What is Pelvic Floor Dyssynergia & How Do I Know if I Have It?

If you're one of the 4 million Americans who suffer from chronic constipation each year, there's a good chance your pelvic floor muscles are part of the problem. In fact, research shows that in up to 50% of people with chronic constipation, pelvic floor muscle dyssynergia (duh-suh-nur-jee-uh) is to blame.

Pelvic floor dyssynergia occurs when the pelvic floor muscles aren't working properly. Imagine pushing the "open" button on a set of elevator doors only to have them stay halfway closed or even slam shut —that's roughly what's happening when you try to poop with pelvic floor dyssynergia.

This lack of coordination leads to a variety of pelvic floor symptoms, including difficult bowel movements. The good news: if you have pelvic floor dyssynergia, there are very effective ways to treat it, including pelvic floor physical therapy. By working with a pelvic floor PT, you can regulate your pelvic muscle movements and support healthy, regular pooping.

Keep reading to learn all about pelvic floor dyssynergia and what you can do if you think it may be causing your constipation.

What is pelvic floor dyssynergia?

Pelvic floor dyssynergia is a type of pelvic floor dysfunction where the pelvic floor muscles are unable to contract and relax at the right times and in coordination with the abdominal muscles.

The pelvic floor muscles form a bowl at the bottom of the pelvis and support your pelvic joints and pelvic organs. When working normally, they contribute to bowel, bladder, and sexual health.

Healthy pelvic floor muscles do all of the following:

• They contract to close the urethra, anus, and vaginal opening and to support the pelvic organs. Contracting is key to preventing bowel and bladder leaks and enhancing sex and orgasm.
• They release and lengthen to allow you to easily and fully empty your bowels and bladder, as well as have pain-free penetrative sex.
• They move in coordination with your abdominals and anal sphincter muscles — releasing as your abdominal muscles contract to help push stool out during a bowel movement.

With pelvic floor dyssynergia — also referred to as anismus, obstructed defecation syndrome, dyssynergic defecation, or a non-relaxing pelvic floor — the pelvic floor muscles have difficulty fully relaxing, and may even contract (known as paradoxical contraction) when you try to move your bowels or empty your bladder. Dyssynergic pelvic floor muscles will often develop trigger points, which can add pain to the mix of symptoms.

What are the symptoms of pelvic floor dyssynergia?

Since your muscles are not working the way they should, pelvic floor dyssynergia can contribute to a variety of bowel, bladder, and sexual symptoms. The following are common symptoms of pelvic floor dyssynergia:

• Chronic constipation
• Difficulties fully emptying your bowel or bladder — you may even need to strain, or manually evacuate stool
• A “weak” or splayed urinary stream
• Pelvic or low back pain
• Pain during sex

What are the causes of pelvic floor dyssynergia?

More research is needed to determine the specific causes of pelvic floor dyssynergia. That said, there are several factors that may increase your risk of developing pelvic floor dysfunction including:

• Pregnancy and childbirth
• Being older, particularly as a result of pelvic floor changes related to menopause
• Chronic pressure or loading on your pelvic floor (chronic straining, COPD, etc)
• Pelvic floor injury (surgery, pelvic floor trauma, etc)

In general, dyssynergic defecation is more common in:

• Adults
• Those with gastrointestinal conditions including slow colonic transit, chronic constipation, rectal ulcers, and IBS (constipation dominant)
• Those who take medications that are constipating, such as opioids
• Those with psychological conditions

How is pelvic floor dyssynergia diagnosed?

If you have constipation, it is important to understand what could be causing your symptoms. When other underlying medical causes are ruled out and the pelvic floor is suspected, there are a variety of tests that can determine if pelvic floor coordination issues are the problem.

According to the Rome Criteria, dyssynergic defecation can be diagnosed if, over the past 6 months, you have had a 3-month history of symptoms, and the following are true:

1. You have functional constipation and/or IBS-C

2. You have abnormal results in at least 2 of the following tests:

• Balloon expulsion testing - Similar to anorectal manometry, during balloon expulsion testing, a balloon catheter is inserted into the rectum and then filled with water. You will then be asked to push out the balloon, as if you are having a bowel movement. Your ability to push out the balloon is assessed, as well as how long it takes to do so.
• Anorectal manometry or surface electromyographic (EMG) testing - This is a quick and easy test that assesses the coordination and function of the anus and pelvic floor muscles. Although specific details of the test may differ based on the individual, in general, the small balloon at the end of the catheter is inflated, and you are asked to contract, relax, and push your muscles while a computer analyzes your muscle performance. If a coordination dysfunction is detected, it may indicate pelvic floor dyssynergia.
• Defecography - During a defecography, a barium enema is placed in the rectum, and then either fluoroscopy (x-ray) or MRI is used to study the changes in the pelvic structures while pushing out the barium.

3. Your pelvic floor muscles contract inappropriately during an abdominal anorectal manometry or surface EMG test, even if you can push hard enough to have an effective bowel movement.

During testing, you may also have a digital rectal exam (DRE). During a DRA your physician places a lubed, gloved finger into your rectum, and then similar to the anorectal manometry, your muscle performance is assessed when asked to contract, relax, and push and bear down. A DRE is extremely helpful, as your physician can assess your anus and lower rectum for signs of injury, scar tissue, muscle spasm/tenderness, or other masses that could be contributing to your constipation symptoms.

How is pelvic floor dyssynergia treated?

Pelvic floor muscle dyssynergia is often easily treated with conservative (aka noninvasive or nonsurgical) measures, including pelvic floor physical therapy. Based on your unique history and pelvic floor symptoms, your pelvic floor PT will use a variety of evidence-based treatment options to help ease your symptoms including:

• Diet and habit changes: For all bowel and bladder-related symptoms, it is important to check in on your diet, and get your bathroom habits on track. It is common to work with your PT to make dietary adjustments to optimize your stool consistency and eliminate bladder irritants. They will also check in on any habits that you may have developed that could be complicating your bowel or bladder function. For example, you may undergo bladder training, and learn optimized toileting mechanics, and pushing techniques that are more effective for helping to empty your bowel and bladder. (Check out these 7 Tips for Healthy Poops for more insight.)
• Manual therapy: If your pelvic floor muscles are tight and overactive, manual therapy techniques are often used to help improve muscle flexibility, reduce trigger points and scar tissue, and ease pelvic floor muscle pain that could be contributing to your symptoms. They may even teach you a belly massage that may help ease any discomfort related to your constipation.
• Biofeedback: Pelvic floor biofeedback is one of the most effective, and important treatment techniques for helping to treat pelvic floor dyssynergia, especially when used as part of a comprehensive physical therapy plan of care. There are various types of biofeedback including balloon-assisted biofeedback, or electronic instrument-based biofeedback (using internal or external sensors). All are designed to teach you about your pelvic floor muscle performance, and help to retrain the proper coordination of your abdominals, pelvic floor, and anal muscles during bowel movements.

If conservative treatments, such as pelvic physical therapy, are not effective some additional medical treatment options exist, including botox injections to the anal sphincter, or even surgical management if additional pelvic conditions such as rectal prolapse are present.

At Origin, our pelvic floor physical therapists are highly skilled at treating constipation related to a variety of pelvic floor disorders, including dyssynergia. They will help you develop an individualized treatment program, and if you need to explore additional medical treatment, they will help you find the support you need.