipation is present if a person experiences two or more of the following symptoms in the past 12 months (without laxative use):

• Fewer than three bowel movements per week
• Excessive straining during at least 25% of bowel movements
• A feeling of partial evacuation in 25% or more of attempts
• Passage of hard or pellet-like stools in at least 25% of cases

While constipation can be caused by dietary habits, lifestyle, medications, or structural abnormalities, it often results from functional problems in bowel movement coordination, this is where Dyssynergic Defecation comes in.

Dyssynergic Defecation (also called pelvic floor dyssynergia or anismus) occurs when the pelvic floor muscles and anal sphincter fail to coordinate properly during defecation. Normally, to pass stool, the rectal muscles contract (to push stool out), while the anal sphincter muscles relax. In DD, this coordination is disrupted. Instead of relaxing, the pelvic floor muscles or anal sphincter may paradoxically tighten, blocking stool passage and leading to chronic constipation.

Common Symptoms of Dyssynergic Defecation:

• Severe straining during bowel movements
• A sensation of “blockage” or incomplete evacuation
• The need for digital manipulation (using fingers to help stool pass)
• Hard, dry, or pellet-like stools
• Abdominal discomfort or bloating
• Reduced frequency of bowel movements

This condition is a functional disorder, meaning there is no structural blockage in the colon, but rather a problem with muscle coordination.

Effective defecation requires coordinated activity between the rectum, abdominal wall muscles, and pelvic floor muscles (including the puborectalis and anal sphincters).

During a normal bowel movement:

• The rectum contracts, pushing stool downward.
• The internal and external anal sphincters relax.
• The puborectalis muscle (which loops around the rectum) also relaxes, straightening the rectoanal angle for stool passage.

In Dyssynergic Defecation, this coordination is lost. Patients may show:

• Inadequate abdominal pressure during defecation,
• Paradoxical contraction of the external anal sphincter, or
• Failure of anal relaxation, increasing outlet resistance.

The result:  stool becomes trapped in the rectum despite normal or increased effort.

Dyssynergic Defecation needs to be diagnosed using both clinical and specialized tests in order to differentiate from slow-transit constipation or structural bowel abnormalities.

This is the gold standard for diagnosing Dyssynergic Defecation.

It measures:

• Rectal pressure (pushing effort)
• Anal sphincter pressure (relaxation/contraction)
• Rectal sensation and reflexes

During this test, patients attempt to “push” as if defecating. Normally, rectal pressure increases while anal pressure decreases. In DD, there may be:

• Inadequate push
• Paradoxical contraction
• No relaxation of the anal muscles

Based on these findings, four subtypes of DD are recognized, each with a distinct pattern of muscle dysfunction.

This imaging technique visualises pelvic floor structures in real time during defecation. It identifies:

• Rectocele (rectal wall bulge)
• Intussusception (rectal folding)
• Rectal prolapse
• Pelvic floor descent
  

In a simple, non-invasive test, a small water-filled balloon is inserted into the rectum. The patient is then instructed to expel it, and failure to do so within one to two minutes shows the presence of DD. Although slow-transit constipation can coexist with DD, tests like marker studies or scintigraphy can be used to evaluate total intestinal motility.

Treatment must be individualised, addressing both the physical and psychological aspects of the condition. Common management strategies include:

Traditional constipation treatments (like fiber supplements, stool softeners, osmotic or stimulant laxatives) may provide mild relief but are often ineffective for DD because the underlying issue is muscle coordination, not stool consistency.

Still, doctors may recommend:

• High-fiber diet (25–30 g/day)
• Adequate hydration
• Regular toilet training
• Timed bowel movements after meals
  

Biofeedback therapy is the most effective, evidence-based treatment for Dyssynergic Defecation. It is a non-invasive, instrument-guided training program that teaches patients to:

• Coordinate their abdominal and pelvic muscles properly
• Increase rectal pressure effectively during defecation
• Relax the anal sphincter and puborectalis muscle

How Biofeedback Works:

Patients learn to control muscle action consciously by receiving visual or auditory feedback from sensors implanted in the anal canal. They "retrain" their defecation reflex over the course of several sessions.

Benefits:

• 70–80% success rate in improving bowel movement
• Non-surgical and safe
• Reduces laxative dependency
• Enhances confidence and quality of life

Most patients require only 6-8 training sessions.

Since stress and anxiety can worsen symptoms, cognitive behavioural therapy (CBT) and relaxation training are valuable adjuncts. Encouraging a positive outlook and addressing emotional distress significantly improve treatment outcomes.

Surgery is rarely needed unless there are structural abnormalities (like rectal prolapse or severe outlet obstruction). Procedures such as colectomy or ileostomy are reserved for patients unresponsive to all conservative measures.

• Establish a fixed toilet routine, ideally after breakfast when colonic movement is strongest.
• To straighten the rectoanal angle, squat (with feet elevated on a footstool).
• Avoid suppressing your urge to defecate.
• Practice in pelvic floor exercises for relaxation and deep breathing.
• Manage stress through yoga, meditation, or counselling.
  

Frequently Asked Questions (FAQs) on Dyssynergic Defecation

In regular constipation, stool is hard or slow to pass. In DD, stool reaches the rectum but cannot be expelled due to muscle dysfunction.

It’s a non-surgical method using sensors to help retrain bowel muscles for proper coordination during defecation.

Laxatives may provide temporary relief, but do not treat the root cause. Biofeedback therapy addresses the underlying muscle dysfunction.

Yes. Chronic stress and anxiety can disrupt pelvic muscle coordination and worsen symptoms.

Most patients see improvement after 4-6 sessions, although complete healing may take many weeks.

It is most common in women, older adults, and individuals with a history of chronic constipation or pelvic surgery. These factors can weaken pelvic floor muscles and elevates the risk of developing related conditions.

Dyssynergic Defecation is a treatable functional disorder, not a lifelong condition. Early recognition, accurate diagnosis through anorectal manometry, and biofeedback therapy can help restore normal bowel function and quality of life.

If you have chronic constipation, heavy straining, or incomplete evacuation, you need to see a gastroenterologist or colorectal specialist. Addressing the condition early alleviates complications and allows you to naturally regain digestive harmony.

Remember that bowel health reflects overall well-being, and restoring correct coordination is the key to lasting relief.