Faculty member Lila Bartkowski- Abbate PT, DPT, MS, OCS, WCS, PRPC teaches the Bowel Pathology, Function, Dysfunction and the Pelvic Floor course for Herman & Wallace. Join her in Tampa on April 2-3, or one of the other two events currently open for registration.

Constipation, an often under reported health issue, afflicts about 30% of Americans. ¹ The diagnosis of chronic constipation may seem like a simple concept, however the etiology of chronic constipation presents itself in many different forms. Dyssynergic defecation is one of many factors that can lead to a presentation of chronic constipation in a patient. Dyssynergic defecation or “paradoxical contraction” occurs when the muscles of the abdominals, puborectalis sling, and external anal sphincter function inappropriately while attempting a bowel movement. ² The lack of coordination of these muscles results in a contraction versus a lengthening of the pelvic floor muscles with baring down. Dyssynergic defecation is different than a structural issue such as a rectocele or hemorrhoids causing the inability to pass stool effectively or constipation due to slow colon transit time or pathological disease. Making the diagnosis of dyssynergic defecation by symptoms alone is often not reliable secondary to overlap of similar symptoms with chronic constipation due to factors such as a structural issue, irritable bowel syndrome (IBS), or irritable bowel disease (IBD). The diagnosis of dyssynergic defecation can be difficult and is often made through physiologic testing such as balloon expulsion testing or MRI with defecography. ² However, physical therapists can often manually feel that a paradoxical contraction is happening when asking a patient to bare down on evaluation.

Patients with dyssynergic defecation may present to pelvic floor physical therapy with complaints of: ¹ ²

1. Abdominal symptoms such as bloating, pain, and cramping
2. Poor response to laxatives and fiber supplementation that does not fully resolve their issue
3. Have had testing for anatomical or neurological abnormalities with no significant findings
4. Complaints of concomitant pelvic pain due to over activity of the pelvic floor muscles

Physical Therapists specializing in pelvic floor rehab can be a valuable part of the medical team with treating these patients. Biofeedback training by physical therapists has been shown to decrease anorectal related constipation symptoms and abdominal symptoms in patients with dyssynergic defecation. In a sample of 77 patients with dyssynergic defecation, physical therapists provided biofeedback training for 6-8 weeks that included manual and verbal feedback, surface EMG, exercises using a rectal catheter, rectal ballooning to improve rectal sensory abnormalities, ultrasound, pelvic floor and abdominal massage, electrical stimulation if needed, and core strengthening and stretching to improve the patients’ maladaptive habits while attempting to pass a bowel movement. Significant decreases were seen on all three domains (abdominal, rectal, and stool) on the PAC-SYM (Patient Assessment of Constipation) questionnaire post biofeedback training. ² It is noteworthy that 74% of these patients presented to the clinic with complaints of abdominal symptoms such as bloating, pain, discomfort, and cramping.

Knowing how to effectively treat these patients and ask the right questions is valuable in the scheme of pelvic floor rehab secondary to overlapping symptoms of different causes of chronic constipation. Physical therapists are able to provide these patients with conservative treatment that can effectively improve or eliminate their problem, recognize dyssynergic defecation as a possible differential diagnosis, and refer to the appropriate medical professional for further testing. Recognizing and treating dyssynergic defecation is something physical therapists will learn how to become effective at in the upcoming Herman and Wallace Course: Bowel Pathology, Function, Dysfunction & the Pelvic Floor April 2-3 in Tampa, FL and October 8-9 in Fairfield, CA.

1. Sahin M, Dogan I, Cengiz M et al. (2015). The impact of anorectal biofeedback therapy on quality of life of patients with dyssynergic defecation. Turk J Gastroenterol. 26(2):140-144

2. Baker J, Eswaran S, Saad R, et al. (2015). Abdominal symptoms are common and benefit from biofeedback therapy in patients with dyssynergic defecation. Clin Transl Gastroenterol. 30(6)e105. doi: 10.1038/ctg.2015.3

As a child, I remember my grandmother rubbing my lower back to help me pass my stubborn stool, a problem which landed me in the hospital twice before I turned 10. Decades later, after the birth of my first baby, I had a grade III perineal tear that made me afraid I would never be able to control my stool from passing. At the time of each situation, I had no idea how many people of all ages experience the two extremes of bowel dysfunction. Thankfully, for patients struggling with either issue, whether it is chronic constipation or fecal incontinence, healthcare practitioners are becoming knowledgeable in how to treat both effectively through classes such as the Herman & Wallace course, “Bowel Pathology, Function, Dysfunction & the Pelvic Floor.”

In 2014, Kelly Scott, MD, authored an article entitled, “Pelvic Floor Rehabilitation in the Treatment of Fecal Incontinence.” She reviews the current literature and notes this area of study lacks high quality randomized controlled trials, and further research is needed to provide evidence on the efficacy of different treatment protocols. Up to 24% of the adult population has been shown to experience fecal incontinence. Under the umbrella of pelvic floor rehabilitation lies pelvic floor muscle training, biofeedback, rectal balloon catheters for volumetric training, external electrical stimulation, and behavioral bowel retraining. The goals of various biofeedback methods include the following: provide endurance training specifically for the anal sphincter and pelvic floor; improve rectal sensitivity and compliance; and, increase coordination and sensory discrimination of the anal sphincter. Overall, the success rate of pelvic floor rehabilitation for fecal incontinence in most of the studies is 50% to 80%, and it is considered safe as well as effective.

On the other end of the spectrum, Vazquez Roque and Bouras (2015) published an article regarding management of chronic constipation. Chronic constipation (CC) in the general population has a prevalence of 20%, and the elderly population has a higher rate than the younger population. Chronic constipation is commonly treated with stool softeners, fiber supplements, laxatives, and secretagogues. However, as in all areas of healthcare, a thorough examination needs to be performed to assess the source of the problem. Determining whether a patient exhibits slow transit constipation or a true pelvic floor dysfunction (PFD) via blood work, rectal exam, and appropriate PFD tests is essential to provide the appropriate treatment. When the CC culprit is dysfunction of the pelvic floor, clinical trials have proven the efficacy of pelvic floor rehabilitation and biofeedback, making them optimal treatments.

When research indicates a particular type of rehabilitation is effective for treating a wide scope of issues in an area of the body, learning how and when to implement the techniques is paramount for a well-rounded practitioner. Most of us do not dream of treating chronic constipation or fecal incontinence; but, as we mature in our clinical practice, the spectrum of dysfunctions we discover through diagnostic testing and experience grows. Continuing education in previously unexplored territories can only expand the population to whom we provide relief.

Scott, K. M. (2014). Pelvic Floor Rehabilitation in the Treatment of Fecal Incontinence. Clinics in Colon and Rectal Surgery, 27(3), 99–105.
Vazquez Roque, M., & Bouras, E. P. (2015). Epidemiology and management of chronic constipation in elderly patients. Clinical Interventions in Aging, 10, 919–930.