Persistent Rectal Urgency: Causes and Solutions

Persistent urge to defecate?

Hello Dr.
Ke, I am the person who asked question #144665.
Thank you for your previous response.
Currently, what troubles me the most is the persistent urge to defecate for almost three weeks.
It started with about 4-5 bowel movements a day for the first three days, which eventually felt like diarrhea, and I experienced a heavy sensation in my rectum, constantly feeling the need to defecate, although there was no abdominal pain.
The stool appeared normal in color, with no signs of blood.
I later visited a regional hospital's colorectal surgery department, where the first doctor performed a digital rectal exam and diagnosed me with both internal and external hemorrhoids (I had no previous issues with hemorrhoids).
I was given an ointment to apply for five days, but I felt no relief.
A week ago, I consulted a second colorectal surgeon, who used an anoscope (or was it a sigmoidoscope?) for examination.
He stated that my rectum appeared normal, there were external hemorrhoids, but internal hemorrhoids were not significant, and the symptoms did not seem to be caused by hemorrhoids.
He suspected it might be irritable bowel syndrome and prescribed some medication, advising me to stop using the ointment.

It has been almost three weeks since the onset.
Although my bowel movements have decreased from 4-5 times a day to about twice now, the heavy sensation in my rectum seems to have lessened, but I still experience a persistent urge to defecate, sometimes feeling a blockage that is uncomfortable.
It is somewhat better during the day, more severe in the afternoon, and slightly improved at night after sleeping.
In the last couple of days, I have been passing gas frequently before my bowel movements.
My first bowel movement in the morning is typically formed, while the second in the afternoon is more loose, with no signs of blood.
The discomfort has caused me anxiety and a bit of fatigue throughout the day.

I found a term online called "rectal heaviness," and the symptoms seem quite similar.
Possible causes include proctitis, anal abscess, rectal prolapse, and rectal cancer.
I would like to ask Dr.
Ke if the digital rectal exam and anoscopy can rule out these conditions? Although the doctor mentioned irritable bowel syndrome, I have never experienced this before, and after taking the medication for a week, I still feel it is not quite right.
Do I need to undergo any further examinations? Thank you, Dr.
Ke, for patiently reading this.
I would greatly appreciate your response.

Mr. Lin, 40~49 year old female. Ask Date: 2019/04/02

Dr. Ke Fangxu reply Surgery

"Anal heaviness," also known as "tenesmus," refers to the persistent sensation of needing to have a bowel movement, which is usually caused by rectal lesions.
Digital rectal examination and anoscopy can only assess up to approximately eight centimeters from the anal opening.
It is recommended that you undergo a sigmoidoscopy or a complete colonoscopy for a more thorough evaluation to rule out other colonic lesions.

Reply Date: 2019/04/02

More Info

Persistent rectal urgency can be a distressing symptom, and it’s understandable that you are seeking clarity on its causes and potential solutions. Based on your description, it seems you have been experiencing a range of gastrointestinal symptoms, including frequent bowel movements, a sensation of rectal fullness, and changes in stool consistency.

Possible Causes
1. Irritable Bowel Syndrome (IBS): Your doctor’s suggestion of IBS is plausible, especially given the fluctuating nature of your bowel habits and the absence of severe abdominal pain. IBS is characterized by a combination of symptoms, including abdominal discomfort, bloating, and altered bowel habits (diarrhea, constipation, or alternating between both). Stress and dietary factors can exacerbate IBS symptoms.

2. Hemorrhoids: While you have been diagnosed with external hemorrhoids, these typically cause discomfort, itching, or bleeding rather than persistent rectal urgency. However, they can contribute to a sensation of fullness or pressure in the rectal area.

3. Rectal Inflammation: Conditions such as proctitis (inflammation of the rectum) can lead to urgency and discomfort. This can be caused by infections, inflammatory bowel disease (IBD), or radiation therapy.

4. Rectal Prolapse: This occurs when part of the rectum protrudes through the anus, which can lead to a sensation of fullness and urgency. It is often diagnosed through physical examination.

5. Other Conditions: Less common causes include rectal abscesses, anal fissures, or even malignancies, although these are less likely given your age and the absence of alarming symptoms such as blood in the stool.

Diagnostic Considerations
The examinations you have undergone, including digital rectal examination and possibly anoscopy or sigmoidoscopy, are essential first steps in ruling out serious conditions. These tests can help identify hemorrhoids, fissures, or signs of inflammation. If these examinations did not reveal any significant abnormalities, it is a good sign, but it does not completely rule out all potential issues.

Next Steps
1. Follow-Up with Your Doctor: Since your symptoms have persisted for almost three weeks, it would be prudent to follow up with your healthcare provider. Discuss your ongoing symptoms, particularly the sensation of urgency and discomfort.
2. Consider Dietary Changes: Sometimes, dietary adjustments can help manage IBS symptoms. A diet low in FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) may be beneficial. Keeping a food diary can help identify any triggers.

3. Medication Review: If the medication prescribed for IBS is not providing relief, discuss this with your doctor. There are various medications available for IBS, including antispasmodics, laxatives, or medications that specifically target diarrhea.

4. Further Testing: If symptoms persist or worsen, additional tests may be warranted. This could include colonoscopy to evaluate for IBD or other conditions that may not have been visible during initial examinations.

5. Stress Management: Since stress can exacerbate IBS symptoms, consider incorporating stress-reducing techniques such as mindfulness, yoga, or counseling.

Conclusion
Persistent rectal urgency can stem from various causes, and while IBS is a common diagnosis, it is essential to continue monitoring your symptoms and maintain open communication with your healthcare provider. If your symptoms do not improve or if you develop new symptoms, further evaluation may be necessary to ensure that no underlying conditions are overlooked. Your health and comfort are paramount, so do not hesitate to seek further assistance if needed.

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