Hi friends! Do you struggle to poop? Do you find yourself pushing and straining to no avail on the toilet? Do you dread needing to poop? You may have a condition called dyssynergic defecation which essentially means the pelvic floor muscles are squeezing and making it very difficult for stool to leave the body. Dyssynergic defecation has been called many different things including: anismus, anal sphincter dyssynergia, pelvic floor dyssynergia, paradoxical pelvic floor contraction, spastic pelvic floor syndrome, paradoxical puborectalis contraction, dyskinetic or non-relaxing puborectalis muscle syndrome, obstructive defecation, and pelvic outlet obstruction (Sadeghi, 2023).
The information in this blog is for education purposes and should not be used for diagnosis. Keep in mind we are physical therapists, but we are not your physical therapist. If you have any concerns, it is important to talk with your medical providers for appropriate evaluation and treatment. True diagnosis of dyssynergic defecation involves testing like anorectal physiology tests and balloon expulsion test (Sadeghi, 2023; Rao, 2016).
Dyssynergic defecation happens because of the inability to coordinate the abdominal and pelvic floor muscles to poop causing tightening of the pelvic floor muscles, specifically the external anal sphincter and puborectalis (Sadeghi, 2023; Rao, 2016). It can lead to overflow fecal incontinence, hemorrhoids, anal fissures, rectal ulcers, bladder and rectal prolapse (Sadeghi, 2023).
Dyssynergic defecation is most common in older males but can affect anyone (Sadeghi, 2023). While the exact cause is not known, studies have found that excessive straining to pass hard stools may lead to dyssynergic defecation over time (Rao, 2016). Other causes can include to pregnancy and childbirth, trauma (especially back injuries), bad toilet habits (e.g., sitting on the toilet for a long time), brain-gut disturbances, rectal hyposensitivity, slow transit constipation, anxiety or psychological stress, and history of sexual abuse (Sadeghi, 2023; Rao, 2016).
The pelvic floor muscles play a big role in all bowel movements. The pelvic floor muscles wrap around each of our exit canals: the urethra (where urine and semen exit the body), the anus (where gas and stool leave the body), and the vagina (in those born with female anatomy). Most of the time, these muscles stay engaged to keep these canals closed, but the muscles need to be able to relax at appropriate times to allow the canals to open. With dyssynergic defecation, the pelvic floor muscles stay contracted and closed instead of relaxing to open.
Normal pooping requires the nervous system and the muscles to be in sync while body position and the type of stool play an important role (Sadeghi, 2023). The Bristol Stool Scale can be used to classify the type of stool. The scale progressed from type 1 poop which is small, hard lumps (like nuts) that are often hard to pass to type 7 which is watery stool with no solid pieces. Typically, the faster your stool travels through your digestive tract, it will have more water in it and be closer to a type 7 (Blake, 2016). The longer stool stays in your system, your body has more time to absorb water and your poop will be more firm. Hard poop is usually harder to get out. Without using the scale, a good comparison of healthy poop is the consistency of a ripe banana.
Getting enough fiber (25 g per day) and fluids can improve the stool type (Rao, 2016). It is important to drink water with fiber intake to avoid hard, bulky stools (Sadeghi, 2023; Rao, 2016). Keep in mind that fiber supplementation can cause bloating, gas, and abdominal discomfort and the benefits of adding fiber are often not evident for days to weeks (Rao, 2016). Individuals with fecal impaction, who are bed bound, or who have fluid restrictions should not supplement fiber (Rao, 2016).
If you have good stool consistency but are still struggling to poop, dyssynergic defecation may be the cause. How can we treat dyssynergic defecation? Many times we think of laxative to help constipation but with dyssynergic defecation laxatives often do not help as a stand alone treatment (Sadeghi, 2023). The most effective treatment has been shown to be biofeedback training (Sadeghi, 2023; Rao, 2016). This treatment can be done either at home or in office (Rao, 2018). There are a few different ways it can be done, but it involved sensors that show what the muscles are doing to help train them to do the right thing at the right time, like relax when we are trying to poop.
Biofeedback can often be done with a pelvic floor therapist. A pelvic floor therapist can help address any other pelvic floor dysfunction you may be experiencing like urinary leakage, urinary urgency, pelvic pain, and prolapse. Ask you provider for a referral or find one near you at www.mypfm.com/find-a-pt.
Other treatments that can help, especially in combination with biofeedback training are (Sadeghi, 2023; Rao, 2016):
Avoiding constipating medications
Regular exercise
Timed toilet training (attempt a bowel movement at least 2x/day, usually 30 min after meals)
Avoiding using digital disimpaction of stools
Good toilet posture (a squatty potty can help)
Regardless of the symptoms you have and how long you have been dealing with them, there is help!
Ready to learn more about your pelvic health? Here are some helpful resources:
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HRV as a Predictor and Intervention in IBS with Dr. Susan Clinton PT, DScPT, OCS, WCS, FAAOMPT, NBC-HWC
Pelvic Floor Rehabilitation for Inflammatory Bowel Disease with Dr. Amanda Olson, PT, DPT, PRPC
The Role of Probiotics & How to Support the Gut Microbiome for Digestive Disorders with Erin Judge, RDN, LDN
Gut Health Q&A with Dr. Will Bulsiewicz, MD, MSCI
Written by Emily Reul, PT, DPT
References
Rao SSC et al. Home versus office biofeedback therapy for dyssynergic defecation: parallel arm randomized control trial. Lancet Gastroenterol Hepatol. 2018;3(11):768-777.
Rao SSC, Patcharatrakul T. Diagnosis and treatment of dyssynergic defecation. J Neurogastroentreol Motil. 2016;22(3):423-434.
Sadeghi A et al. Dyssynergic defecation: a comprehensive review on diagnosis and management. Turk J Gastroenterol. 2023;34(3):182-195.