Understanding Pelvic Floor Dysfunction and Dyssynergic Defecation

Have you suffered from chronic constipation only to be told to eat more fiber or drink more water, but feel like it's only getting worse? Or maybe you’ve tried every laxative and nothing happens, or you only have watery diarrhea. Maybe you strain even to pass soft stools or feel like sometimes something leaks out without you even noticing it. If these sound familiar, it’s possible that you may have a defecation disorder that’s related to pelvic floor dysfunction.

Pelvic floor dysfunction (PFD) is quite common and can affect men and women of all ages. It can play a major role in digestive disorders, especially chronic constipation. In fact, it’s estimated that up to half of patients with chronic constipation may have pelvic floor dysfunction. So what is pelvic floor dysfunction?

Let’s get into it.

What is the pelvic floor?

The pelvic floor is a group of muscles and connective tissues that support the pelvic organs—including the bladder, rectum, and, in women, the uterus and vagina. These muscles help control:

• Urination
• Bowel movements
• Sexual function
• Core stability

Like any other muscle group, the pelvic floor can become weak, tight, uncoordinated, or dysfunctional—leading to symptoms that can be frustrating and, if untreated, can seriously impact quality of life.

The Pelvic Floor During a Bowel Movement

During a bowel movement, the pelvic floor muscles go through a precise and coordinated sequence so stool can pass easily without excessive straining. When the rectum senses that it’s full of stool, it sends signals to the brain and the brain then sends a message to the muscles of the pelvic floor and anal sphincters to prepare for defecation.

Here are the steps that occur during a “normal” trip to the bathroom.

1. The pelvic floor relaxes
   
   1. The levator ani muscles (main pelvic floor muscles) relax and drop slightly.
   2. This lowers the pelvic floor and opens up the anorectal angle (the bend between the rectum and anal canal), making it easier for stool to pass.
2. The anal sphincter relaxes
   
   1. Triggered by rectal stretch, the internal anal sphincter, an involuntary muscle, relaxes first.
   2. The external anal sphincter, a voluntary muscle, then relaxes when you consciously decide to go.
   3. Together, these sphincters open the anal canal.
3. The abdominal muscles kick in
   
   1. The abdominal muscles gently contract and increase intra-abdominal pressure.
   2. This pressure, combined with the rectum contracting, pushes stool toward the open anal canal.
4. Evacuation
   
   1. The pelvic floor stays relaxed until the stool is fully passed.
   2. Once empty, the pelvic floor and sphincters contract again to restore support and close the anal opening.

When the pelvic floor functions correctly, the result of these steps is a complete bowel movement that occurs with no straining. Now, in pelvic floor dysfunction, the muscles can be over active, underactive, or uncoordinated, and this can lead to dyssynergic defecation, chronic constipation, incomplete evacuation, or fecal incontinence.

Types of Pelvic Floor Dysfunction

There are multiple types of pelvic floor dysfunction and each type can lead to symptoms. Knowing the specific type is essential for proper treatment.

Pelvic Floor Dyssynergia

With pelvic floor dyssynergia, the pelvic muscles may be too tight, too loose, and uncoordinated. Essentially, the muscles that should coordinate during a bowel movement don’t work together properly. Instead of relaxing to allow stool to pass, the pelvic floor and/or anal sphincter muscles contract or fail to generate enough pressure.

There are four different types of pelvic floor dyssynergia - all involve abnormal sphincter behavior. The four types are:

• Type I: Paradoxical Contraction with Adequate Push
  
  • You push with enough abdominal force or normal to high rectal pressure.
  • But instead of relaxing, the anal sphincter contracts known as paradoxical contraction.
  • The anal canal stays closed blocking stool.
  • This is like trying to push toothpaste out with the top still on the tube- nothing is getting out!
• Type II: Paradoxical Contraction with Inadequate Push
  
  • The abdominal push is weak with low rectal pressure.
  • The anal sphincter still contracts paradoxically instead of relaxing.
  • This is a double problem because there’s a weak push and the outlet is closed.
  • Think of this like a weak squeeze on the toothpaste tube with the top on.
• Type III: Absent or Incomplete Relaxation with Adequate Push
  
