MMM Physiology of Defecation

Physiology of
Defecation
Presented by
Dr Mayuri Mane
PG scholar(surgery)
Nashik
Defecation
– Like urination, the elimination of feces is not a

continual event but is episodic and is controlled
by neurological reflexes and sphincters; thus, it
ordinarily occurs only in appropriate
circumstances and times.
– Filling of the stomach with a new meal triggers a gastrocolic reflex through the enteric
nervous system, inducing mass movements that propel feces from the upper colon
toward the rectum.
– Stretching of the rectum then sets off both enteric and spinal reflexes called defecation
reflexes,which account for the urge to defecate.
– One of the defecation reflexes, called the intrinsic defecation reflex, is controlled
through the enteric plexus of the colonic wall. Stretch signals from the rectum are
conducted through the plexus
– (1) to the descending and sigmoid colon, further activating a peristaltic wave that
drives feces downward, and
– (2) to the internal anal sphincter, causing it to relax. In an infant, this alone results in
defecation.
– The other reflex, called the parasympathetic defecation reflex, is spinal. Stretch signals are conducted to
the spinal cord and return to the rectum through a visceral reflex arc via parasympathetic nerve fibers in
the pelvic nerves. These signals likewise intensify peristalsis and relax the internal anal sphincter.
– Obviously and fortunately, once we have acquired bowel control in childhood,we are not at the mercy of
these two involuntary reflexes. The external anal sphincter is skeletal muscle and therefore under
voluntary control. Feces usually are voided only if we voluntarily relax that sphincter in addition to the
foregoing involuntary reflexes.
– The external anal and urinary sphincters are controlled together by inhibitory signals from the
brainstem. This is why we find it hard to defecate without also urinating.
Applied
physiology
Constipation
Dyssynergic defecation
Fecal incontinence
Spinal trauma
Constipation
Defination Passage of dry , hard stools or unsatisfactory motion for few weeks
Normal range Thrice a day OR once in 3 days

– Defination
Causes Lack of exercise & fibre, less water intake etc.
Disease such as fissure , hemorrhoids, IBS
factors Old age, change in routine,
Medications like iron supplements, pregnancy
Medications Laxatives & purgatives

Purgative Stronger action resulting in more fluid evacuation
Laxative Milder action, elimination of soft but formed stools.
[Aperients (to get rid off) < Laxatives (to loosen) < Emolient (to smooth and soften) <
Evacuant (to empty) < Purgatives (to clean)< Cathartic (to utterly clean)]
– The most common digestive complaint
of older people is constipation, which
results from reduced muscle tone and
weaker peristalsis of the colon. This
seems to stem from a combination of
factors: atrophy of the muscularis
externa, reduced sensitivity to
neurotransmitters that promote
motility, less fiber and water in the
diet, and less exercise.
Dyssynergic defecation
– In dyssynergic defecation, it appears that the coordination between the muscles

that make up the pelvic floor is impaired i.e. the puborectalis muscle and the
internal and external sphincters of the anus. Improper contraction and/or
relaxation of these muscles during bowel movements appear to be major
contributors to the problem.
– To complicate things further, there is some evidence that some individuals who
suffer from dyssynergic defecation have an impairment in their perception of
stool within the rectum. This may lead to missing cues about the need to
initiate a bowel movement, thus exacerbating the constipation problem.
Alternate Names
The condition of dyssynergic defecation has been called by a wide variety of names
over the years, including:
– Anal sphincter dyssynergia

– Anismus
– Obstructive defecation
– Paradoxical puborectal contraction
– Pelvic floor dyssynergia
– Pelvic outlet obstruction
– Spastic pelvic floor syndrome
Symptoms
The symptoms of dyssynergic defecation parallel those of chronic constipation.
– Abdominal bloating
– Excessive straining
– Feeling of incomplete evacuation
– Hard stools
– Less than three bowel movements per week
– Digital evacuation (using fingers to assist in a bowel
movement)
Incontinence
– As continence is dependent upon the structural and functional integrity of both

