Standard Treatment
This should consist of a detailed clinical assessment and correction of coexisting issues such as avoiding constipating medications, adequate fiber (up to 25 g per day) and fluid intake, and regular exercise. These life style modifications can be useful although there is limited evidence to support this. In addition, they should be encouraged to capitalize on mechanisms that stimulate the colon, such as after waking and after a meal and avoid postponing defecation, as the urge subsides after a few minutes and may not return for hours. Patients should receive instructions regarding timed toilet training and effective straining methods. Timed toilet training consists of educating the patient to attempt a bowel movement at least twice a day, usually 30 minutes after meals. During attempted defecation, they must be instructed to push at a 50–70% of their maximum effort of straining and to strain for no more than 5 minutes. It is important to emphasize that stool impaction should be prevented at all costs. Patients should be advised to refrain from digital disimpaction of stools.
Fiber supplements
Fiber accelerates colonic transit and bulks the stool either by drawing fluid to colonic lumen or by facilitating fermentation and affecting gut microbiota or epithelial permeability. A systematic review on the effects of fiber in chronic constipation showed that fiber is beneficial for mild to moderate constipation and constipation predominant IBS. It improved global symptoms, decreased straining, increased stool frequency, softened stool consistency, and decreased laxative uses. Although most of the studies used soluble fiber, such as psyllium, there is limited evidence that insoluble fiber, such as calcium polycarbophil, bran and methylcellulose, and mixed fiber supplements that contain both soluble and insoluble fiber as well as natural dietary fiber, such as prunes, are effective. It is important to recommend patients to take adequate water intake while taking fibers to avoid hard and bulky stools, and to inform them about adverse effects including bloating, flatulence, and abdominal discomfort. The benefits of adding fibers are not evident for days to weeks. A study showed that patients with dyssynergic defecation respond poorly to 30 grams of fiber supplementation per day, whereas those without an underlying motility disorder (slow transit constipation) improved. Patients with fecal impaction, or those confined to the bed or requiring fluid restriction should not be given fiber supplements.
Pharmacologic Approaches
Laxatives and newer drugs such as intestinal secretagogues and serotonergic enterokinetic agents, have not been systematically evaluated in patients with dyssynergic defecation, but they can be effective and can be used as an adjunctive treatment along with biofeedback therapy, Long term follow-up studies show that after biofeedback therapy, the proportion of patients using laxatives decreases over time.
Biofeedback therapy
Biofeedback therapy is a technique that trains people to improve their health by controlling certain bodily processes that normally happen involuntarily, such as heart rate, blood pressure, muscle tension, skin temperature and relaxation of pelvic floor muscles during straining to pass stools .