Feeling like you’re not “done” after pooping—what if that’s the clue?

Feeling like you’re not “done” after pooping—what if that’s the clue?

A persistent sensation of incomplete evacuation (also called tenesmus when painful) can be frustrating. It’s common, affecting up to 20% of adults at some point. While it often stems from benign causes, it can also signal an underlying problem that deserves attention.

What is “sensation of incomplete evacuation”?
This term describes the feeling that stool remains in the rectum after a bowel movement. You may strain to finish, go back to the bathroom repeatedly, or feel relief only after passing gas. It differs from true constipation (low stool frequency) but often overlaps.

Possible causes
• Pelvic-floor dyssynergia (anismus)
– Involuntary contraction of anal or pelvic muscles during defecation
– Leads to poor coordination when trying to push stool out
– Chiarioni et al. (2007) describe this as a leading cause of functional defecatory disorders
• Structural abnormalities
– Rectocele (bulging of the front wall of the rectum into the vagina)
– Anal fissure or stricture (scarring/narrowing)
– Hemorrhoids (swollen veins that may block stool passage)
• Irritable Bowel Syndrome (IBS)
– IBS-constipation subtype often includes incomplete evacuation
– Discomfort, bloating and altered bowel habits
• Slow-transit constipation
– Delayed movement of stool through the colon
– Causes infrequent, hard stools and sensation of incomplete emptying
• Inflammatory or infiltrative disease
– Ulcerative colitis, Crohn’s disease, radiation proctitis
– Rectal inflammation triggers urgency and tenesmus
• Neurological disorders
– Spinal cord injury, multiple sclerosis, diabetes-related nerve damage
– Impaired nerve signals to pelvic floor and rectum
• Medications and medical conditions
– Opioids, anticholinergics, calcium-channel blockers
– Dehydration, hypothyroidism, hypercalcemia, cirrhosis with ascites or diuretic use

When it might be more serious
Most causes are benign or treatable, but see a doctor if you have:
• Rectal bleeding or dark stools
• Unintended weight loss
• Severe abdominal or rectal pain
• Anemia (fatigue, paleness)
• A family history of colorectal cancer
• Changes in stool caliber (pencil-thin stools)
• New onset after age 50

These “alarm” signs may warrant colonoscopy or imaging to rule out cancer, strictures or inflammatory disease.

How it’s evaluated

1. Medical history and symptom diary
   – Stool frequency, consistency (Bristol Stool Chart), strain level
   – Relation to diet, stress or activity
2. Physical exam
   – Abdominal exam for masses or tenderness
   – Digital rectal exam to assess tone, masses, strictures, fissures
3. Anorectal manometry
   – Measures muscle pressures and coordination in the rectum and anus
4. Balloon-expulsion test
   – Tests ability to expel a simulated stool
5. Defecography (dynamic imaging)
   – X-ray or MRI of pelvic floor during defecation
6. Colonoscopy or CT/MRI
   – If alarm signs or to rule out inflammatory or neoplastic disease

Management strategies
Lifestyle and dietary changes
• Increase soluble fiber (psyllium, oats) gradually to 20–30 g/day
• Drink 1.5–2 L of fluids daily (unless fluid-restricted)
• Establish a regular toilet routine, ideally 30 minutes after meals
• Exercise regularly (30 min of moderate activity most days)

Behavioral therapies
• Biofeedback therapy
– Teaches you to relax pelvic floor muscles during pushing
– Shown in Chiarioni et al. (2007) to improve dyssynergia and emptying
• Pelvic-floor physiotherapy
– Manual techniques and guided exercises

Medications and supplements
• Bulk-forming laxatives (psyllium, methylcellulose)
• Osmotic laxatives (polyethylene glycol, lactulose)
• Stool softeners (docusate)
• Prokinetics (in select cases under medical supervision)

Procedures and surgery (for selected patients)
• Botulinum toxin injection into puborectalis muscle (for dyssynergia)
• Repair of rectocele or intussusception
• Dilation of strictures or fissures
• Hemorrhoidectomy (for severe hemorrhoids)

Special considerations for cirrhosis
Patients with advanced or decompensated cirrhosis (D’Amico et al. 2006; EASL 2018) may experience altered bowel habits due to:
• Ascites compressing the colon
• Diuretics that can cause dehydration and electrolyte imbalance
• Changes in gut motility from liver dysfunction
Management in cirrhosis focuses on:
• Careful fluid and diuretic balance
• Adequate protein intake to maintain muscle strength, including pelvic-floor muscles
• Avoidance of medications that worsen constipation (e.g., high-dose opioids)
• Coordination with a hepatologist or liver specialist

When to consider a free, online symptom check
If you’re unsure how serious your symptoms are, you might consider doing a free, online symptom check for assessing bowel concerns. This can help you decide whether to try simple self-care steps first or seek medical evaluation right away.

Next steps and when to seek help
• Try conservative measures for 2–4 weeks. If no improvement, ask your doctor about specialized testing.
• If you have any alarm signs (bleeding, weight loss, severe pain), speak to a doctor promptly.
• Discuss pelvic-floor biofeedback or refer to a colorectal specialist if you suspect dyssynergia.

When to “speak to a doctor”
Although most cases of incomplete evacuation are treatable, never ignore:
• Rectal bleeding or dark, tar-like stools
• Severe, persistent abdominal or rectal pain
• Unexplained weight loss or fatigue
• New symptoms that significantly affect daily life

A timely medical evaluation can rule out serious conditions such as colorectal cancer, strictures or inflammatory bowel disease.

Bottom line
A sensation of incomplete evacuation after pooping can be a clue to functional or structural issues in the rectum and pelvic floor. With simple lifestyle changes, behavioral therapy and targeted treatments, most people find relief. But if you have concerning signs or fail to improve, see your doctor to make sure nothing serious is missed. Remember—you don’t have to live with the discomfort. Take the first step today by considering a free, online symptom check for your bowel concerns, then speak to a healthcare professional about the best plan for you.