Case 38: Motility

Motility Case Study

72 y/o female with past medical history of IgG immunodeficiency, fibromyalgia, depression, GERD, migraines, thyroid disease presenting for consultation of long-standing history of constipation and irritable bowel syndrome with constipation (IBS-C) diagnosed in 2020.

Despite thorough previous management efforts involving fiber and MiraLAX, Colace remains her mainstay for managing constipation, supplemented with peppermint oil intervention. She notes continued feeling of incomplete evacuation, straining, diarrhea (likely overflow diarrhea), and urgency. Her gastrointestinal symptoms persist despite diverse therapeutic approaches, and the coordinated integration of lifestyle, pelvic floor physical therapy, nutritional, and psychological support. A digital rectal exam was completed and mild dyssynergia noted. A one view abdominal x-ray was completed and noted large stool burden and subsequently underwent a bowel purge using a bowel prep and advised to start the next day following on Linaclotide 145 mcg daily the next day.

Given continued incomplete defecatory symptoms she underwent an anal rectal manometry (ARM) study for evaluation of lower gastrointestinal motility and rectal sensation.

Anal Rectal Manometry

RESULTS

• The max anal sphincter resting pressure was 47 mmHg (F 44-104)
• The max rectal resting pressure was 50 mmHg (M 13-16) (F 6-13)
• The max anal sphincter squeeze pressure was 156 mmHg (F 115-209)
• The max rectal squeeze pressure was 108 mmHg (M 7-31) (F 7-21)
  
• Duration of sustained squeeze was 20 s (M 27-30) (F28-30)
• Intrarectal pressure with bear down: 9 mmHg (M 28-52) (F 28-43)
• Anal sphincter residual pressure with bear down: 39 mmHg (M 38-92) (F 39-55)
• Percent anal relaxation 12 (>20%)
  
• The rectoanal inhibitory reflex as assessed by balloon distention of the rectum was present (M/F >25% decrease in sphincter pressure post intra-rectal balloon inflation)
  
• The rectal sensation as measured by balloon inflation indicated a sensation threshold of 30 cc (F 20-40 cc), an desire to defecate of 60 cc (F 40-75cc), and a maximal tolerable volume of 70 cc (F 60-120cc)
  
• 3D: No focal deficit
  
• Cough Reflex: present
• Balloon Expulsion Test (BET): Patient was able to expel a 50 cc water filled balloon in 15 seconds (<1 min)

IMPRESSION

• Normotensive average resting sphincter pressure consistent with normal strength of the internal anal sphincter
• Normotensive average squeeze sphincter pressure consistent with normal strength of the external anal sphincter and the puborectalis muscle
• Inadequate sphincter relaxation and inadequate rectal push pressures are consistent with mild pelvic floor dysfunction, type IV (unable to generate adequate pushing force and demonstrates an absent or incomplete anal sphincter relaxation)
• RAIR is present
• Normal Rectal sensitivity.  Correlate clinically
• 3D: No focal deficits
• BET: Passed

The procedure revealed mild pelvic floor dysfunction type four (incomplete anal sphincter relaxation with inadequate pushing force).

Question:

What is the most important intervention for a patient with pelvic floor dysfunction?

1. Secretagogue
2. Pelvic floor physical therapy
3. Psyllium fiber
4. Cognitive behavioral therapy

Intervention

Given the patient’s pelvic floor dysfunction and dyssynergia, pelvic floor physical therapy (PFPT) with biofeedback was recommended and initiated by a trained physical therapist. Her symptoms improved significantly with daily well-formed stools without blood, feelings of incomplete evacuation, straining, diarrhea, or urgency.

After several months, she developed diarrhea with Linaclotide due to the side effects and was subsequently started on Lubiprostone 24 mcg twice daily and returned to PFPT with biofeedback.

