Editorial Digestion 12: 3 9 -4 2 (1975)
Psychosomatic Aspects of Defecation and Its Disturbances Z. Maratka Department o f Medicine, Hospital Bulovka. Prague
Key Words. Colon irritable • Constipation • Diarrhea • Feces • Gastrointestinal motility • Tenesm Abstract. Constipation and diarrhea are usually defined in terms of frequency of defe cation and consistency of stool. However, the subjective component in these symptoms is so great that the objective criteria cannot be satisfactory. An important additional aspect is provided by the analysis of sensations and postures in the three phases of the act of defecation (announcing, emptying, subsequent phase). Taking account of the subjective aspects may contribute to a better differentiation and classification not only of constipation and diarrhea but also of such disturbances as organic rectal disease and irritable colon.
Received: December 12, 1974.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 2/23/2018 11:22:48 AM
From the pathophysiology standpoint, constipation and diarrhea used to be related to the intestinal transit time; this viewpoint has been erroneously taken over by some roentgenologists and clinicians. In most textbooks of gastroenter ology the definition of constipation and diarrhea takes regard mainly to the frequency of defecation. From large studies in various populations (1) it may be inferred that a bowel action less than three times weekly and more than three times daily may be regarded as abnormal. Consistency of stool and difficulty in passing a motion are additional criteria mentioned in most textbooks. Such definitions, however, are not satisfactory. Constipation, and to a cer tain extent also diarrhea, are subjective terms which are not always in keeping with objective indicators of gastrointestinal motility. Many patients seeking help for these symptoms have no objective deviations from the usual standards, and conversely, some people are definitely abnormal in this respect without com plaining. In a previous publication (2) constipation was defined as ‘difficulty in moving the bowels’. In other words, constipated are those ‘who need or believe
40
Mafatka Table 1 Phase announcing (defecation call)
emptying
subsequent (feeling)
Normal defecation Simple constipation
adequate lacking
coordinated difficult
Simple diarrhea
augmented, urgent augmented, urgent abnormal (colicky pain)
hasty
pleasant incomplete evacuation persisting call
Tenesmus (organic rectal disease) Irritable colon
inadequate persisting call or none persisting pain spastic 'constipation' and spastic 'diarrhea’
to need purgatives’. Evidently, the psychological aspect, the personal posture has a definite role in deciding whether or not the subject considers himself as sick. Let us, therefore, analyze sensations that accompany defecation and its distur bances.
Normal Defecation Three phases may be distinguished: (1) phase of announcing; (2) phase of emptying, and (3) subsequent phase (table I). In the phase of announcing the call to defecate appears — which under normal conditions is moderately urgent — not to be unpleasant or painful. Like other physiological ‘tumescent’ feelings it includes some anticipation of pleasant detuniescency. Emptying is accom plished through coordinated activity of visceral and abdominal muscles, straining is adequate, not painful. Following defecation a pleasant feeling of emptiness and a good mood appears. The sensations in these three phases, their interpretation and psychological work-up are typically altered in people complaining of disturbances of defeca tion.
Let us consider the simple constipation, i.e. pure dyschezia not complicated by cathartic colon. The phase of announcing is practically lacking. The patient
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 2/23/2018 11:22:48 AM
Constipation
Psychosomatic Aspects of Defecation and Its Disturbances
41
has no spontaneous desire to defecate even if the rectum is full of scybala. The absence of the call to defecate makes the patient nervous and often leads to hypochondric reactions. Sooner or later artificial means to elicit defecation begin to be used and thus the basic symptomatology of dyschezia obscured. In the phase of emptying the contraction of the bowel is diminished or abolished and expulsion of feces has to be accomplished through often excessive and exhaustive straining. After such strainful defecation the patient has a feeling of incomplete evacuation, fullness in the abdomen. Usually he is unsatisfied with the quantity of feces and continues to indulge in purging. Chronic purging brings about catharic colon in which symptoms of constipation and diarrhea may be intermingled.
Diarrhea In simple diarrhea - such as caused by dietary disturbance — the call to defecate is augmented and has an urgent and depressing character. The sphincter ani externus has to be used which makes the patient feel uncertain and afraid of incontinence. The expulsion of feces is accomplished through spastic intestinal contraction, abdominal pressure is not coordinated. Defecation is hasty and painful. After defecation the urge to defecate does not cease, the patient feels that the defecation is not finished, he does not leave the lavatory or returns repeatedly.
