Chronic
constipation is often treated as a single disease. GI motility and
neurogastroenterology specialist Dr Zubin Sharma says the reality is far more
complex, and understanding the underlying physiology may be the key for
patients who remain constipated despite years of treatment.
For
millions of people, constipation follows a familiar pattern.
A
laxative is prescribed.
It
works for some time.
The
dose is increased.
Another
medicine is added.
Dietary
fibre, probiotics, herbal remedies and home treatments follow.
Yet
the problem continues.
According
to Dr Zubin
Sharma, a gastroenterologist specialising in gastrointestinal
motility and neurogastroenterology, the reason may be surprisingly simple:
constipation is not one disease.
“Two
patients can use exactly the same word, constipation, and yet have completely
different physiological problems,” says Dr Zubin Sharma. “If the mechanism is
different, the treatment may also need to be different.”
For
patients with difficult or refractory constipation, this distinction can be
critical.
Constipation
Is a Symptom, Not a Complete Diagnosis
Most
people define constipation by how often they pass stool.
But
frequency is only one part of the picture.
Some
patients pass stool infrequently. Others go every day but experience excessive
straining, incomplete evacuation or a sensation of blockage.
Some
spend 30 to 45 minutes in the toilet.
Others
repeatedly return to the washroom because they never feel completely empty.
According
to Dr Zubin Sharma, these differences provide important clues.
“When
I evaluate a patient with chronic constipation, I don't only ask how many times
they pass stool,” he explains. “The pattern of defecation can tell us a great
deal about the underlying physiology.”
Modern
GI motility science broadly recognises that constipation can arise through
different mechanisms.
In
some patients, stool moves slowly through the colon.
In
others, the colon may move reasonably well, but the muscles involved in
defecation fail to coordinate appropriately.
There
can also be abnormalities of rectal sensation, overlapping irritable bowel
syndrome or combinations of different mechanisms.
Calling
all of these patients simply “constipated” may therefore hide important
differences.
When the
Pelvic Floor Works Against the Patient
One
of the most frequently overlooked causes of difficult defecation is a problem
with pelvic floor coordination.
Passing
stool is an active physiological process.
The
rectum generates pressure while the anal sphincter and pelvic floor must relax
in a coordinated manner.
In
some patients, this coordination is disturbed.
Instead
of relaxing appropriately during attempted defecation, the muscles may fail to
relax or may paradoxically contract.
The
patient pushes harder.
But
the harder they push, the more difficult evacuation may become.
This
condition is commonly described as dyssynergic defecation.
Dr
Zubin Sharma says such patients often arrive after years of laxative use.
“If
the primary problem is the mechanics of evacuation, increasing the amount of
stool or making it progressively softer may not completely solve the problem,”
says Dr Zubin Sharma.
These
patients may describe prolonged toilet time, excessive straining, a persistent
sensation of incomplete evacuation or the need for unusual manoeuvres to pass
stool.
Why More
Laxatives May Not Be the Answer
Laxatives
remain an important and effective treatment for many patients with
constipation.
Dr
Zubin Sharma cautions against interpreting physiology-based treatment as an
argument against laxatives.
“The
question is not whether laxatives are good or bad,” he says. “The question is
whether we are treating the dominant mechanism responsible for that patient's
symptoms.”
For
example, a patient with slow movement through the colon may require medicines
that improve bowel movement or secretion.
A
patient with pelvic floor dyssynergia may benefit more from specialised pelvic
floor biofeedback.
Another
patient may require treatment directed towards altered gut sensation or a
disorder of gut-brain interaction.
The
same symptom can therefore lead to very different treatment pathways.
This
is where GI motility testing can become useful in
carefully selected patients.
What Is
Anorectal Manometry?
Anorectal
manometry is a specialised physiological investigation used to assess the
function of the rectum and anal sphincter.
The
test can evaluate anal pressures, rectal sensation and the coordination of
muscles during attempted defecation.
According
to Dr Zubin Sharma, the value of the test lies not simply in generating numbers
or colourful graphs.
“The
manometry report has to be interpreted in the context of the patient's symptoms
and other physiological findings,” he explains.
In
selected cases, additional investigations such as a balloon expulsion test or
gastrointestinal transit assessment may be required.
Dr
Zubin Sharma emphasises that not every person with constipation requires
advanced testing.
However,
patients with persistent symptoms despite appropriate treatment, significant
evacuation difficulty or a clinical suspicion of pelvic floor dysfunction may
require a more detailed physiological assessment.
Biofeedback
Can Retrain the Defecation Process
Perhaps
one of the most interesting aspects of pelvic floor dysfunction is that
treatment may involve retraining the body.
Specialised
biofeedback therapy helps patients understand and modify the muscle
coordination required for normal defecation.
Using
physiological feedback and structured training, patients can learn how to
generate appropriate abdominal pressure while relaxing the pelvic floor.
Dr
Zubin Sharma believes this is an area where India requires greater awareness
and more structured services.
“Biofeedback
is not simply asking a patient to perform Kegel exercises,” he says. “The
treatment of dyssynergic defecation requires targeted training based on the
physiological abnormality.”
This
distinction is important.
Traditional
pelvic floor strengthening exercises may not address a coordination disorder
and, inappropriately prescribed, may even focus on the wrong physiological
goal.
Dr Zubin
Sharma Advocates a Physiology-First Approach
Through
his work in GI motility and neurogastroenterology, Dr
Zubin Sharma has increasingly focused on patients with complex constipation and
evacuation disorders.
He
believes difficult constipation should be approached through a structured
clinical pathway.
The
first step remains a detailed history and appropriate exclusion of secondary
causes.
But
when conventional treatment repeatedly fails, the question should change.
Instead
of asking, “Which laxative should we add next?”
Doctors
may need to ask:
“Why
is this patient unable to evacuate normally?”
For
Dr Zubin Sharma, this represents the broader direction in which
gastrointestinal medicine is evolving.
“Symptoms
are the starting point,” he says. “Physiology helps us understand the
mechanism.”
A Different
Future for Patients With Chronic Constipation
Chronic
constipation can significantly affect quality of life.
Patients
may plan travel around bowel movements, spend prolonged periods in the toilet
and progressively restrict their diets.
Many
quietly accept the problem for years.
Dr
Zubin Sharma believes greater awareness of GI motility disorders could help
selected patients reach the correct diagnosis earlier.
Not
every constipation patient needs manometry.
Not
every patient has pelvic floor dysfunction.
And
not every laxative failure indicates a rare disease.
But
when symptoms persist despite repeated treatment, understanding the mechanism
may be more useful than simply escalating the prescription.
As
Dr Zubin Sharma puts it:
“Before
treating constipation harder, sometimes we need to understand constipation
better.”
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