Introduction

Dyschezia is a common condition that can affect people at all stages of life. This article will explore the condition in greater detail, how it is diagnosed and its treatment options.

What is Dyschezia

Dyschezia refers to pain or difficulty experienced in the passing of faeces.¹ It is a term that is often used interchangeably with constipation, and while individuals may experience both at the same time, they are clinically distinct. Constipation refers to a set of symptoms related to difficulties in defecation, which include: infrequent bowel movements, excessive straining, hard or lump stools, sensation of incomplete evacuation, blockage and in some cases, the use of manual manoeuvres to facilitate evacuation.² If these symptoms persist for more than 3 months, the condition is referred to as chronic constipation.³

Dyschezia on the other hand is merely diagnosed on a self-reported basis as a symptom when individuals describe pain when defecating; it is normally indicative of a wider issue or disease.¹ Such conditions associated with dyschezia include:

• Rectocele (herniation of the rectal tissue into the vaginal)⁴
• Endometriosis (the growing of endometrial tissue outside of the uterus)⁵
• Anal fissures (damage to the anal canal)⁶
• Haemorrhoids (swelling of veins in the lower rectum)⁷

Infant Dyschezia

Clinically distinct from the pain experienced as a result of excretion, infant dyschezia is diagnosed using the Rome IV criteria.⁸ The Rome criteria is a set of processes and classifications used to diagnose Functional Gastrointestinal Disorders (FGIDs); it is updated semi-regularly, with the 4^th iteration released in May 2016.⁹ In the latest update, the age limit for diagnosis of the disease has been increased from 6 months to 9 months as a result of a study which argued that the prior age limit was too strict and that it needed increasing.¹⁰

Another aspect that has been changed is the exact conditions for the diagnosis of infant dyschezia to be made. Previously, for a diagnosis to be made, there must be a period of straining and crying in the infant for the last 10 minutes before the successful passage of a soft stool, without any other health issues being present.¹¹ However, the Rome IV modified this diagnostic criteria so that the successful passage of stools is no longer required, which means a diagnosis can be made in infants who experience pain and difficulty for a prolonged period while attempting to pass stools, whether the outcome is successful or not.⁸ It is theorised that the underlying mechanism responsible for infant dyschezia relates to an inability to coordinate an increase in intra-abdominal pressure along with the relaxation of the pelvic floor muscles.¹²

Treatment options for Dyschezia

There are a number of established and emerging treatment options for those suffering from dyschezia. In the following section, each course of action will be explored in greater detail.

CO₂ releasing suppositories 

One such treatment option that has been trialled to relieve dyschezia-related symptoms in adults are CO₂ releasing suppositories. The suppositories contain potassium acid tartrate, sodium bicarbonate and excipients and work via insertion into the rectum of patients suffering from dyschezia, where then the suppository releases approximately 100mL of CO₂, which stimulates mechanoreceptors in the rectum, resulting in defecation and minimising straining during bowel movements.¹³

It has been trialled in combination with the bulk fibre laxative Psyllium, which is effective in treating constipation.¹⁴ Bouchoucha et al. demonstrated in a trial of 20 constipated patients, that the combination of CO₂ releasing suppository treatment and Psyllium was more effective in reducing straining and the sensation of incomplete evacuation during defecation than treatment with Psyllium alone.¹⁵ Furthermore, Lazzaroni et al. showed in a double-blind, randomised, placebo-controlled trial in 29 patients that a CO₂ releasing suppository was effective in promoting more frequent stools, with a more normal consistency in chronic functionally constipated patients than a placebo.¹⁶

Building upon this existing evidence, Cotelle et al. proposed the daily use of CO₂ releasing suppositories to alleviate symptoms associated with dyschezia.¹³ To test whether this application would work, a multicentre, randomised, double-blind, placebo-controlled study was conducted on 122 patients with dyschezia. The placebo in this study was anorectal biofeedback training, which is a conditioning treatment which makes use of electric stimulus and either visual or auditory information to retrain the pelvic floor muscles to improve their coordination and reduce their dysfunction.¹⁷

