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Symptoms include:
- Straining to pass fecal material
- Tenesmus (a feeling of incomplete evacuation)
- Feeling of anorectal obstruction/blockage
- Digital maneuvers needed to aid defecation
- Difficulty initiating and completing bowel movements
Esophageal spasm is rare. Often, symptoms that may suggest esophageal spasm are the result of another condition such as gastroesophageal reflux disease (GERD) or achalasia. The symptoms can also include dysphagia, regurgitation, noncardiac chest pain, heartburn, globus pharyngis (which is a feeling that something is stuck in the throat) or a dry cough.
Anismus is classified as a functional defecation disorder. It is also a type of rectal outlet obstruction (a functional outlet obstruction). Where anismus causes constipation, it is an example of functional constipation. Some authors describe an "obstructed defecation syndrome", of which anismus is a cause.
The Rome classification subdivides functional defecation disorders into 3 types, however the symptoms the patient experiences are identical.
- Type I: paradoxical contraction of the pelvic floor muscles during attempted defecation
- Type II: inadequate propulsive forces during attempted defecation (inadequate defecatory propulsion)
- Type III: impaired relaxation with adequate propulsion
It can be seen from the above classification that many of the terms that have been used interchangeably with anismus are inappropriately specific and neglect the concept of impaired propulsion. Similarly, some of the definitions that have been offered are also too restrictive.
Abnormal descent of the perineum may be asymptomatic, but otherwise the following may feature:
- perineodynia (perineal pain)
- Colo-proctological symptoms, e.g. obstructed defecation, dyschesia (constipation), or degrees of fecal incontinence
- gynaecological symptoms, e.g. cystocele (prolapse of the bladder into the vagina) and rectocele (prolapse of the rectum into the vagina)
- lower urinary tract symptoms, e.g. dysuria (painful urination), dyspareunia (pain during sexual intercourse), urinary incontinence & urgency
Other researchers concluded that abnormal perineal descent did not correlate with constipation or perineal pain, and there are also conflicting reports of the correlation of fecal incontinence with this condition.
FI affects virtually all aspects of peoples' lives, greatly diminishing physical and mental health, and affect personal, social and professional life. Emotional effects may include stress, fearfulness, anxiety, exhaustion, fear of public humiliation, feeling dirty, poor body-image, reduced desire for sex, anger, humiliation, depression, isolation, secrecy, frustration and embarrassment. Some people may need to be in control of life outside of FI as means of compensation. The physical symptoms such as skin soreness, pain and odor may also affect quality of life. Physical activity such as shopping or exercise is often affected. Travel may be affected, requiring careful planning. Working is also affected for most. Relationships, social activities and self-image likewise often suffer. Symptoms may worsen over time.
Esophageal spasm or oesophageal spasm is a disorder of esophageal motility. The esophagus is an organ in vertebrates which consists of a fibromuscular tube through which food passes, aided by peristalsis contractions, from the upper esophageal sphincter to the stomach through waves of coordinated muscle contraction, or peristalsis.
There are two types of esophageal spasm:
- Diffuse esophageal spasm (DES), where there is uncoordinated esophageal contractions where several sections of the esophagus can contract at once.
- Nutcracker esophagus (NE) also known as hypertensive peristalsis, where the contractions are coordinated but with an excessive amplitude.
Both conditions can be linked with Gastroesophageal reflux disease (GERD).
When the coordinated muscle contraction are irregular or uncoordinated, this condition may be called diffuse esophageal spasm. These spasms can prevent food from reaching the stomach where food gets stuck in the esophagus. At other times the coordinated muscle contraction is very powerful, which is called nutcracker esophagus. These contractions move food through the esophagus but can cause severe pain.
A common symptom is a continual urge to have a bowel movement—the rectum could feel full or have constipation. Another is tenderness and mild irritation in the rectum and anal region. A serious symptom is pus and blood in the discharge, accompanied by cramps and pain during the bowel movement. If there is severe bleeding, anemia can result, showing symptoms such as pale skin, irritability, weakness, dizziness, brittle nails, and shortness of breath.
Symptoms are ineffectual straining to empty the bowels, diarrhea, rectal bleeding and possible discharge, a feeling of not having adequately emptied the bowels, involuntary spasms and cramping during bowel movements, left-sided abdominal pain, passage of mucus through the rectum, and anorectal pain.
FI may present with signs similar to rectal discharge (e.g. fistulae, proctitis or rectal prolapse), pseudoincontinence, encopresis (with no organic cause) and irritable bowel syndrome.
