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  • Obstructed defecation
  • Pelvic floor dyssynergia
  • Paradoxical puborectalis syndrome
  • Anismus

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  • 564.0 Constipation
  • 564.02 Outlet dysfunction constipation

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  • K59.0 Constipation
  • K59.02 Outlet dysfunction constipation
  • R32 Unspecified urinary incontinence

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  • As of May 2013, the APTA’s Guide to Physical Therapist Practice does not include practice patterns for organ system pathology; therefore, the associated or secondary musculoskeletal, cardiovascular/pulmonary, or potential neuromuscular patterns would be indicated
  • Pattern 4C: impaired muscle performance1

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Description

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  • Difficulty passing feces
  • Obstructed defecation is also known as anismus, sphincter dyssynergia, and non-relaxing puborectalis
    • Pelvic floor muscles and external anal sphincter inappropriately contract instead of relaxing during defecation

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General Considerations

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  • Constipation is a symptom and is not a disease
  • Constipation is the most common digestive complaint
  • The chief cause of constipation is inadequate alimentary fiber content

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Demographics2

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  • In the U.S., estimates are between 2% to 34%
    • 16.7% (1 in 6 people)
    • 6% of children
    • 80% of nursing home residents
    • In children: more common in males than females
    • In adults: more common in females than males
    • Very common during pregnancy and postpartum
    • In elders, equally as common in males and females
    • More common in non-whites than whites
  • More than 3 million prescriptions per year for laxatives; over $725 million spent on over-the-counter laxatives
  • 15% to 38% of patients with constipation have obstructed defecation3

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Signs and Symptoms4,5

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  • ROME-III criteria for constipation: in a patient who does not take laxatives or have IBS (Irritable Bowel Syndrome), patient has at least two of the following in any 12 weeks of the last 6 months
    • Straining more than 25% of BMs (bowel movements)
    • Fewer than three BMs/week
    • Sensation of incomplete evacuation/anorectal blockage more than 25% of BMs
    • Lumpy or hard stool in more than 25% of BMs
    • The necessity of digital manipulation to facilitate evacuation more than 25% of BM

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Functional Implications

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  • Headache
  • Decreased energy
  • Bad breath
  • Difficulty concentrating
  • Decreased appetite
  • Coating on the tongue
  • Abdominal bloating
  • Gas/flatulence
  • Skin problems
  • Depression

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Possible Contributing Causes

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  • Underactive, overactive, or non-functioning pelvic floor muscles
  • Medications: multiple medicines can cause constipation
  • Hormonal fluctuations: pregnancy, lactation, menopause
  • Neurological conditions: Parkinson’s disease, multiple sclerosis
  • Diabetes mellitus
  • Scleroderma
  • Anorexia nervosa
  • Thyroid disease
  • Hyperparathyroidism
  • Hysterectomy
  • Dietary: inadequate fiber, fluid, weight loss
  • Poor defecation patterns, ignoring urge to defecate
  • Travel: change in food, time zones, stress
  • Change in routine: exercise, sleep, new job
  • Admission to hospital or nursing home
  • Decreased activity, bed rest

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Differential Diagnosis

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  • Hirschsprung’s disease: aganglionosis
  • Colorectal neoplasm
  • Colorectal stricture, scarring
  • Diverticular disease
  • Irritable bowel syndrome
  • Anorectal fissure, hemorrhoids, episiotomy scar
  • Pelvic organ prolapse; cystocele, rectocele, descended perineum
  • Rectal prolapse
  • Referred pain from the gut
  • Abdominal pain or tenderness; constant or intermittent, possibly related to ingesting food
  • Nausea, vomiting
  • ...

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