Case history
Case history #1
A 39-year-old woman presents with a 2-year history of gradually worsening constipation. She complains of bloating, gas, and lower abdominal discomfort with irregular bowel habits. She describes her stool as mostly sausage-shaped, hard, and lumpy. She takes metoprolol for hypertension and lansoprazole for heartburn. She has previously used sennosides and bisacodyl without improvement of her symptoms. She also increased her daily fiber and fluid intake without relief. Physical exam is unremarkable except for mild abdominal distention and palpable stool in the right and left lower quadrants. Perianal inspection is normal, and the anocutaneous reflex is present in all four quadrants. Digital rectal exam reveals a large amount of stool in the rectum. When asked to push and bear down, she shows adequate pelvic descent with normal anal relaxation.
Case history #2
A 50-year-old woman presents with a lifelong history of constipation that has worsened over the past 2 years. She reports decreased stool frequency and straining during defecation. She has a feeling of incomplete evacuation and admits to applying pressure over her posterior vaginal wall during defecation. She describes her stool as separate hard lumps. She has had two vaginal deliveries, with no known history of tears. She has had a hysterectomy and bladder suspension surgery. She has used psyllium and milk of magnesia with limited relief. Exam is unremarkable. Her abdomen is soft and nondistended with no palpable masses. Perianal inspection is normal, and the anocutaneous reflex is present in all four quadrants. Digital rectal exam reveals no stool in the rectum. On digital rectal exam, resting anal tone is weak but her squeeze tone is normal. She does not relax the puborectalis muscle or the external anal sphincter when simulating defecation; she also has 2-cm perineal descent with straining.
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