Treatment of Incomplete Evacuation of Stool

Initial Conservative Management

The American Gastroenterological Association recommends increasing fluid intake specifically in patients with low baseline fluid consumption, as those in the lowest quartile for fluid intake are more likely to be constipated 1
The American Gastroenterological Association suggests adding fiber supplementation with psyllium starting at low doses and titrating gradually, taken with 8-10 ounces of fluid per dose 1, 3
Establishing regular toileting schedules, particularly after meals, can leverage the gastrocolic reflex and is recommended by the American Gastroenterological Association 4, 3
Ensuring adequate privacy and comfort during defecation attempts is also recommended by the American Gastroenterological Association 4

The American Gastroenterological Association strongly recommends PEG as first-line osmotic laxative therapy based on moderate-certainty evidence from multiple randomized controlled trials 1
The dosing of PEG is recommended to be 17g once daily mixed in 8 ounces of liquid by the American Gastroenterological Association 1
PEG increases complete spontaneous bowel movements (CSBMs) by 2.90 per week and spontaneous bowel movements (SBMs) by 2.30 per week compared to placebo, according to the American Gastroenterological Association 1
The response rate to PEG is 312 more patients per 1,000 achieving treatment response compared to placebo, as reported by the American Gastroenterological Association 1
The response to PEG is durable over 6 months, according to the American Gastroenterological Association 1
Common side effects of PEG include abdominal distension, loose stool, flatulence, and nausea, as reported by the American Gastroenterological Association 1

The sensation of incomplete evacuation is relatively specific (54% specificity) for defecatory disorders, though sensitivity is high at 84%, according to the American Gastroenterological Association 5, 2
Proceeding to anorectal manometry and balloon expulsion testing in patients who fail empiric laxative trials can identify inadequate rectal propulsive forces, paradoxical pelvic floor contraction (dyssynergia), incomplete anal sphincter relaxation, and reduced rectal sensation, as recommended by the American Gastroenterological Association 2, 5, 4

Pelvic floor biofeedback therapy is the treatment of choice for defecatory disorders, improving symptoms in more than 70% of patients with dyssynergic defecation, according to the American Gastroenterological Association 6, 4
The treatment should focus on retraining coordination of abdominal, rectal, and pelvic floor muscles during defecation and includes sensory retraining for patients with rectal hyposensitivity, as recommended by the American Gastroenterological Association 4

The American Gastroenterological Association recommends not assuming infrequent bowel movements alone define the problem, as patients with daily bowel movements can still have constipation with incomplete evacuation 2, 5
The American Gastroenterological Association advises not proceeding to colonic transit testing before evaluating for defecatory disorders, as defecatory disorders are present in 59% of constipated patients and must be addressed first 2
The American Gastroenterological Association recommends not empirically treating without establishing diagnosis when possible, as testing helps identify the specific pathophysiology, supports antibiotic stewardship, and addresses the common occurrence of multiple diagnoses 6