bubble_chart Concept

Abdominal pain before defecation, with an urgent need to defecate but difficulty in doing so is referred to as rectal urgency; the distress during defecation with difficulty in passing stool is called tenesmus. When both symptoms occur simultaneously, it is collectively referred to as tenesmus, which is a main symptom in dysentery.

The term tenesmus was first mentioned in Nan Jing, where the Fifty-seventh Difficulty states: "In severe dysentery, there is tenesmus, frequent urge to defecate but inability to do so, and pain in the urethra." Both the "Treatise on Cold Damage Diseases" and Jingui Yaolue contain passages on diarrhea with tenesmus. Danxi Xinfa mentions "sitting in vain and straining" in the ten methods for treating dysentery, which is quite similar to this condition, but the difference is that "sitting in vain and straining" involves a constant urge to defecate, but difficulty in doing so when attempting to defecate. This is more common in patients with chronic dysentery and yin blood deficiency, and the symptoms are more severe than tenesmus, but abdominal pain is not very pronounced.

bubble_chart Pattern Analysis

1. Dampness-heat︰Abdominal pain, urgent desire to defecate, difficulty in defecation, anal heaviness and burning sensation, bloody and purulent diarrhea, fever and thirst, chest and gastric stuffiness, yellow and greasy tongue coating, scanty and dark urine, and mostly slippery and rapid pulse. In cases where dampness-heat is predominant, symptoms such as abdominal pain with a desire to defecate, difficulty and tenesmus, anal burning sensation, gastric stuffiness, chest tightness, and greasy tongue coating are more prominent. The treatment focuses on {|###|}clearing heat and draining dampness{|###|}, supplemented by regulating qi, and the prescription selected is Peony Root Decoction.
2. Qi Stagnation︰It mostly manifests as abdominal distension and fullness, pain or scurrying pain, sometimes even extending to the hypochondriac region. The pain is often accompanied by an urge to defecate, and the pain subsides after bowel movements. There may be difficulty in defecation, anal distension, and the passage of pus and blood in the stool, with a wiry pulse. When qi stagnation is predominant, symptoms include rectal urgency, abdominal pain extending to the hypochondriac region, anal tenesmus, and difficulty in defecation. The treatment focuses on regulating qi and transforming stagnation, using Aucklandia and Areca Pill with modifications.
3. Qi Deficiency︰Abdominal pain is dull and intermittent, with frequent urge to defecate, but the stool is difficult to pass and feels sticky, accompanied by a sensation of heaviness in the anus, and in severe cases, prolapse of the rectum. Mental fatigue, lethargy, shortness of qi, reluctance to speak, palpitations, and spontaneous sweating are present. The stool contains more white mucus than blood. The tongue texture is pale and swollen, and the pulse is thin and slow. In cases of qi deficiency, prolonged dysentery damages the spleen, impairing its transportation and transformation functions, leading to a lack of source for the generation and transformation of qi and blood. Qi deficiency causes sinking, resulting in heaviness of the anus, or even prolapse of the rectum that fails to retract. The stool contains more white mucus than blood, accompanied by poor appetite, lack of vitality, and physical exhaustion that is difficult to endure. Zhangshi Yitong states in "Dysentery": "Frequent rectal urgency with soiling of clothes is a sign of qi collapse." The treatment focuses on tonifying qi, supplemented with sour and astringent herbs to consolidate and restrain. The Middle-Tonifying Qi-Replenishing Decoction can be used, with additions such as charred Smoked Plum.
4. Blood Deficiency and Fluid Depletion︰abdominal pain lingering, rectal urgency with desire to defecate, straining at stool with difficulty in passing or only discharging a few drops of mucus, anus feeling empty and sagging, dysentery with mixed red and white discharge or more red than white, dry mouth and lips, afternoon tidal fever, or fever worsening at night, emaciation and mental fatigue, red tongue with scant coating or peeling coating, thin and rapid pulse. For yin-blood deficiency, often caused by prolonged dysentery damaging yin and depleting nutrient-blood, symptoms include sticky dysentery discharge like jelly, straining with difficulty in passing, heart vexation and dry mouth, pulse thin and rapid. Treatment should focus on nourishing yin and blood, clearing the intestine to stop dysentery. The recommended formula is Coptis and Ass Hide Glue Decoction plus Chinese Angelica and Smoked Plum.

During the course of dysentery, dampness-heat and qi stagnation often coexist and influence each other. The pathogenic dampness-heat stagnates in the intestines, obstructing the movement of qi, leading to rectal urgency and abdominal pain with a desire to defecate. When pathogenic heat enters the large intestine, qi stagnation and heat accumulation cause foul substances to be unable to exit, resulting in a sensation of heaviness and distension in the anus. The *Lai Su Ji, Volume 4* of *Cold-Damage Disease* states: "Sudden diarrhea with urgency belongs to heat; dysentery with tenesmus is due to dampness-heat and foul qi depression obstructing the rectum, causing difficulty in defecation." Moreover, the obstruction of qi movement leads to poor transportation of water-dampness, which stagnates and transforms into heat, pressing downward on the large intestine and causing abdominal pain and tenesmus. Therefore, dampness-heat and qi stagnation are often seen coexisting, each with its own emphasis.

Qi deficiency and fluid injury with blood deficiency both belong to deficiency pattern, commonly seen in patients with chronic dysentery. "Qi is the commander of blood, and blood is the mother of qi." Qi deficiency can lead to blood deficiency, and blood deficiency can also lead to qi deficiency. The two are interrelated, yet they have distinct differences in symptoms and treatment.

Tenesmus is a subjective symptom in dysentery, which can be classified as deficiency or excess. Dampness-heat and qi stagnation belong to excess pattern, with treatment focusing on clearing and promoting diuresis, as well as dispersing and transforming. Qi deficiency and blood deficiency are deficiency pattern, with treatment emphasizing tonifying qi and nourishing blood.

bubble_chart Documentation

1. Wenre Jingwei Xue Sheng-bai dampness-heat disease chapter: "When there is internal binding with a desire to defecate, sitting for a long time but still unable to defecate, it is called 'empty sitting with straining.' Generally, internal binding is mostly related to fire. The nature of fire is to transmit rapidly, stagnating in the large intestine, causing urgency to defecate, but the stool is still not relieved. Therefore, in the treatment of dysentery, Skullcap Root is often used to clear fire, and in severe cases, Rhubarb Rhizoma is used to expel heat. If dysentery persists and leads to blood deficiency, insufficient blood can generate internal heat, also causing rectal urgency and a desire to defecate, but sitting for a long time without being able to defecate. This heat is generated by blood deficiency, so the treatment focuses on tonifying blood. Internal binding is different from tenesmus. Internal binding refers to urgent desire to defecate; tenesmus refers to a heavy, sinking sensation in the anus. Internal binding can be divided into deficiency and excess: excess is due to an excess of fire pathogen, while deficiency is due to insufficient nutrient-blood. Tenesmus also has deficiency and excess distinctions: excess is due to pathogenic excess obstructing downward, while deficiency is due to qi deficiency causing sinking. Therefore, treating internal binding involves either clearing heat and nourishing yin or moving qi and lifting tonification. The differentiation between deficiency and excess must be clearly understood."