Practice Pearls

Epidemiology

Dyssynergia defecation (DD) is an acquired behavioral disorder with an unclear etiology. Many patients experience frequent hard stools and prolonged straining, which over time may lead to abnormal defecation patterns, including paradoxical muscle contraction and poor coordination (dyssynergia).⁷  DD has been associated with a range of contributing factors, supporting a multifactorial etiology.⁵  These include:

• Obstetric events such as pregnancy and childbirth
• Physical trauma, particularly involving the back
• Maladaptive toileting behaviors (e.g., prolonged sitting)
• Inappropriate learning of defecation dynamics during childhood, potentially linked to behavioral issues or parent–child conflict.
  

Pathogenesis/Pathology

It is characterized by ineffective defecation due to a failure of relaxation—or paradoxical contraction—of the puborectalis and external anal sphincter muscles⁵. This dysfunction narrows the anorectal angle and elevates anal canal pressure, thereby impairing stool evacuation. A prospective study of patients with DD demonstrated impaired coordination among the abdominal, rectal, and pelvic floor muscles during defecation. ⁷ The observed dysfunctions included impaired rectal contraction (61%), paradoxical anal contraction (78%), inadequate anal relaxation (22%), or a combination of these abnormalities.⁷

Diagnosis

The diagnosis of DD requires a combination of clinical, physiological, and objective findings. Patients must first meet the Rome IV criteria for functional constipation or IBS-C. In addition, there must be evidence of a dyssynergic pattern on anorectal manometry or surface electromyography, indicating impaired coordination of the defecatory muscles. Finally, at least one supportive abnormal test is required, such as a prolonged balloon expulsion test, delayed colonic transit, or imaging (e.g., defecography) demonstrating incomplete rectal evacuation.⁷ See table below.³

Additional contributing mechanisms may involve neurogenic disturbances of the brain–gut axis, rectal hyposensitivity, and coexisting slow-transit constipation. Psychosocial factors, including anxiety, psychological stress, and a history of sexual abuse, have also been implicated in its development. ⁷

Transanal Irrigation Treatment

• In individuals with dyssynergia defecation who do not improve with biofeedback, fiber, or laxatives, transanal irrigation can serve as a useful alternative treatment option.⁷
• Example: Peristeen 

References

1. Bertin, L., Zanconato, M., Crepaldi, M., Marasco, G., Cremon, C., Barbara, G., Barberio, B., Zingone, F., & Savarino, E. V. (2024). The Role of the FODMAP Diet in IBS. Nutrients, 16(3), 370. https://doi.org/10.3390/nu16030370
   
2. Black, C. J., & Ford, A. C. (2018). Chronic idiopathic constipation in adults: epidemiology, pathophysiology, diagnosis and clinical management. The Medical journal of Australia, 209(2), 86–91. https://doi.org/10.5694/mja18.00241
   
3. Drossman, D. A., & Hasler, W. L. (2016). Rome IV—Functional GI disorders: Disorders of gut–brain interaction. Gastroenterology, 150(6), 1257–1261. https://doi.org/10.1053/j.gastro.2016.03.035
   
4. Radziszewska, M., Smarkusz-Zarzecka, J., & Ostrowska, L. (2023). Nutrition, Physical Activity and Supplementation in Irritable Bowel Syndrome. Nutrients, 15(16), 3662. https://doi.org/10.3390/nu15163662
   
5. Sadeghi, A., Akbarpour, E., Majidirad, F., Bor, S., Forootan, M., Hadian, M. R., & Adibi, P. (2023). Dyssynergic Defecation: A Comprehensive Review on Diagnosis and Management. The Turkish journal of gastroenterology : the official journal of Turkish Society of Gastroenterology, 34(3), 182–195. https://doi.org/10.5152/tjg.2023.22148
   
6. UpToDate. (2026). Psyllium: Drug information. Wolters Kluwer. https://www.uptodate.com/contents/psyllium-drug-information
   
7. Young, S. S., Smukalla, S., & Rao, S. S. C. (2021). Dyssynergic defecation and constipation. In V. Stanghellini et al. (Eds.), Handbook of gastrointestinal motility and disorders of gut-brain interactions (2nd ed., pp. 277–291). Springer

Author

Marteen Barni, DNP, a Family Nurse Practitioner specializing in gastroenterology at Rush University Medical Center.