The patients were asked to evaluate the intensity of their symptoms using a Visual Analogue Scale (VAS) at the beginning of the trial, before their treatment, throughout as they received treatment, and at the end of their treatment, which lasted for 21 days.¹⁶ The results of the study demonstrated that CO₂ releasing suppository treatment combined with 4 to 5 anorectal biofeedback training sessions provided greater relief of dyschezia-related symptoms than biofeedback alone, suggesting it is an effective treatment for dyschezia. 

Lifestyle modification

Positive changes to one’s lifestyle may also improve dyschezia-related symptoms, as increases in physical activity and improvements to diet are known to be able to relieve constipation and have positive effects on bowel movement.¹⁸ A study of 50 women with endometriosis showed that effective lifestyle modification significantly decreased the severity of endometriosis-related pain symptoms, including dyschezia.¹⁹

Treatment for infant Dyschezia

Many clinicians do not recommend any treatment or intervention for treating infant dyschezia, other than observation, as it is usually a benign condition which usually disappears on its own as the infant learns to better coordinate their bowel movements.²⁰ Some evidence suggests that a 2-week treatment of 2% or 4% lactulose, which is a laxative, can help normalise stool passage and consistency.²¹

However, clinicians and parents should be wary that infant dyschezia may be indicative of a greater pathology in some children, such as:²⁰

• Low anorectal malformations (minor anomalies in the development of the distal rectum and anal canal)²²
• Hirschsprung’s disease (absence of the intrinsic nervous system of the gut in the variable portion of the distal colon)²³
• Colonic stenosis (a narrowing of portions of the descending and sigmoid colon)²⁴
• Hypothyroidism (an autoimmune disease caused by primary gland failure of the pituitary gland or insufficient stimulation of the pituitary gland by the hypothalamus, which can result in neuromuscular dysfunction)²⁵
• Dysfunctions of the renal and/or hepatic systems (kidney and liver, respectively)²⁰

Summary

Dyschezia is a term used to describe a sensation of pain or difficulty experienced when attempting to defecate. It is sometimes thought of as an interchangeable term for constipation, however, it is clinically distinct. Constipation comprises a range of symptoms including excessive straining, infrequent bowel movements, hard or lumpy stools, blockage, a sensation of incomplete evacuation, and the use of manual manoeuvres to facilitate evacuation; if these symptoms persist for more than 3 months, the condition is diagnosed as being chronic.

Dyschezia, on the other hand, is diagnosed on a self-reported basis, as and when individuals experience pain or difficulty when defecating. It is often reported as a symptom of a wider medical condition or issue, such as endometriosis, rectocele, anal fissures and haemorrhoids.

In adults, dyschezia can be diagnosed through communication with a clinician, however, when the condition occurs in infants too young to communicate, a separate diagnostic criteria is used. According to the Rome IV criteria, infant dyschezia can be diagnosed in infants at any point from birth to up until they are 9 months old. Infants within this age range are diagnosed with the condition if they experience a period of straining and crying for 10 minutes or more, before the successful or unsuccessful passage of a soft stool, without any other health issues also present. This is because infant dyschezia is often thought to be a result of the infant being unable to properly coordinate bowel and pelvic muscle contractions, to effectively pass stools.

One treatment option for dyschezia in adults, which has been trialled to good measure is the use of CO2 releasing suppositories. These suppositories contain sodium bicarbonate, potassium acid tartrate and excipients and work via insertion into the rectum, where the suppository then releases ~100mL of CO2, which stimulates rectal mechanoreceptors to facilitate bowel movement and reduces straining and pain associated with defecation. Other treatment options include lifestyle modification and laxatives. For infant dyschezia, observation is the only treatment option widely accepted as the condition is often benign and fixes itself.