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Feeling of incomplete bowel emptying

by Alison Hainsworth

April 2017

Current Definition 2016

The feeling of incomplete bowel evacuation is the complaint that the rectum does not feel empty after defaecation and may be accompanied by a desire to defaecate again (1). This is a post defecatory symptom.


Old Definition

The 2010 definition is similar (2) though the term ‘accompanied by a desire to defaecate again’ is new. There is no previous definition which is now thought to be wrong or no longer used.

Perspectives and Controversies

A Feeling of incomplete bowel evacuation may contribute to the overall diagnosis of functional constipation according to the Rome criteria (1)(3).

A feeling of incomplete bowel evacuation is often multifactorial (see pathophysiology section below) (4) and the link between structural abnormalities and this symptom is not absolute (5). Therefore, it is often not possible to distinguish between different pathologies based on this symptom alone.

A feeling of incomplete bowel evacuation often co-exists with faecal incontinence, slow transit constipation and symptoms attributable to anterior and middle pelvic floor disorders.

Pathophysiology

A feeling of incomplete bowel evacuation may be caused by both functional (for example dyssynergy or anismus) and anatomical (for example rectocoele, enterocoele and intussusception) abnormalities.

A rectocoele may cause ‘trapping’ of stool and prevent evacuation of faeces (this may be visualised as the retention barium paste within the rectocoele despite rectal emptying on defaecatory imaging though this sign should be interpreted with caution (6)). Intussusception may also cause ‘trapping’ of stool (7) or the presence of the infolding rectal wall may be mistaken for stool resulting in a feeling of incomplete bowel evacuation. It is not clear if enterocoele actually causes incomplete evacuation of stool (8) though the presence of an enterocoele may lead to the pressure symptoms and the feeling of incomplete evacuation.


Therapies

All aspects (functional and anatomical) must be addressed for optimal treatment outcomes (4). Conservative measures include pelvic floor retraining, lifestyle modifications, correct toilet positioning, glycerine suppositories and rectal irrigation. Surgical management should prove the ‘last resort’ but aims to correct anatomical abnormalities and should be performed in conjunction with conservative measures.

References

1) An International Urogynecological Association (IUGA)/ International Continence Society (ICS) Joint Report on the Terminology for Female Anorectal Dysfunction Abdul H. Sultan, Ash Monga, Joseph Lee, Anton Emmanuel, Christine Norton, Giulio Santoro, Tracy Hull, Bary Berghmans, Stuart Brody and Bernard T. Haylen. Neurourology and Urodynamics. 2016. October 24. [epub ahead of print].

2) Haylen BT, de Ridder D, Freeman RM, et al. An international urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J 2010;21:5–26.

3) Drossman DA. The Functional Gastrointestinal Disorders and the Rome III Process. Gastroenterology 130[5], 1377-1390. 2006.

4) Pescatori M, Spyrou M, Pulvirenti dA. A prospective evaluation of occult disorders in obstructed defecation using the 'iceberg diagram'. Colorectal Dis 2007 Jun;9(5):452-6.

5) Zbar AP, Lienemann A, Fritsch H, Beer-Gabel M, Pescatori M. Rectocele: pathogenesis and surgical management. Int J Colorectal Dis 2003 Sep;18(5):369-84

6) Greenberg T, Kelvin FM, Maglinte DD. Barium trapping in rectoceles: are we trapped by the wrong definition? Abdom Imaging 2001 Nov;26(6):587-90.

7) Dvorkin LS, Knowles CH, Scott SM, Williams NS, Lunniss PJ. Rectal intussusception: characterization of symptomatology. Dis Colon Rectum 2005 Apr;48(4):824-31.

8) Halligan S, Bartram C, Hall C, Wingate J. Enterocele revealed by simultaneous evacuation proctography and peritoneography: does "defecation block" exist? AJR Am J Roentgenol 1996 Aug;167(2):461-6.