the neurological pathways and the gastrointestinal tract, the risk factors for anal
incontinence are many.
– Sphincteric causes of incontinence may be classified as structural, in which
there is disruption (or atrophy) of part of the sphincter muscles, neuropathic
(previously termed idiopathic), in which the nerve supply to the sphincters is
damaged, usually by chronic straining or complicated vaginal delivery
(prolonged second stage), or a combination of the two.
– The commonest causes of sphincteric disruption are obstetric damage, anal
surgery (following haemorrhoidectomy, dilatation or sphincterotomy for anal
fissure, and fistulotomy for anal fistula) and trauma.
Spinal trauma
– Sensory nerve endings present in the rectum and anal
canal can detect pressure exerted by the bulk of a stool.
As this pressure mounts, a person feels the urgency to
pass the stool. The flatus that gathers in the lower
intestine and colon also exerts pressure and triggers a
need to pass wind.
Mechanism of
– Flatulence often makes a sound, as the flatus passes
flatulence through the tight anal sphincter. The speed the gas is
passed at, the tightness of the sphincter and other factors
such as water and body fat content, determine the type
and pitch of the sound. Flatulence can occur accidentally
when pressure within the abdomen is suddenly raised due
to coughing, sneezing, sexual intercourse or laughing,
Defecography
Defecography (also known as proctography, defecating/defecation proctography,

evacuating/evacuation proctography or dynamic rectal examination) is a type of medical
radiological imaging in which the mechanics of a patient's defecation are visualized in real
time using a fluoroscope. The anatomy and function of the anorectum and pelvic floor can
be dynamically studied at various stages during defecation.
Defecography may be indicated for the following reasons:
– Evaluation of rectal outlet obstruction (obstructed defecation) symptoms
– Evaluation of all types of rectal (fecal) incontinence.
– Suspected conditions such as internal rectal intussusception, enterocele, anismus,
rectocele or sigmoidocele.
– To compare pre- and post-surgical repair of rectal outlet obstruction (obstructed
defecation)
Cinedefecography and MRI defecography
Cinedefecography is a technique that is an evolution of defecagography.

The defecation cycle is recorded as a continuous series rather than
individual still radiographs.More recent techniques involve the use of
advanced, cross-sectional imaging modalities such as
magnetic resonance imaging. This is known as dynamic pelvic MRI, or
MRI proctography. The MRI proctography also called MRI defecography is
not as efficient as conventional x-ray defecography for some problems.
Anorectal
manometry
Anorectal manometry is a technique
used to measure contractility in the
anus and rectum. This technique uses a
balloon in the rectum to distend the
rectum and a pressure sensor at the
internal anal sphincter to measure the
presence or absence of the
rectosphincteric reflex.
It may be used to assist in the diagnosis
of Hirschsprung disease[3] in which
there is an absence of the
rectosphincteric reflex that should relax
the internal anal sphincter upon
distension of the rectum. It is also used
in the assessment of rectocele.
Diagnostic yield and interpretation
Anatomical and physiological parameters that can be objectively measured by this investigation include:
– Anorectal angle This is the "mid-axial longitudinal axis of the rectum and the anal canal", created by the anterior
pull of the puborectalis sling at the level of the anorectal junction. At rest, it is held at 90 - 100°. This becomes
more acute (70 - 90°) when the patient contracts the anal sphincters and pelvic floor muscles, and more obtuse
(110 - 180°)during defecation.
– Perineal descent This is "the caudad movement of the pelvic floor [during] straining". Defecation normally
involves a relaxation of the pelvic floor (levator ani), leading to descent of the perineum. After straining, the
opposite occurs, the perineum rises. From the proctogram, descent is calculated by drawing an imaginary line (the
pubococcygeal line) between the most inferior point on the pubic bone and the tip of the coccyx. Normal perineal
descent or elevation is less than 4 cm from the pubococcygeal line in either direction (superior or inferior).
– Efficiency of emptying/evacuation Normally, there is 90-100% evacuation of rectal contents.
– Anal canal length This is measured during maximal evacuation.
– Anal canal width Again measured during maximal evacuation, this is usually less than 2.5 cm.

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Physiology of

– Like urination, the elimination of feces is not a

Normal range Thrice a day OR once in 3 days

Medications Laxatives & purgatives

– In dyssynergic defecation, it appears that the coordination between the muscles

– Anal sphincter dyssynergia

– As continence is dependent upon the structural and functional integrity of both

Defecography (also known as proctography, defecating/defecation proctography,

Cinedefecography is a technique that is an evolution of defecagography.

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