- If feasible, discontinue medications that can cause constipation before further testing.
- A careful digital rectal examination that includes assessment of pelvic floor motion during simulated evacuation is preferable to a cursory examination without these maneuvers and should be performed before referral for anorectal manometry. However, a normal digital rectal examination does not exclude defecatory disorders.
The key components of the rectal examination include:
- In the left lateral position, with the buttocks separated, observe the descent of the perineum during simulated evacuation and the elevation during a squeeze aimed at retention. The perianal skin can be observed for evidence of fecal soiling and the anal reflex tested by a light pinprick or scratch.
- During simulated defecation, the anal verge should be observed for any patulous opening (suspect neurogenic constipation with or without incontinence) or prolapse of anorectal mucosa.
- The digital examination should evaluate resting tone of the sphincter segment and its augmentation by a squeezing effort. Above the internal sphincter is the puborectalis muscle, which should also contract during squeeze. Acute localized tenderness to palpation along the puborectalis is a feature of the levator ani syndrome. Finally, the patient should be instructed to integrate the expulsionary forces by requesting that she or he "expel my finger."
- An examination should then be conducted to evaluate for a rectocele or consideration be given to gynecologic consultation.
Testing for Medical Causes
January 1, 2013
Supplemental Implementation Tools
External Publication Status
Country of Publication
Target Patient Population
Adults with constipation
Male, Female, Adult, Older adult
Health Care Settings
Nurse, nurse practitioner, physician, physician assistant
Assessment and screening, Treatment, Management
D003248 - Constipation
American Gastroenterological Association, Bharucha AE, Dorn SD, Lembo A, Pressman A. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013 Jan;144(1):211-7. doi: 10.1053/j.gastro.2012.10.029. PMID: 23261064.