Introduction 

Do you know urges to pee or poop can be stress or mental health-related?

Tenesmus is a troublesome sensation characterised by frequent urges of bowel and/or bladder emptying without being able to. Despite the wide range of organic causes like rectal inflammation, constipation, or urinary tract infection (UTI)-induced neuromuscular overactivity. Psychosomatic causes, such as emotional stress, anxiety, and various mental health issues that disrupt the integrated mind-body connection, as well as functional abnormalities upon the digestive or urinary systems that affect normal bowel or bladder function, could also worsen or trigger the sense of incomplete evacuation. While understanding this combined impact is crucial for effective treatment approaches, continue reading to gain awareness and insight into potential psychosomatic causes of tenesmus. 

What are the psychosomatic causes of tenesmus?

Emotional stress and anxiety 

Emotional stress and anxiety can be a trigger or exacerbating factor of tenesmus, especially in cases of irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD). The brain and gut are intimately connected (gut-brain axis) by the enteric and autonomic nervous system (ANS). Once a person is under emotional stress, the ANS is activated to increase intestinal motility and spasms. Cortisol released through the hypothalamic-pituitary-adrenal (HPA) axis could also alter gut permeability and inflammation. The chronic dysregulation of gut-related neurotransmitters such as serotonin and acetylcholine, that worsen pelvic floor muscle tension, results in a cycle of worry. This further reinforces sustained spasms and hypersensitivity during bowel and bladder emptying.¹ The constant urge to urinate or defecate could also lead to emotional distress and anxiety, in turn, intensifying tenesmus.² 

Somatic symptom disorder 

Somatisation-induced tenesmus is when emotional distress manifests physically due to gut-brain axis dysfunction. Increased activity in the anterior cingulate cortex and insula alters central and peripheral visceral sensory processing. Perception of bowel and bladder sensations is amplified, exaggerating potential rectal and/or bladder urgency and discomfort. Dysregulated autonomic functions increase gut motility and pelvic floor muscle contractions by mimicking incomplete bowel or bladder emptying. Altered serotonin and cortisol levels can further disrupt gastrointestinal motility and pain perception. These, altogether, intensify chronic stress and discomfort, disrupting adaptive neural processing further, amplifying tenesmus symptoms, despite the lack of structural abnormalities. Functional MRI studies have also suggested the hyperactivity of pain-processing brain regions in bowel dysfunction, linking psychological stressors to persistent tenesmus.³ 

Depression 

Depression can cause tenesmus by affecting gut motility through serotonin abnormalities that arise from a dysregulated gut-brain axis. The reduced serotonin levels in depression can slow down gut transit (peristalsis), leading to constipation and tenesmus. The ANS is also altered, affecting gut motility by increasing sympathetic tone, resulting in spastic rectal or bladder contractions. Depression-related chronic inflammation and dysbiosis could further disrupt intestinal function, heightening visceral hypersensitivity. The elevated cortisol level from HPA dysregulation also impairs gut coordination, leading to worsening tenesmus.^4,5 

Health anxiety (hypochondriasis) 

Health anxiety (hypochondriasis)-induced tenesmus originates from the obsessive self-awareness of bodily sensations and dysregulated autonomic nervous system activity (dysautonomia). Individuals suffering with hypervigilance towards bodily sensations that amplify normal gut signals frequently misinterpret them as abnormal or discomfort. The sympathetic activation driven by cognitive biases and hyperfocus in anxiety can hypermobilise the intestine, causing pelvic floor dysfunction, spasms and incomplete bowel or bladder emptying. Excessive cortisol released from the HPA axis could also alter gut-brain signalling, thereby increasing visceral hypersensitivity. Imbalances in serotonin and norepinephrine pathways further add to symptom persistence.^6,7  

What are the functional causes of tenesmus?

Irritable bowel syndrome

Irritable bowel syndrome (IBS) causes tenesmus through abnormal gut motility, visceral hypersensitivity and pelvic floor dysfunction. Dysregulated serotonin signalling within the ANS can also trigger uncoordinated bowel contractions, making it difficult to fully evacuate stool. Additionally, heightened intestinal sensitivity and pain perception can strain the bowel and exacerbate the sense of incomplete evacuation, even when empty. Furthermore, the chronic low-grade inflammation and imbalanced gut microbiome can also develop a heightened gastrocolic response to certain foods like dairy, wheat, and beans, in persistent bowel irritation – hence, the urge to defecate after eating. Mental stress and anxiousness induced by discomfort can hyper-activate the ANS, and further intensify rectal spasms.^8,9 

Pelvic floor dysfunction

Pelvic floor dysfunction can cause tenesmus due to the inability to relax and coordinate pelvic floor muscles, often related to chronic straining, stress, past trauma, or learned dysfunctional behaviours. When muscles become too tense or fail to relax properly, bowel emptying becomes incomplete, leading to a persistent urge to defecate. Chronic muscle tightness can therefore lead to spasms, increased rectal pressure and discomfort. Additionally,  pelvic nerve dysfunctions that heighten pain perception cause urgency or normal bowel sensations to become painful.^9,10 

Functional constipation and dyssynergic defecation 

Functional constipation (obstructed defecation) and dyssynergic defecation disrupt normal bowel emptying, leading to tenesmus. In functional constipation, delayed colonic transits create hard, dry stool, causing strain and the sensation of incomplete evacuation. Dyssynergic defecation (anismus), resulting from uncoordinated abdominal, sphincter and pelvic muscles, makes stool harder to pass, preventing effective stool expulsion. The uncoordinated contraction and relaxation or failure of the anal sphincter can increase rectal pressure, prolonging the urge to defecate. Chronic straining and heightened rectal hypersensitivity further reinforce persistent discomfort, along with neural dysregulation and heightened pain perception contribute to persistent discomfort. 