Fecal incontinence to gas, liquid, solid stool, or mucus in the presence of obstructed defecation symptoms may indicate occult rectal prolapse (i.e. rectal intussusception), internal/external anal sphincter dysfunction, or descending perineum syndrome.
Obstructed defecation, is "difficulty in evacuation or emptying the rectum [which] may occur even with frequent visits to the toilet and even with passing soft motions". The conditions that can create the symptom are sometimes grouped together as defecation disorders. The symptom tenesmus is a closely related topic.
Another source defines evacuatory dysfunction as "a constellation of symptoms such as prolonged repeated straining at bowel movements, sensation of incomplete evacuation, and the need for digital manipulation".
Some describe an "obstructed defecation syndrome", defining it loosely as "difficulty in evacuation, which may or may not be associated with constipation"
Others inappropriately equate obstructed defecation with anismus. Although anismus is a type of obstructed defecation, obstructed defecation has many other possible causes other than anismus.
Adenoma is the most common colorectal polyp. Adenomas are not malignant, but rarely adenocarcinoma can develop from them. Large adenomas can cause rectal bleeding, mucus discharge, tenesmus, and a sensation of urgency. Mucus production may be so great that it can cause electrolyte disturbances in the blood.
There are many different types of rectal discharge, but the most common presentation of a discharge is passage of mucus or pus wrapped around an otherwise normal bowel movement.
Rectal discharge has many causes, and may present with other symptoms:
- Staining of undergarments
- Constant feeling of dampness around anus
- Frequent urge to open bowels, but passage of only small amounts of mucus or pus-like liquid rather than normal feces
- Rectal pain
- Rectal malodor, when the discharge is foul-smelling, e.g. associated with certain infections
- Pruritus ani
- Rectal bleeding
- Perianal erythema, swelling and tenderness
One of the most common causes of rectal pain is an anal fissure. It involves a tear in the anal canal probably due to trauma from defecation and are usually treated effectively with sitz baths, stool softeners, and analgesics.
DES manifests as intermittent difficulty swallowing (dysphagia) for solid foods and liquids, and atypical chest pain. The chest pain may appear similar to cardiac chest pain (angina pectoris), so investigating the possible existence of heart disease is often indicated.
Two more highly common causes of functional anorectal pain are levator ani syndrome (LAS) and proctalgia fugax. Both of these conditions are thought to be caused by muscle spasms of the either the levator ani muscle or the anal sphincter muscle respectively, and may overlap symptomatically with a third less-common condition called coccygodynia which is the result of previous trauma to the coccyx bone. Stress, prolonged sitting, and constipation all seem to be associated with LAS. The majority (90%) of those reporting chronic episodes of such pain are women. Some researchers group these conditions under the medical category of "tension myalgia of the pelvic floor". Less than a third of those experiencing these conditions seek medical treatment for them. Treatment can involve the use of antispasmotic medications as well as the down-training (conscious involvement and relaxation of previously unconscious muscle movements) so that spasms occur less frequently or not at all.
Descending perineum syndrome (also known as Levator plate sagging) refers to a condition where the perineum "balloons" several centimeters below the bony outlet of the pelvis during strain, although this descent may happen without straining. The syndrome was first described in 1966 by Parks "et al".
An anal fissure, fissure in Ano or rectal fissure is a break or tear in the skin of the anal canal. Anal fissures may be noticed by bright red anal bleeding on toilet paper and undergarments, or sometimes in the toilet. If acute they may cause pain after defecation, but with chronic fissures, pain intensity is often less. Anal fissures usually extend from the anal opening and are usually located posteriorly in the midline, probably because of the relatively unsupported nature and poor perfusion of the anal wall in that location. Fissure depth may be superficial or sometimes down to the underlying sphincter muscle.
Rectal prolapse often used to mean complete rectal prolapse (external rectal prolapse), where the rectal walls have prolapsed to a degree where they protrude out the anus and are visible outside the body. However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depending on if the prolapsed section is visible externally, and if the full or only partial thickness of the rectal wall is involved.
Rectal prolapse may occur without any symptoms, but depending upon the nature of the prolapse there may be mucous discharge (mucus coming from the anus), rectal bleeding, degrees of fecal incontinence and obstructed defecation symptoms.
Rectal prolapse is generally more common in elderly women, although it may occur at any age and in both sexes. It is very rarely life-threatening, but the symptoms can be debilitating if left untreated. Most external prolapse cases can be treated successfully, often with a surgical procedure. Internal prolapses are traditionally harder to treat and surgery may not be suitable for many patients.
