Not All Constipation Is the Same
Steven Sandberg-Lewis
N.D., DHANP
Rectal Dyssynergia:
Not All Constipation is the Same! A Focus on Outlet Constipation.
Most of us have experienced constipation at some point in our lives due to a number of causes. For some, constipation might have been the result of going overboard at their first fondue party in over a year, while for others extreme stress could have resulted in a temporary break up with fiber. In other cases, the causes of constipation are more serious, and may require medical intervention. To properly treat chronic constipation, first determine the cause of the constipation, which in this article is defined as various combinations of the following symptoms:
Passing fewer than three bowel movements per week
Excessive straining
Lumpy or hard stools
A feeling as if the passage of stool is blocked
A feeling as if bowel movements are incomplete
The need to manually remove stools
People who have chronic constipation rarely have loose stools unless they take laxatives.
The three general types of primary constipation (those without a secondary* cause) are:
1) Slow transit constipation - transit of food and stool is too slow through the small intestine and/or colon)
2) Normal transit constipation - also called functional constipation
3) Outlet constipation or rectal dyssynergia - whether intestinal transit is adequate or not, passage of a bowel movement is impeded in the rectum or anus. This article will focus on this type of constipation.
*Some types of constipation are secondary to (caused by) other health conditions. Common examples are constipation secondary to diabetes and thyroid diseases; drugs, and dementia. Some examples of medications likely to cause constipation include narcotics (eg. oxycodone, tramadol), NSAIDs (eg. ibuprofen), antidepressants (eg. effexor, lexapro, zoloft), medicines for treating high blood pressure (eg. calcium channel blockers, diuretics) and calcium or iron supplements. Less common causes of secondary constipation include colon narrowing due to cancer or inflammatory diseases, rectocele (a portion of the rectum that protrudes into the area behind the vagina), pituitary and parathyroid disorders, Hirschsprung’s and spinal cord disorders; nerve diseases such as multiple sclerosis and Parkinson’s disease and autoimmune diseases such as scleroderma.
In the case of healthy mechanics of bowel movements, when bearing down to express the stool, normal contraction of rectal muscles occurs and nerve reflexes cause the anal sphincter muscles to relax. The external sphincter normally is contracted to prevent an involuntary bowel movement, but needs to be able to relax to allow passage of stool when intentionally having a bowel movement. Outlet constipation occurs when these sphincter muscles in the anus are too tense or uncoordinated in their contraction and relaxation. I often use the analogy of the garage door. If you are ready to drive your car out of your garage, but the garage door won’t open fully – you won’t get the car out (carstipation?).
People with rectal dyssynergia will feel that they need to have a bowel movement, but it won’t come out or will be very slow and difficult to pass. In the case of women, they may resort to innovative solutions to promote passage of stool, such as inserting fingers into the vagina and pressing toward the anterior wall of the vagina to add pressure, or actually inserting a finger into the anus to scoop out the stool.
The initial cause of dyssynergia may have been damage to the anus when giving birth by vaginal delivery or due to chronic anal pain from fissures or hemorrhoids. Other cases may be caused by the psychic trauma of sexual abuse, or a tendency to suppress the urge to have a bowel movement. Still other cases of dyssynergia have no known underlying cause.
This kind of constipation often fails to respond to standard good practices such as increasing fluid and fiber intake, or using abdominal exercises or abdominal massage. The garage door is the problem!
The good news is that specially trained physical therapists can help with pelvic floor massage techniques, breathing exercises and biofeedback training. The patient can learn to coordinate the anal sphincter muscles to relax during bowel movements and contract properly at all other times.
Rectal dyssynergia is one area of practice Hive Mind Medicine has extensive experience in treating. If you are experiencing symptoms that you would like to discuss, please contact us to set up an appointment.
Steven Sandberg-Lewis, ND, has been in clinical practice for 43 years, with a focus on functional gastroenterology. He has been a professor since 1985, teaching a variety of courses but primarily focusing on gastroenterology and GI physical medicine. In 2019, Dr. Sandberg-Lewis co-founded Hive Mind Medicine, continuing his specialization in gastroenterology with a focus on reflux, SIBO, inflammatory bowel disease and functional GI disorders.
Hive Mind Medicine blog posts are for educational purposes only and are not intended as medical advice. Please consult with your health care practitioner for personalized guidance. Click on the contact button below if you would like to schedule with one of our Hive Mind practitioners.