What is the exact diagnosis for a patient with chronic constipation, straining during bowel movements, and associated symptoms of bladder and sexual dysfunction?

Pelvic Floor Dysfunction (Functional Defecation Disorder)

This patient has a functional defecation disorder, most specifically dyssynergic defecation (also called pelvic floor dyssynergia), which is part of the broader category of pelvic floor dysfunction. 1 The constellation of chronic constipation with straining, combined with bladder and sexual dysfunction, indicates sacral nerve involvement affecting the entire pelvic floor complex. 2

Understanding the Exact Diagnosis

Dyssynergic defecation is the precise term for this disorder, characterized by paradoxical contraction or incomplete relaxation of the pelvic floor muscles and external anal sphincter during attempted defecation. 1 This is not simply "constipation"—it represents a neuromuscular coordination problem where the pelvic floor paradoxically contracts when it should relax. 2

Why the Associated Symptoms Occur

• The bladder and sexual dysfunction are not coincidental—they reflect sacral nerve dysfunction that directly controls defecation, bladder function, and sexual response through the same neural pathways. 2

• All three symptom domains (bowel, bladder, sexual) share common sacral nerve innervation (S2-S4), which explains why dysfunction manifests across multiple pelvic organs simultaneously. 2, 3

• Chronic straining causes reduced rectal sensation and impaired awareness of the need to defecate, which often extends to bladder sensations as pelvic floor coordination deteriorates. 2

Clinical Features That Confirm This Diagnosis

The specific pattern of symptoms strongly indicates dyssynergic defecation rather than simple slow transit constipation:

• Straining even with soft stools is pathognomonic for a defecatory disorder rather than a colonic motility problem. 1, 4

• Need for digital disimpaction or perineal pressure to evacuate stool is an even stronger indicator of pelvic floor dyssynergia. 1

• Sensation of incomplete evacuation despite prolonged straining is characteristic. 5, 6

• The presence of bladder dysfunction (likely urinary hesitancy, incomplete emptying, or altered sensation) alongside bowel symptoms confirms multi-compartment pelvic floor involvement. 1, 2

Diagnostic Confirmation Required

While the clinical picture is highly suggestive, the diagnosis must be confirmed with anorectal manometry combined with balloon expulsion testing. 1

• A careful digital rectal examination should be performed first, assessing pelvic floor motion during simulated evacuation, though a normal exam does not exclude the diagnosis. 1, 4

• Anorectal manometry will demonstrate paradoxical anal contraction or inadequate relaxation during attempted defecation. 1

• Balloon expulsion test will show inability to expel a 50mL water-filled balloon within 1 minute. 5

• Defecography (fluoroscopic or MR) may be added if structural abnormalities like rectocele, rectal prolapse, or intussusception are suspected, particularly in women with multi-compartment prolapse. 1

Alternative Terminology You May Encounter

This condition has multiple names in the literature, all referring to the same disorder:

• Dyssynergic defecation (most commonly used term) 1, 5
• Pelvic floor dyssynergia 1, 7
• Anismus (older term, less preferred) 1
• Functional defecation disorder (Rome IV classification umbrella term) 1

Critical Distinction from Other Constipation Types

This is NOT slow transit constipation (STC), which would present with infrequent bowel movements but normal ease of evacuation when stool is present. 1, 8, 4 Patients with STC do not typically have bladder or sexual dysfunction unless there is concurrent pelvic floor involvement. 2

Prognosis and Treatment Implications

The good news is that dyssynergic defecation responds excellently to biofeedback therapy, with success rates exceeding 70%. 2 This is critical because:

• Biofeedback specifically improves rectal sensory perception and often translates to improved bladder awareness as pelvic floor coordination normalizes. 2

• Bladder sensation recovery is more predictable than sexual function recovery (70%+ improvement expected for bladder symptoms). 2

• Sexual function recovery is more variable and depends on the degree of preoperative genital sensory loss—patients with complete perineal anesthesia have poorer sexual recovery even with optimal treatment. 2

• The earlier the intervention, the better the recovery of sensory function. 2

Common Pitfall to Avoid

Do not continue escalating laxatives indefinitely—this will not address the underlying pelvic floor dysfunction and delays definitive treatment. 2, 4 The patient needs neuromuscular retraining (biofeedback), not more bowel stimulants. 2