It’s something doctors call ‘incomplete bowel evacuation/movement’ and is common if you have irritable bowel syndrome and/or constipation.
Incomplete evacuation is what we’re going to look at in this article.
What are the symptoms of incomplete evacuation?
Simply that there is still some stool left in the bowel after you’ve been for a bowel movement. This may be clear if your doctor examines your rectum or you may just not feel the bowel has emptied itself.
You may also have urinary problems such as urgency or pain when you pee, or you may feel the bladder hasn’t emptied properly when you go.
Incomplete bowel evacuation can cause a feeling or pain or pressure in the vagina or rectum.
You may have some abdominal pain, especially if it’s caused by constipation.
If the incomplete evacuation is caused by pelvic floor dysfunction (see the section below), which affects about 50% of people with long term constipation, the symptoms include:
- Constipation and straining when having a bowel movement. This can cause painful bowel movements, which in turn puts you off wanting to ‘go’. This means the stool in the bowel becomes drier, harder and more difficult to pass. This makes it more painful, and you can see how the cycle persists.
- Pain in the lower back, pelvic area, genitals or rectum.
- Pain in the pelvic muscles themselves. They may also go into spasm, which is painful.
- Needing to urinate more often.
- Painful intercourse for women.
What causes incomplete evacuation?
You may think that having a bowel movement is as simple as pulling down your pants, sitting and letting go (probably with some straining if you have constipation).
Not so much.
It actually involves the coordination of a number of sets of muscles: the muscles of the gut, the rectum (lower bowel), the pelvic floor muscles and the muscles of the anal sphincter. They all need to contract and relax at the right times to enable a normal bowel movement and this is all an unconscious process.
The Mayo Clinic says that as many as half the people who have chronic constipation have pelvic floor dysfunction (PFD).
The pelvic floor is the ‘hammock’ or sling of muscles that run from the pubic bone at the front to the tail bone at the back. The urethra (from the bladder), vagina in women, and the bowel all run down through the pelvic floor muscles. If these muscles becomes stretched and damaged they don’t work as effectively.
These muscles can become damaged through:
- Being overweight
- Having surgery or radiation treatment to the pelvic area. This can damage the nerves in the pelvic floor muscles.
- There may some genetic causes.
- Repeated heavy lifting, which puts an extra strain on these muscles.
- It can be associated with psychological, physical or sexual abuse.
- It is not considered a normal part of ageing, although it becomes more common as people get older.
Another cause of incomplete evacuation is having a rectocele (say rek-toe-seel). A rectocele happens when the wall between the vagina and rectum (see the diagram) is damaged and doesn’t keep its shape. This means it prolapses – collapses somewhat – either into the bowel or into to vagina.
What tests will the doctor do for incomplete evacuation?
The doctor will
- listen to what you have to say about your symptoms,
- ask you about your medical history, what medications you take, your smoking, alcohol and recreational drugs,
- examine your abdomen and rectum,
- may order some blood tests to check for any imbalance that can cause constipation.
There are medical criteria for describing constipation. These are called Rome II Criteria:
Adults having 2 or more of these criteria for at least 12 weeks in the preceding 12 months:
- If you strain on more than a quarter of occasions, when you have a bowel movement.
- Lumpy or hard stools in more than 25% of bowel movements.
- Sensation of having incomplete evacuation with more than 25% of bowel movements.
- Sensation of having an obstruction or blockage in the bowel or rectum in more than 25% of bowel movements.
- Having to use fingers to help with bowel movement, or having to use fingers to support the pelvic floor when having a bowel movement, in more than 25% of bowel movements.
- Fewer than 3 bowel movements each week.
What is the treatment for incomplete evacuation?
At the Mayo Clinic they use an approach that combines
- dietary improvement for constipation,
- pelvic floor re-training exercises,
- biofeedback training and
- behaviour modification.
Patients work with a nurse specialist to tailor the suggested routine to their individual needs over time. Patients are advised on a routine of a fibre supplement in the evening, mild physical activity in the morning, a hot caffeinated drink with a fibre cereal breakfast, followed by another hot drink.
This morning routine should be done within 45 minutes of waking. The natural contractions of the gut and bowel (called peristalsis) are at their strongest in the morning. This routine helps the bowel in making the most of them.
Biofeedback is a non-surgical, non-painful and common treatment for pelvic floor dysfunction and is done with the help of a physiotherapist/physical therapist. It teaches you how to effectively contract and relax the pelvic floor muscles to make them stronger and more responsive.
Many people have tried pelvic floor exercises (Kegel exercises) but not had much improvement if they have been contracting the wrong muscles, or contracting them incorrectly. There are Kegel exercise devices you can buy, but the biofeedback and learning out to use the pelvic floor muscles correctly is best done with a qualified practitioner.
Biofeedback for pelvic floor dysfunction involves putting sensors in the rectum or vagina to measure the contraction the muscles’ contraction and relaxation. These sensors are hooked up to a computer monitor, which gives visual feedback to show you how strong the contractions are. You then learn how to change the visual feedback.
This takes some time, so patience is key to the process – don’t expect too much too soon. A course of treatment may take up to 12 weeks. But with success rates of up to 90% (the Cleveland Clinic quote 75%) it’s worth it.
Medication. Some people may need mild or low-dose muscle relaxants to help with pelvic floor dysfunction.
Relaxation techniques such as yoga, relaxation exercises and warm baths can all be useful.
Surgery may be necessary if the cause of the incomplete evacuation is found to be a prolapse or rectocele.
Counselling. If the pelvic floor has become damaged because of abuse or violent trauma, it is recommended that you have psychological support as well as physical treatment.
Who gets incomplete evacuation?
- It affects men and women.
- Women who have had children, especially by a vaginal delivery.
- People who have irritable bowel syndrome and have constipation, where straining to have a bowel movement means the pelvic floor muscles become damaged.
- People who are overweight.
- Weight lifters.
What’s the outcome for people who have incomplete evacuations?
If the cause of the problem is found to be pelvic floor dysfunction, the outlook is good. There are some studies which look at the short and medium term effectiveness of biofeedback, and they show that up to half of patients who use it are still doing well 12-44 months after treatment.
How can I prevent incomplete evacuation and pelvic floor damage?
See your physician sooner rather than later if you have an on going problem with constipation.
Address your dietary fibre intake to see if this will help your constipation.
These points, as well as taking gentle and regular exercise and drinking plenty of fluid are among the guidelines for preventing and treating constipation.
If you’re worried about your symptoms or medical problem but don’t want to seek professional help because you feel embarrassed, silly or that it’s your fault in some way, read this page now: How to talk to a doctor about an embarrassing problem.
For more on pelvic floor training see this article from the Mayo Clinic.