The patient seeking medical help because of intestinal disease often ex presses his complaints in terms of either constipation or diarrhea. However, symptomatic disturbances of defecation differ from simple constipation and simple diarrhea by more or less typical features that may be analyzed according to the scheme given above. Tenesmus. If the area in which the normal call to defecation originates (i.e. rectosigmoid) is involved by organic disease such as cancer or inflammation (proctitis, proctocolitis) the tenesmus is the typical symptom. In tenesmus the sensations in the three phases are much the same as in diarrhea, but the fundamental difference is in the phase of emptying where the quantity and quality of intestinal contents is not adequate. Little or no stool is emptied after great urge, the contents often consist of blood and/or mucus only. The disproportion between the urge and the result is one of the most important symptoms of organical rectal disease and should be carefully looked for in all patients complaining of either constipation or diarrhea.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 2/23/2018 11:22:48 AM
Disturbances o f Defecation in Common Diseases o f the Colon and Rectum
Mafatka
42
Disturbances o f defecation in irritable colon. Patients with irritable colon usually complain either of constipation or of diarrhea: however, an analysis of the symptoms and sensations in the three phases clearly shows the differences between this syndrome and simple constipation or diarrhea. In the phase of announcing the desire to defecate is present, but qualitatively different: instead of the normal call the patient feels pain of colicky character: he rather thinks that he would be relieved by moving the bowels. The defecation itself is always abnormal. Some call irritable colon only those cases in which constipation is predominant. However, two variants may be distinguished, namely (a) the type with constipation ('spastic constipation’ in contrast to 'simple constipation’ in dyschezia): the defecation is delayed and difficult, the stool scybalous or rib bon-like; (b) the type with diarrhea ('spastic diarrhea’): the defecation is fre quent, usually fractionated especially in the morning and after meals, the stool is soft or liquid, sometimes plug-like (i.e. hard scybalon is emptied by straining after which soft stool squirts out like after cork). In either instance the emptying is spastic and the difference between the two variants as to the clinical signifi cance is nonessential. Sometimes the two types alternate in the same individual. Following defecation the patient is left unrelieved with painful abdomen which he usually calls ‘gas’, but which has little to do with increased contents of gas in the intestine.
References 1 2
Hinton. J.M.: in Jones and Godding Management of constipation (Blackwell. Oxford1973). Maratka, Z.: Constipation (SZN, Prague 1957).
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 2/23/2018 11:22:48 AM
Z. Mafatka. Hospital Bulovka, 18081 Praha 8 (Czechoslovakia)
Psychosomatic Aspects of Defecation and Its Disturbances Z. Maratka Department o f Medicine, Hospital Bulovka. Prague
Key Words. Colon irritable • Constipation • Diarrhea • Feces • Gastrointestinal motility • Tenesm Abstract. Constipation and diarrhea are usually defined in terms of frequency of defe cation and consistency of stool. However, the subjective component in these symptoms is so great that the objective criteria cannot be satisfactory. An important additional aspect is provided by the analysis of sensations and postures in the three phases of the act of defecation (announcing, emptying, subsequent phase). Taking account of the subjective aspects may contribute to a better differentiation and classification not only of constipation and diarrhea but also of such disturbances as organic rectal disease and irritable colon.
Received: December 12, 1974.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 2/23/2018 11:22:48 AM
From the pathophysiology standpoint, constipation and diarrhea used to be related to the intestinal transit time; this viewpoint has been erroneously taken over by some roentgenologists and clinicians. In most textbooks of gastroenter ology the definition of constipation and diarrhea takes regard mainly to the frequency of defecation. From large studies in various populations (1) it may be inferred that a bowel action less than three times weekly and more than three times daily may be regarded as abnormal. Consistency of stool and difficulty in passing a motion are additional criteria mentioned in most textbooks. Such definitions, however, are not satisfactory. Constipation, and to a cer tain extent also diarrhea, are subjective terms which are not always in keeping with objective indicators of gastrointestinal motility. Many patients seeking help for these symptoms have no objective deviations from the usual standards, and conversely, some people are definitely abnormal in this respect without com plaining. In a previous publication (2) constipation was defined as ‘difficulty in moving the bowels’. In other words, constipated are those ‘who need or believe
40
Mafatka Table 1 Phase announcing (defecation call)
emptying
subsequent (feeling)
Normal defecation Simple constipation
adequate lacking
coordinated difficult
Simple diarrhea
augmented, urgent augmented, urgent abnormal (colicky pain)
hasty
pleasant incomplete evacuation persisting call
Tenesmus (organic rectal disease) Irritable colon
inadequate persisting call or none persisting pain spastic 'constipation' and spastic 'diarrhea’
to need purgatives’. Evidently, the psychological aspect, the personal posture has a definite role in deciding whether or not the subject considers himself as sick. Let us, therefore, analyze sensations that accompany defecation and its distur bances.