  • You push well and have normal or high rectal pressure.
  • The anal sphincter does not contract, but it also doesn’t relax fully -  the residual tone remains too high.
  • The anal canal is only partially open, so stool struggles to pass through it completely.
  • Think of the toothpaste tube opening, being partially blocked with only small amounts of toothpaste being released.
• Type IV: Absent or Incomplete Relaxation with Inadequate Push
  
  • There’s weak abdominal push, or low rectal pressure.
  • The anal sphincter is unable to completely relax with residual tightness.
  • There’s low propulsion and high resistance making passing stool very difficult.
  • There is light pressure being applied and a blocked opening of the “toothpaste tube.”

Pelvic Organ Prolapse or Rectocele

1. Organs like the rectum, bladder, or uterus may drop from their normal position and press into the vaginal or rectal walls.
2. Can create a pocket, physical blockage, and may present with a sensation of pressure that interferes with bowel movements. The stool becomes trapped and leads to a feeling of incomplete emptying.

Signs of Pelvic Floor Dysfunction

Now that you’ve learned about the types of pelvic floor dysfunction, let's discuss signs or symptoms you may experience if your pelvic floor is playing a role. Below are signs that you may have a pelvic floor problem:

• Experiencing chronic constipation even with adequate fluid and fiber intake.
• Straining for extended periods to have a bowel movement.
• Having feelings of incompleteness or feeling like you need to go again right after going.
• Needing to use your fingers to help stool pass by pressing on the perineum or inside the vaginal wall or rectum.
• Experiencing leakage of stool and urgency
• History of:
  
  • Women: having a vaginal birth, history of sexual abuse, history of hysterectomy, or painful sexual intercourse.
  • Men: having a history of prostatitis, urinary issues, or sexual dysfunction.

It’s important to note that with anything related to the bowel and bowel movements, experiencing symptoms once or twice does not mean that you have a disorder, but something that occurs on a regular basis will merit a discussion with your healthcare team.

Diagnosis and Treatment of Pelvic floor Dysfunction

If you’ve experienced some of the above symptoms or have suffered from chronic constipation or leakage, it is recommended that you speak with your healthcare provider - either a gynecologist or a gastroenterologist who can provide you with a diagnosis. This will typically include a detailed health history with a physical exam and digital rectal exam. Additional testing using anorectal manometry, balloon expulsion, or an MRI defecography can help confirm a diagnosis.

Once diagnosed, treatment for pelvic floor dysfunction often includes working with a physical therapist who specializes in the pelvic floor. They may include several methods into the treatment such as:

• Biofeedback -  a method using sensors and a screen that helps to retrain and coordinate the muscles of the pelvic floor.
• Physical Therapy -  using exercise techniques to strengthen, help relax, or aid in coordinating the muscles of the pelvic floor.
• Lifestyle Changes - using stool softeners, fiber supplements, toilet stools, Botox, and posture adjustments.
• Surgery - to repair severe cases of prolapse or a rectocele.

Food and Pelvic Floor Dysfunction

While changing your diet will not fix your pelvic floor dysfunction, the food you eat can influence how you feel and affect your stool consistency, gut motility, and abdominal pressure. A dietitian can help you identify ways to modify your stool consistency using specific types of fiber, especially soluble forms of fiber like those found in oats or psyllium. This can either bulk or  keep your stool moist and easily passable. Additionally, a dietitian can help with other symptoms such as gas and bloating by recommending foods that are less gas-producing or low-FODMAP. Some fermentable foods can increase abdominal pressure which can make it difficult to coordinate the pelvic muscles and relaxation.  

You’re Not Alone—and It Is Treatable

Pelvic floor dysfunction is more common than many people think—and it’s highly treatable with the right approach. If you’ve been silently struggling with constipation, incomplete evacuation, or changes in bowel control, it’s worth asking your doctor about your pelvic floor.

Whether you're male, female, postpartum, aging, or just frustrated by gut symptoms that won’t go away—this might be the missing piece. And while food can’t “fix” pelvic floor dysfunction alone, working with a GI-expert dietitian to tailor the diet to produce soft, formed stools and reduce bloating can help relieve symptoms and make it easier to have complete bowel movements.