Obstructed Defecation

What is obstructed defecation syndrome?

Obstructed defecation means difficulty pooping. This can be for a variety of reasons, both mechanical and psychological. People with obstructed defecation syndrome (ODS) feel that they can’t poop when they want to, they aren’t pooping often enough or they aren’t pooping everything out all the way. They suffer from constipation, but also sometimes from fecal incontinence, when backed-up poop overflows. They spend a lot of time on the toilet, waiting or straining to poop (defecate). Over time, excessive straining and passage of hard stools can deteriorate the muscles and nerves involved, which adds to the problem.

How does this condition affect my body?

ODS is a broad umbrella term describing a range of conditions that involve constipation and difficulty defecating. What they have in common are the symptoms of constipation.

Diagnosis of constipation requires two or more of the following symptoms, consistently for 90 days:

• Straining on more than 25% of bowel movements.
• The feeling that you didn’t completely empty your bowels (incomplete evacuation) on more than 25% of bowel movements.
• Hard stools on more than 25% of bowel movements.
• Needing to use your fingers to help pass stools more than 25% of the time.
• Fewer than three bowel movements a week.

These symptoms may only be the tip of the iceberg, however. They often result from underlying conditions that have yet to be discovered.

Having chronic constipation for a long time can also cause its own set of problems. Sometimes, it’s hard to tell what the original cause was and what the effect was.

People with obstructed defecation might also have:

• Pelvic floor dysfunction. The muscles and nerves in your pelvic floor can’t coordinate correctly to make a bowel movement.
• Organ prolapse. One of the pelvic organs, such as the bladder, uterus or bowel, has fallen out of place and is bulging into another organ or falling out of the body.
• Rectal hyposensation. A loss of the ability to sense stool in the rectum or the need to have a bowel movement.
• Pooping anxiety. They might have a conscious or unconscious habit of guarding against hard, painful stools by stopping bowel movements.

How common is this condition?

About 18% of the population suffers from the broad range of conditions known as obstructed defecation syndrome. It’s especially common in women and after middle age.

What are the symptoms of obstructive defecation syndrome?

Obstructed defecation feels like:

• You need to poop but can’t.
• It’s hard work and/or painful to poop.
• You can't poop everything out all the way.
• Something is blocking your poop from coming out.

You may need to:

• Strain hard to poop.
• Wait for a long time for poop to come out.
• Use your fingers to help poop come out.
• Use laxatives or enemas to poop.

It may cause:

• Constipation.
• Fecal incontinence.
• Constant discomfort.
• Anxiety or depression.

Common complaints include:

• Inflamed or swollen rectum.
• Abdominal pain and distension.
• Anal pain.
• Nausea, feeling tired and lack of appetite.

Why can’t I poop?

ODS has many causes, both organic and functional. Organic, mechanical causes include things like anatomical defects and physical blockages. Functional causes involve things like the brain and nervous system. Often both kinds are involved, and one kind may have caused another kind.

Mechanical causes of ODS include:

• Perineal hernia. When organs in your abdomen or pelvis bulge through your pelvic floor.
• Pelvic organ prolapse. When one of your pelvic organs has fallen out of place, intruding on your rectum or anus (rectal prolapse, rectal intussusception, rectocele).
• Solitary rectal ulcer syndrome. One or several ulcers in your rectum.

Functional causes include:

• Anismus (dyssynergic defecation). Inability to relax your sphincter muscles and/or push adequately to evacuate your bowels.
• Rectal hyposensitivity. Loss of sensation in your rectum, possibly due to nerve damage.
• Psychological disorders. Anxiety, depression, phobias, OCD (obsessive-compulsive disorder) and eating disorders.

Any of these may be either primary causes or secondary effects of obstructed defecation.

They may also have been caused by:

• Pregnancy and childbirth.
• Surgery in your pelvic region.
• Traumatic injury or abuse.

How is obstructed defecation syndrome diagnosed?

Your healthcare provider will begin by asking you about your symptoms. They may use a scoring chart like this to rate how severe your symptoms are:

Your score would range from 0 to 20, with 20 points indicating severe symptoms.

A high score indicates chronic constipation, but to diagnose ODS, your healthcare provider will need to rule out simple causes. They’ll do this through evaluation of your medical history and testing.

What tests will be done to diagnose this condition?

Once your healthcare provider understands your symptoms, they will recommend tests to learn more. These might include:

• Digital Rectal Exam. This first line of testing is usually a physical exam using lubricated gloved fingers. Your healthcare provider can look for blockages, causes of pain and signs of organ prolapse, as well as test your muscle reflexes.
• Defecography. X-ray or MRI imaging of your insides while you try to poop. Your healthcare technician will inject a medical substance into your anus for you to push out like you would a stool. You’ll do so in a private photographic chamber while they watch your organs on a computer screen outside.
• Anorectal Manometry. This test measures how well your muscles and nerves work together to push poop out. A catheter with a balloon attached is inserted into your rectum and the balloon is inflated with warm water. The other end of the catheter is attached to a machine that will measure your muscle activity.

How is obstructed defecation syndrome treated?

Because its causes tend to be complex, with many factors involved, treatment is often conservative and holistic. It’s rarely as simple as corrective surgery. Even when surgery is recommended, and even when it’s successful in correcting an anatomical problem, it doesn't always lead to lasting relief. Symptoms may persist or come back. There are often still other factors to address, perhaps undiscovered yet.

For all people, healthcare providers begin by recommending:

• More dietary fiber, with a goal of 30 to 40 grams per day.
• More water intake, with a goal of more than 2 liters per day.
• Stool softeners or laxatives, home enemas and colonic irrigation.
• Yoga and guided relaxation techniques.

For neurological and psychosomatic symptoms, which affect up to two-thirds of people, they recommend:

• Biofeedback therapy, especially for anismus and pelvic floor dysfunction.
• Psychotherapy, when needed.

For anatomical problems such as organ prolapse, healthcare providers may recommend surgery when other treatments fail. Possible procedures include:

• Posterior colporrhaphy for rectocele, to push your fallen rectum back into place.
• Stapled transanal rectal resection (STARR) for rectocele and intussusception, to reinforce the anterior anorectal junction wall.
• Rectopexy for rectal prolapse, restoring your rectum to its normal position, often with mesh to support it. Sometimes, this also involves the removal of part of your colon.

What is the outlook for people with this condition?

Conservative treatments show improvement in 30% of people. Lifestyle changes and home remedies like laxatives and enemas may be needed indefinitely, but they can offer real relief. Therapies such as biofeedback and psychotherapy require time and commitment to yield results, but they can offer lasting improvements. Surgery has uneven results. It seems to be most successful when combined with other treatments.

A note from Cleveland Clinic

Obstructed defecation is an urgent problem, but understanding what’s causing it can be difficult. You might be surprised to learn how many different body systems are involved in pooping — not to mention the brain. Fortunately, many of the treatments healthcare providers recommend for ODS can apply to anyone suffering from constipation. You can begin implementing lifestyle changes, home remedies and therapy techniques immediately. But it’s still a good idea to see your healthcare provider for testing. They’ll need to rule out or address any contributing diseases or structural problems, and they can talk you through the diagnosis after learning more about your condition.