A significant portion of anal diseases cannot be diagnosed because some complaints that surgeons do not ask about and patients cannot express because they are embarrassed are not investigated. When patients state that they are "constipated", they actually mean that they cannot defecate, that they cannot fully defecate, that they frequently go to the toilet due to incomplete evacuation, and that sometimes they defecate with their hands. The doctor's failure to ask for details and the patient's embarrassment make the diagnosis impossible. Your closest person has been taking medication for perhaps 20 years and is struggling in despair and darkness with his own problems. Patients with intussusception (Intussusception) or women who cannot evacuate their stool (Rectocele) due to the ballooning of the hind intestine, go to the toilet frequently, think they are feeling the urge to defecate, stay in the toilet for a long time, strain, and excrete a little slimy stool, but are unable to pass the stool. Since they cannot evacuate, their social life is paralyzed.
How is defecation difficulty or constipation classified?
Defecation difficulty is also called dyschezia, constipation, and dyssynergic defecation. These are Rome III criteria. According to these criteria, at least two of the following items must be present for 3 months and the patient's complaints must have started at least 6 months ago.
Rome III criteria for defecation difficulty
The complaints must have started 6 months ago and have been persistent for the last 3 months.
Failure of the balloon excretion test
Proof of defecation difficulty by defecography
Determining that there is a contraction defect in the pelvic floor muscles by anal manometry, anorectal electromyography or anorectal EMG
Proving that there is a thrust defect by anal manometry or defecography
Rome III criteria for defecation difficulty
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Defecation less than three times a week
Excessive straining in at least 25% of defecations
Solid defecation in at least 25% of defecations and having bulky defecation
Feeling of not being able to fully evacuate the stool in at least 25% of defecations
Feeling of the stool being stuck or blocked in at least 25% of defecations
Defecation� Requiring finger support in at least 25% of cases (defecation with fingers or defecation by supporting the pelvic bone or pelvic muscles)
Not being able to pass soft stools without using stool relaxant or softening medication (laxative)
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Presence of weak irritable bowel syndrome (IBS) symptoms
American Gastroenterology Society (ACG) criteria for difficulty in defecation
Presence of at least three of the following symptoms for the last year
Defecating less than three times a week
Difficulty in defecation requiring excessive straining
Absence of the feeling of defecation
Not passing the stool completely inability to defecate
Defecation in hard and small pieces
Existence of long periods of defecation
Needing finger support for defecation
In which cases is difficulty in defecation observed?
Inadequate fluid intake
Inadequate fiber intake
Stress
Hemorrhoids
Anal fissure
Pregnancy
Hypothyroidism (underactive thyroid gland)
Irritable bowel syndrome (IBS)
Intestinal cancer
Hirschuprung disease
Chagas disease
Meningocele
Multiple sclerosis (MS) disease
Parkinson's disease
Being paralyzed
Intussusception
Anal prolapse (rectal prolapse)
Rectocele
Sigmoidocele
Anismus
Excess calcium
Low potassium
Excess urea (uremia)
Diabetes
Excess parathyroid gland study (hyperparathyroidism)
Scleroderma
What kind of tests are performed in case of difficulty in defecation?
Colonoscopy
Thick intestinal x-ray
Anorectal manometry
Defecography (video-defecography, CT defecography, MRI defecography)
What does obstructive defecation mean?
Difficulty or incomplete evacuation of feces in the rectum, the last part of the large intestine, is called 'obstructive defecation'.
What causes obstructive defecation?
A healthy stool internal anus muscle, which is an involuntary muscle during the act of defecation (anal sphincter) relaxes and the external anal sphincter (external anal sphincter) and pelvic floor muscles, which are voluntary muscles, relax. Base of the pelvis or roof bone or pelvic floor; It consists of the levator ani muscle, coccygeus muscle and connective tissue. The levator ani muscle is; It consists of the pubococcygeus muscle, puborectal muscle and iliococygeus muscle. These muscles are responsible for the contraction and relaxation movements of the anus, urinary tract (urethra), prostate and female organ (vagina). Cameron et al. In a study, it was reported that 1/3 of women with anal prolapse (rectal prolapse) and difficulty in defecation experienced urinary incontinence. Similarly, Morgan et al. In a study, it was reported that 1/3 of women with defecation problems experienced gas and fecal incontinence.
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