Interstitial cystitis 

Interstitial cystitis (IC) or bladder pain syndrome (BPS) can cause tenesmus through:

• Chronic bladder inflammation
• Bladder, ureter, and urethra lining (urothelial) dysfunction
• Pelvic floor muscle overactivity, exacerbated by mental stress 

The damaged bladder lining has increased permeability, allowing irritants to trigger sensory nerve hypersensitivity. This could amplify urination urgency, even when the bladder is empty. Bladder spasms and pelvic floor dysfunction are intensified by neurogenic inflammation and altered ANS signalling, leading to a persistent sense of incomplete voiding. Furthermore, central sensitisation that heightens pain perception can further aggravate tenesmus.¹¹ 

Diagnosis and assessment  

A comprehensive diagnostic and assessment process is done to understand the exact cause of tenesmus: 

Clinical history and psychological evaluation

Clinical history of psychosomatic or functional tenesmus typically includes a thorough review of bowel and/or urinary symptom onset, triggers, pain patterns, duration, past gastrointestinal or neurological disorders, and psychological factors like anxiety, depression, or recent emotional distress. 

Psychological evaluation, including the screening of health anxiety and somatisation through PHQ-15 or DSM-5 criteria,aids diagnosis. Multidisciplinary specialists, including gastroenterologists, psychologists and psychiatrists, ensure comprehensive assessment and proper management.   

Exclusion of organic causes

Excluding organic causes is crucial when diagnosing psychosomatic or functional tenesmus. A thorough evaluation, including as blood tests, digital rectal exam, flexible sigmoidoscopy, and possibly colonoscopy, can help rule out IBS, infections, tumours, or neurological disorders. Once organic causes are excluded, psychological factors such as anxiety, stress, depression, or trauma should be considered, with a focus on heightened gut-brain axis sensitivity or pelvic floor dysfunction in those with tenesmus. 

Functional tests 

Functional tests can help assess psychosomatic or functional tenesmus by checking anorectal function and pelvic floor coordination. 

• Anorectal manometry measures rectal pressure, sensation, and sphincter function, to identify dyssynergic defecation
• Balloon expulsion tests determine the ability to expel a simulated stool, detecting pelvic floor dysfunction 
• Defecography helps to visualise rectal emptying and observe abnormalities such as rectocele or anismus 
• Electromyography (EMG) evaluates pelvic floor muscle activity or inappropriate contractions

Management approaches 

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT), as a psychotherapy, can help manage psychosomatic and functional tenesmus by addressing the stress, anxiety, and maladaptive thinking patterns related to tenesmus. In addition to learning about the specific triggers of bowel urgency, techniques such as cognitive restructuring and psychoeducation on the interconnectedness of anxiety and actual symptoms can be beneficial in managing tenesmus. Coping skills like gradual exposure to difficult situations, relaxation training, and even adaptive problem solving through role play could help to reduce symptom-related distress, improving pelvic floor coordination and gut-brain axis for long-term relief.¹² 

Stress reduction techniques

Stress-reduction techniques like mindfulness meditation, deep breathing, and progressive muscle relaxation can help address psychosomatic and functional tenesmus, while improving gut-brain axis regulation to minimise bowel discomfort and urgency. Regular exercise and trigger avoidance could lessen stress-induced gastrointestinal symptoms.¹³ 

Biofeedback and pelvic floor therapy

Biofeedback and pelvic floor therapy can retrain pelvic muscle coordination in psychosomatic and functional tenesmus. Sensors are used to monitor pelvic floor activity in biofeedback to facilitate the teaching of proper relaxation and defecation.¹⁴ Pelvic floor therapy, incorporated with manual techniques and exercises, is helpful to reduce tension and improve pelvic control, thereby, alleviating symptoms and restoring normal bowel function.¹⁵  

Medications 

For cases where psychotherapy and biofeedback retraining are not effective enough, various medications can be utilised to target gut-brain axis dysregulation: 

• Antispasmodics in relieving rectal spasms 
• Low-dose antidepressants like tricyclic antidepressants(TCAs) in modulating pain sensitivity and selective serotonin reuptake inhibitors (SSRIs) in handling anxiety-related visceral hypersensitivity 
• Laxatives or stool softeners to facilitate bowel regularity 
• Neuromodulators for refractive cases 

Gut-directed hypnotherapy

Gut-directed hypnotherapy helps manage psychosomatic and functional tenesmus through calming and modulating the gut-brain axis, to reduce visceral hypersensitivity and improve bowel function. While relaxation is promoted and subconscious responses are retrained, it is typically used to enhance long-term symptom control and relief, especially when conventional treatments fail. 

Summary 

Tenesmus, the constant urge to defecate or urinate, despite an empty bowel or bladder, is a distressing symptom caused by a variety of conditions. Despite the significant role of mental health issues and dysregulated neural connectivity, the psychosomatic and functional aetiologies of tenesmus are often underestimated. However, there is a close link between the gut and brain. A holistic consideration and comprehension of both psychological and physiological mechanisms and diagnostic approach are essential for accurate diagnosis and the development of appropriate management of underlying stressors, symptom relief and improved quality of life.