Normal Defecation Three phases may be distinguished: (1) phase of announcing; (2) phase of emptying, and (3) subsequent phase (table I). In the phase of announcing the call to defecate appears — which under normal conditions is moderately urgent — not to be unpleasant or painful. Like other physiological ‘tumescent’ feelings it includes some anticipation of pleasant detuniescency. Emptying is accom plished through coordinated activity of visceral and abdominal muscles, straining is adequate, not painful. Following defecation a pleasant feeling of emptiness and a good mood appears. The sensations in these three phases, their interpretation and psychological work-up are typically altered in people complaining of disturbances of defeca tion.
Let us consider the simple constipation, i.e. pure dyschezia not complicated by cathartic colon. The phase of announcing is practically lacking. The patient
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 2/23/2018 11:22:48 AM
Constipation
Psychosomatic Aspects of Defecation and Its Disturbances
41
has no spontaneous desire to defecate even if the rectum is full of scybala. The absence of the call to defecate makes the patient nervous and often leads to hypochondric reactions. Sooner or later artificial means to elicit defecation begin to be used and thus the basic symptomatology of dyschezia obscured. In the phase of emptying the contraction of the bowel is diminished or abolished and expulsion of feces has to be accomplished through often excessive and exhaustive straining. After such strainful defecation the patient has a feeling of incomplete evacuation, fullness in the abdomen. Usually he is unsatisfied with the quantity of feces and continues to indulge in purging. Chronic purging brings about catharic colon in which symptoms of constipation and diarrhea may be intermingled.
Diarrhea In simple diarrhea - such as caused by dietary disturbance — the call to defecate is augmented and has an urgent and depressing character. The sphincter ani externus has to be used which makes the patient feel uncertain and afraid of incontinence. The expulsion of feces is accomplished through spastic intestinal contraction, abdominal pressure is not coordinated. Defecation is hasty and painful. After defecation the urge to defecate does not cease, the patient feels that the defecation is not finished, he does not leave the lavatory or returns repeatedly.
The patient seeking medical help because of intestinal disease often ex presses his complaints in terms of either constipation or diarrhea. However, symptomatic disturbances of defecation differ from simple constipation and simple diarrhea by more or less typical features that may be analyzed according to the scheme given above. Tenesmus. If the area in which the normal call to defecation originates (i.e. rectosigmoid) is involved by organic disease such as cancer or inflammation (proctitis, proctocolitis) the tenesmus is the typical symptom. In tenesmus the sensations in the three phases are much the same as in diarrhea, but the fundamental difference is in the phase of emptying where the quantity and quality of intestinal contents is not adequate. Little or no stool is emptied after great urge, the contents often consist of blood and/or mucus only. The disproportion between the urge and the result is one of the most important symptoms of organical rectal disease and should be carefully looked for in all patients complaining of either constipation or diarrhea.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 2/23/2018 11:22:48 AM
Disturbances o f Defecation in Common Diseases o f the Colon and Rectum
Mafatka
42
Disturbances o f defecation in irritable colon. Patients with irritable colon usually complain either of constipation or of diarrhea: however, an analysis of the symptoms and sensations in the three phases clearly shows the differences between this syndrome and simple constipation or diarrhea. In the phase of announcing the desire to defecate is present, but qualitatively different: instead of the normal call the patient feels pain of colicky character: he rather thinks that he would be relieved by moving the bowels. The defecation itself is always abnormal. Some call irritable colon only those cases in which constipation is predominant. However, two variants may be distinguished, namely (a) the type with constipation ('spastic constipation’ in contrast to 'simple constipation’ in dyschezia): the defecation is delayed and difficult, the stool scybalous or rib bon-like; (b) the type with diarrhea ('spastic diarrhea’): the defecation is fre quent, usually fractionated especially in the morning and after meals, the stool is soft or liquid, sometimes plug-like (i.e. hard scybalon is emptied by straining after which soft stool squirts out like after cork). In either instance the emptying is spastic and the difference between the two variants as to the clinical signifi cance is nonessential. Sometimes the two types alternate in the same individual. Following defecation the patient is left unrelieved with painful abdomen which he usually calls ‘gas’, but which has little to do with increased contents of gas in the intestine.
References 1 2
Hinton. J.M.: in Jones and Godding Management of constipation (Blackwell. Oxford1973). Maratka, Z.: Constipation (SZN, Prague 1957).
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 2/23/2018 11:22:48 AM
Z. Mafatka. Hospital Bulovka, 18081 Praha 8 (Czechoslovakia)