Symptoms include:
- Straining during defecation
- Mucous rectal discharge
- Rectal bleeding
- Sensation of incomplete evacuation (tenesmus)
- constipation, or more rarely diarrhea
- fecal incontinence (rarely)
Most anal fissures are caused by stretching of the anal mucosa beyond its capability.
Superficial or shallow anal fissures look much like a paper cut, and may be hard to detect upon visual inspection, they will generally self-heal within a couple of weeks. However, some anal fissures become chronic and deep and will not heal. The most common cause of non-healing is spasming of the internal anal sphincter muscle which results in impaired blood supply to the anal mucosa. The result is a non-healing ulcer, which may become infected by fecal bacteria.
In adults, fissures may be caused by constipation, the passing of large, hard stools, or by prolonged diarrhea. In older adults, anal fissures may be caused by decreased blood flow to the area. When fissures are found laterally, tuberculosis, occult abscesses, leukemic infiltrates, carcinoma, acquired immunodeficiency syndrome (AIDS) or inflammatory bowel disease should be considered as causes. Some sexually transmitted infections can promote the breakdown of tissue resulting in a fissure. Examples of sexually transmitted infections that may affect the anorectal area are syphilis, herpes, chlamydia and human papilloma virus.
Other common causes of anal fissures include:
- childbirth trauma in women
- anal sex
- Crohn's disease
- ulcerative colitis
- poor toileting in young children.
Proctitis is an inflammation of the anus and the lining of the rectum, affecting only the last 6 inches of the rectum.
Diffuse esophageal spasm (DES) is a condition characterized by uncoordinated contractions of the esophagus, which may cause difficulty swallowing (dysphagia) or regurgitation. In some cases, it may cause symptoms such as chest pain, similar to heart disease. The cause of DES remains unknown.
Certain abnormalities on x-ray imaging are commonly observed in DES, such as a "corkscrew" or "rosary bead esophagus", although these findings are not unique to this condition. Specialized testing called manometry can be performed to evaluate the motor function of the esophagus, which can help identify abnormal patterns of muscle contraction within the esophagus that are suggestive of DES. The treatment of DES consists primarily of medications, such as acid suppressing agents (like proton pump inhibitors), calcium channel blockers, hyoscine butylbromide, or nitrates. In only extremely rare cases, surgery may be considered. People with DES have higher incidences of gastroesophageal reflux disease (GERD) and anxiety.
Anal stricture or anal stenosis is a narrowing of the anal canal. It can be caused by a number of surgical procedures including: hemorrhoid removal and following anorectal wart treatment.
Internal hemorrhoids usually present with painless, bright red rectal bleeding during or following a bowel movement. The blood typically covers the stool (a condition known as hematochezia), is on the toilet paper, or drips into the toilet bowl. The stool itself is usually normally coloured. Other symptoms may include mucous discharge, a perianal mass if they prolapse through the anus, itchiness, and fecal incontinence. Internal hemorrhoids are usually only painful if they become thrombosed or necrotic.
It most often occurs in the middle of the night and lasts from seconds to minutes, an indicator for the differential diagnosis of levator ani syndrome, which presents as pain and aching lasting twenty minutes or longer. In a study published in 2007 involving 1809 patients, the attacks occurred in the daytime (33 per cent) as well as at night (33 per cent) and the average number of attacks was 13. Onset can be in childhood; however, in multiple studies the average age of onset was 45. Many studies showed that women are affected more commonly than men. This can be at least partly explained by men's reluctance to seek medical advice concerning such a delicate case as rectal pain.
During an episode, the patient feels spasm-like, sometimes excruciating, pain in the anus, often misinterpreted as a need to defecate. The pain must arise de novo, that is in absence of clear cause. As such, pain associated with penetrative anal intercourse, trauma or rectal foreign body insertion preclude a diagnosis of proctalgia fugax. Simultaneous stimulation of the local autonomic system can cause erection in males. In some people, twinges sometimes occur shortly after orgasm. Because of the high incidence of internal anal sphincter thickening with the disorder, it is thought to be a disorder of the internal anal sphincter or that it is a neuralgia of pudendal nerves. It is recurrent and there is also no known cure. However, some studies show effective use of botulinum toxin, pudendal nerve block, and calcium channel blockers. It is not known to be linked to any disease process and data on the number of people afflicted vary, but prevalence may be as high as 8–18%. It is thought that only 17–20% of sufferers consult a physician, so obtaining accurate data on occurrence presents a challenge.
The pain episode subsides by itself as the spasm disappears on its own, but may reoccur.