bubble_chart Concept

Difficult defecation refers to the prolongation of the interval between bowel movements and the difficulty in passing stools. This condition is different from constipation, and there are three main distinctions: in this condition, stools can still be passed on one's own, but with difficulty, usually once every other day. In constipation, the interval between bowel movements is several days or more, and it is difficult to pass stools without treatment; the stools in this condition are generally not too dry, although some patients may have stools as dry as dates or foxtail millet, whereas constipated stools are inevitably dry and hard; although there may be no bowel movement for several days in this condition, there is little abdominal discomfort, whereas the abdominal symptoms of constipation are more pronounced.

The term "difficult defecation" first appeared in Neijing, Suwen. Zhizhenyao Da Lun: "Taiyin celestial control, dampness being restricted... difficult defecation." In the "Treatise on Cold Damage Diseases," there are terms such as "difficult defecation," "not changing clothes," "no bowel movement," and "splenic constipation," some of which belong to constipation, such as yangming fu-organ pattern. However, there are also those that belong to difficult defecation, and later physicians have also elaborated on the disease cause and mechanism of disease of difficult defecation.

bubble_chart Pattern Analysis

1. Large Intestine Heat Accumulation︰Difficult defecation, dry or granular stools, abdominal distension, or distending pain with tenderness, flushed face, dysphoria and thirst, yellow urine, dry tongue with greasy or yellow and rough coating, deep and strong pulse. Pathogenic heat invades the Yangming fu organs, heat accumulation in the large intestine, or habitual consumption of spicy foods leading to heat accumulation in Yangming, stagnation in the stomach, and damage to fluids, resulting in dryness and depletion of gastrointestinal fluids and difficult bowel movements. Although it has not reached the level of excess-heat constipation, there is still dry stool stagnating in the intestines, hence symptoms such as abdominal distension, abdominal pain with tenderness or palpable masses. To clear heat and promote bowel movements, the prescription selected is Stomach-Regulating Purgative Decoction.
2. Dampness-heat︰Difficulty in defecation, sticky and turbid feces or initially hard and later loose stools, or alternating diarrhea and constipation, lower abdominal distension, gastric stuffiness, chest tightness, heavy body, bitter taste in the mouth, absence of thirst, scanty and dark urine, yellow and greasy tongue coating, slippery and rapid pulse. Heat combined with dampness obstructs the stomach and intestines. Dampness, being a sticky and greasy pathogenic factor, most impedes the smooth flow of qi movement. When qi movement is obstructed, the ascending and descending functions become abnormal, and the transportation and transformation are impaired, leading to difficulty in defecation. Due to the combination of heat and dampness, symptoms such as chest tightness, gastric stuffiness, heavy body, absence of thirst, and greasy tongue coating manifest as signs of dampness obstruction. Clearing heat and resolving dampness to promote bowel movement, Minor Purgative Decoction with the addition of Anemarrhena and Phelloendron Bark.
3. Spleen-lung Qi Deficiency︰Difficult and unsmooth bowel movements, straining with difficulty in passing stools, sweating and shortness of breath, or even panting, mental fatigue, limb weariness, shortage of qi and reluctance to speak, low and timid voice, a sensation of emptiness and sagging in the lower abdomen, or possibly prolapse of rectum, tongue texture puffy and tender or with tooth marks on the edges, weak and feeble pulse. Primarily due to qi deficiency (facial puffiness, panting, spontaneous sweating, aversion to wind, poor appetite, and fatigue). The lungs govern the qi of the entire body, oversee purification and descent, and are externally-internally related to the large intestine. The spleen is the source of generation and transformation, dominates the circuit of element qi, distributes essential nutrients. Spleen deficiency leads to weakened transportation and transformation, slackening of the large intestine muscles, and retention of waste in the intestinal tract. If lung qi fails to descend, the large intestine lacks the driving force, resulting in difficult and sluggish bowel movements. The focus is on replenishing the qi of the spleen and lungs, using the formula Middle-Tonifying Qi-Replenishing Decoction supplemented with Bitter Apricot Seed and Trichosanthes seeds. Ye Shi’s treatment for intestinal obstruction always involves opening the lung and stomach, reflecting Danxi’s principle of opening the upper orifices to unblock the lower orifices.
