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    Rome IV Diagnostic Criteria for Functional Defecation Disorders

    Official Rome IV criteria for the diagnosis of functional defecation disorders.

    INSTRUCTIONS

    Patients who have symptoms consistent with functional constipation or IBS with constipation and in whom a defecation disorder is suspected. 

    Do NOT use in patients:

    • Without age appropriate colorectal cancer screening.

    • With secondary intervenable causes for constipation (e.g. medications).

    When to Use
    Pearls/Pitfalls
    Why Use

    Patients who have symptoms consistent with functional constipation or IBS with constipation and in whom a defecation disorder is suspected. A digital rectal examination should be performed. Evidence for dyssynergic defecation (e.g. lack of relaxation of anorectal and puborectalis muscles during simulated defecation) should lead to anorectal physiologic testing (e.g. anorectal manometry and rectal balloon expulsion test).

    Pelvic floor tests can have discordant or clinically non-significant results:

    • Inadequate anal relaxation and paradoxical puborectalis contraction can be found in asymptomatic adults on anorectal manometry (ARM).

    • Thus, important to have more than one objective testing parameter suggest pelvic floor pathology prior to making diagnosis.

    Balloon expulsion test (BET) is preferred screening test:

    • Highly reproducible within subjects on different days.

    • Will not define mechanism of disordered defecation.

    • Patients with normal BET may have abnormal ARM or radiographic findings as the balloon may not mimic patient’s stool.

    Anorectal testing often affected by testing conditions artificially simulating a private process (e.g. anorectal manometry performed in decubitus position with technician present) leading to false positive and false negative findings.

    Defecography is helpful for structural evaluation and if ARM and BET are equivocal and performed in more physiologic position (more private, on commode).

    • Inter-observer agreement is poor.

    • Some findings (e.g. rectocele, intussusception) seen in asymptomatic controls.

    • MRI defecography provides better soft tissue resolution without radiation but limited availability and performed with patient in supine position.

    Colonic transit testing should follow anorectal testing for FDD since this can slow colon transit time.

    • A proportion of individuals with pelvic floor dyssynergia may have a history of prior sexual trauma. 

    • Pelvic floor dyssynergia is a conditioned behavioral response that is amenable to anorectal biofeedback.

    In patients with constipation inadequately responsive to conservative treatments, pelvic floor pathophysiology is highly prevalent and may be contributing to the lack of response to treatment. 

    Treatment for pelvic floor pathology can include modalities such as physical therapy and biofeedback which are safe, effective, and can have enduring therapeutic benefit and lead to decreased medication use.

    Must have the following:

    For 3 months prior with symptom onset ≥6 months ago

    Additional criteria for inadequate defecatory propulsion:
    Additional criteria for dyssynergic defecation:

    Diagnostic Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights
    Dr. Douglas Drossman

    About the Creator

    Douglas Drossman, MD, is professor emeritus of medicine and psychiatry at the University of North Carolina School of Medicine. He is founder, President Emeritus and Chief of Operations of the Rome Foundation. He is also the founder of the Drossman Center for the Education and Practice of Biopsychosocial Care and Drossman Consulting, LLC. Dr. Drossman has written over 500 articles and book chapters, has published two books, a GI procedure manual and a textbook of functional GI disorders (Rome I-IV), and serves on six editorial and advisory boards.

    To view Dr. Douglas Drossman's publications, visit PubMed

    Dr. Lin Chang

    About the Creator

    Lin Chang, MD is responsible for the oversight and coordination of the Rome IV calculators on MDCalc. She is a Professor of Medicine at the Vatche and Tamar Manoukian Division of Digestive Diseases at UCLA and is a member of the Rome Foundation Board of Directors.

    To view Dr. Lin Chang's publications, visit PubMed

    The Rome Foundation

    About the Creator

    The Rome Foundation is an independent not for profit 501(c) 3 organization that provides support for activities designed to create scientific data and educational information to assist in the diagnosis and treatment of Disorders of Gut-Brain Interaction (DGBI), also known as functional gastrointestinal (GI) disorders. Their mission is to improve the lives of people with DGBI. Over the last 3 decades, the Rome organization has sought to legitimize and update our knowledge of the DGBIs. This has been accomplished by bringing together scientists and clinicians from around the world to classify and critically appraise the science of GI function and dysfunction. This knowledge permits clinical scientists to make recommendations for diagnosis and treatment that can be applied in research and clinical practice. Diagnosis is based on the use of symptom-based criteria which are used in clinical trials and daily practice. The list of Rome IV categories and the Chair and Co-Chair of each chapter committee are listed below.

    Committees Chair Co-Chair
    Esophageal Disorders Ronnie Fass, MD John Pandolfino, MD
    Gastroduodenal Disorders Nicholas J. Talley, MD, PhD, FRACP Vincenzo Stanghellini, MD
    Bowel Disorders Fermin Mearin, MD Brian Lacy, MD, PhD
    Gallbladder and Sphincter of Oddi Disorders Grace Elta, MD Peter Cotton, MD
    Centrally Mediated Disorders of Gastrointestinal Pain Peter J. Whorwell, MD Laurie Keefer, PhD
    Anorectal Disorders Adil E. Bharucha, MD, MBBS Satish S. C. Rao, MD, PhD, FRCP
    Childhood Functional Gastrointestinal Disorders: Neonate/Toddler Sam Nurko, MD Marc A. Benninga, MD
    Childhood Functional Gastrointestinal Disorders: Child/Adolescent Carlo Di Lorenzo, MD Jeffrey S. Hyams, MD

    Rome IV Diagnostic Criteria Chapters, Chairs and Co-Chairs

    Rome IV Editorial Board: Douglas A. Drossman, MD, Senior Editor, Lin Chang, MD, William D. Chey, MD, John Kellow, MD, Jan Tack, MD, PhD, and William E. Whitehead, PhD.

    To view The Rome Foundation's publications, visit PubMed

    Content Contributors
    • Justin Brandler, MD
    Reviewed By
    • Max J. Schmulson W., MD
    About the Creator
    Dr. Douglas Drossman
    Dr. Lin Chang
    The Rome Foundation
    Content Contributors
    • Justin Brandler, MD
    Reviewed By
    • Max J. Schmulson W., MD