From the Guidelines
The workup for frequent urge to defecate at night should begin with a thorough history and physical examination to identify potential causes, and initial evaluation should include stool studies and blood tests to assess for inflammatory markers, complete blood count, and comprehensive metabolic panel, as recommended by the american gastroenterological association medical position statement: irritable bowel syndrome 1.
Initial Evaluation
The initial evaluation should include:
- Stool studies including fecal calprotectin, stool culture, ova and parasite examination, and testing for Clostridioides difficile
- Blood tests to assess for inflammatory markers (ESR, CRP), complete blood count, comprehensive metabolic panel, thyroid function tests, and celiac disease antibodies
- A food and symptom diary for 2-3 weeks to help identify dietary triggers
Further Testing
Further testing may include:
- Colonoscopy with biopsies to evaluate for inflammatory bowel disease, microscopic colitis, or malignancy
- Abdominal imaging (CT or MRI) to assess for structural abnormalities
- Motility studies or hydrogen breath testing for bacterial overgrowth
Symptomatic Treatment
While awaiting diagnosis, symptomatic treatment may include:
- Loperamide 2mg before bedtime, as it slows small and large intestinal transit and reduces stool frequency and urgency in patients with IBS at doses of 4–12 mg daily 1
- Cholestyramine 4g once or twice daily if bile acid malabsorption is suspected
Common Causes
Common causes of nocturnal bowel movements include:
- Inflammatory bowel disease
- Irritable bowel syndrome
- Microscopic colitis
- Malabsorption syndromes
- Medication side effects (particularly antibiotics, metformin, or magnesium-containing supplements)
- Endocrine disorders like hyperthyroidism or diabetes Nocturnal diarrhea is considered abnormal and warrants thorough investigation as it may indicate a significant underlying condition requiring specific treatment.
From the Research
Frequent Urge to Defecate at Night Workup
- The frequent urge to defecate at night can be a symptom of various gastrointestinal disorders, including irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) 2, 3, 4.
- In patients with IBS, loperamide has been shown to be effective in reducing stool frequency and improving stool consistency, particularly in those with painless diarrhea or alternating bowel habits associated with abdominal pain 2, 3.
- For patients with IBS-D, current treatment options include loperamide, bile acid sequestrants, antispasmodics, tricyclic antidepressants, alosetron, eluxadoline, and rifaximin 5.
- In patients with inflammatory bowel disease, fecal urgency can be a distressing symptom, and management may involve nonpharmacologic measures, such as dietary regimen and cognitive behavioral program, as well as medications like loperamide, tricyclic antidepressants, or biofeedback therapy 4.
- A thorough evaluation of the patient's history, physical examination, and diagnostic testing is essential to guide individualized treatment and management of medically refractory patients 6.
Diagnostic Considerations
- A comprehensive diagnostic workup may include anorectal tests to evaluate for defecatory disorders, colonic transit studies to assess colonic motility, and manometry or barostat studies to identify colonic dysmotility 6.
- The use of nonvalidated questionnaires to assess fecal urgency highlights the need for a systematic approach to assessment and the importance of considering fecal urgency as an outcome in clinical trials 4.
Treatment Options
- Loperamide has been shown to be safe and effective in reducing stool frequency and improving stool consistency in patients with IBS, and may be considered an alternative symptomatic treatment in some patients 2, 3.
- Other treatment options, such as eluxadoline and rifaximin, have also been shown to be effective in managing IBS-D symptoms 5.
- Biofeedback therapy may be beneficial in patients with defecatory disorders, and intestinal secretagogues and/or prokinetic agents may be used to manage chronic constipation 6.