4. Liver and Spleen Disharmony︰Difficulty in defecation, tenesmus with a desire to defecate but inability to do so, excessive flatus, and relief of abdominal discomfort upon passing gas. Hypochondriac distending pain, mental depression, and frequent belching. In women, menstrual distending pain of the breasts may occur, with a wiry or deep wiry pulse. Emotional disharmony, frustration, worry, or overthinking leads to the liver's failure to regulate and free the flow of qi, resulting in qi depression and stagnation in the liver and spleen, obstruction of qi movement, and disruption of the ascending and descending functions. This causes disordered transmission in the large intestine, making it difficult to expel waste. The clinical features include prominent symptoms of tenesmus, an urge to defecate without success, hypochondriac distending pain, belching, and nausea—all signs of disordered qi movement. These differ from symptoms of large intestine heat accumulation, such as abdominal distension, fullness, tenderness, thirst, and a greasy tongue coating. Treatment should focus on regulating qi and relieving stagnation, descending qi to promote bowel movements. The recommended formula is Liu Mo Yin with modifications.
5. Spleen-kidney Yang Deficiency︰Commonly seen in the elderly, it manifests as difficult bowel movements with dry or normal stool. Symptoms include aversion to cold, mental fatigue, soreness and weakness in the lower back and knees. Clear and profuse urine, increased nocturia, or dribbling after urination. The tongue texture is pale and swollen with tooth marks, tongue coating is white and moist, and the pulse is slow or deep. This is due to the decline of life-gate fire, which lacks the strength to transform and transport. Jingyue Quanshu·Miscellaneous Syndromes states: "Deficiency of lower energizer yang leads to stagnation of qi, and stagnation of qi results in impaired transmission." The kidneys are the root of yang qi and the dwelling of life-gate fire, serving as the source of the body's dynamic energy. When kidney yang deficiency occurs, pudendal coldness arises internally, yang qi fails to circulate, and transmission becomes weak, leading to obstructed and difficult bowel movements. Thus, it is often accompanied by symptoms of kidney yang deficiency such as fear of cold, cold limbs, and increased nocturia. Treatment should focus on warming yang and tonifying the kidneys, as Jingyue said: "Simply boosting yang will naturally resolve yin congelation." Recommended formulas include Fluid-Replenishing Decoction or Right-Restoring Pill.
6. Yin Deficiency with Blood Depletion︰Difficult and hard bowel movements, dizziness and blurred vision, palpitation insomnia, pale complexion, or afternoon tidal fever, flushed cheeks, dry mouth and throat, red tongue with scant coating, thready and rapid pulse. Rebing damage to yin, or prolonged pestilent qi with unrecovered blood, or postpartum loss of blood excessive, or mistaken use of diaphoresis and diuresis, or old age and weak constitution with inherent deficiency of yin and blood, etc., can all lead to yin deficiency and blood depletion, body fluids exhaustion, resulting in the intestines lacking fluids and blood for nourishment and lubrication, causing difficult and hard bowel movements. This syndrome differs from spleen-lung qi deficiency or spleen-kidney yang deficiency constipation. Qi deficiency and yang deficiency involve zang-fu organ hypofunction, muscle laxity, and impaired transmission leading to difficult bowel movements, often accompanied by functional decline symptoms (mental fatigue, lassitude, shortness of breath, spontaneous sweating, cold limbs, fear of cold, etc.). In contrast, yin deficiency and blood depletion stem from insufficient tangible substances, dry intestines, and lack of fluids for lubrication, commonly presenting symptoms like dizziness, tinnitus, dry mouth and throat, palpitation insomnia, and other signs of yin-blood insufficiency. For treatment, cases leaning toward blood deficiency should nourish blood to moisten the intestines for laxation, using formulas such as Blood-Benefiting Intestine-Moistening Pill supplemented with fleeceflower root, sesame, etc.; cases leaning toward yin deficiency should enrich yin and produce fluids, as stated by Zhang Jing-yue: "Simply strengthen the water, and the rivers will flow naturally." Modify Blood-Benefiting Intestine-Moistening Pill combined with Fluid-Increasing Decoction.

The symptom of difficult defecation is rarely seen in clinical excess pattern, and is mostly deficiency pattern. Excess pattern may be caused by large intestine excess heat, or by dampness-heat accumulation, or by qi stagnation. Deficiency pattern may be caused by spleen-lung qi deficiency, or by spleen-kidney yang deficiency, but mostly by yin deficiency, blood deficiency, and insufficient body fluids. Its treatment, as stated in Suwen. Zhizhenyao Da Lun says: "Carefully observe the mechanism of disease, each according to its category, seek what is present, seek what is absent, blame the excess, blame the deficiency."