Chronic constipation is often treated as a single disease. GI motility and neurogastroenterology specialist Dr Zubin Sharma says the reality is far more complex, and understanding the underlying physiology may be the key for patients who remain constipated despite years of treatment.
For millions of people, constipation follows a familiar pattern.
A laxative is prescribed.
It works for some time.
The dose is increased.
Another medicine is added.
Dietary fibre, probiotics, herbal remedies and home treatments follow.
Yet the problem continues.
According to Dr Zubin Sharma, a gastroenterologist specialising in gastrointestinal motility and neurogastroenterology, the reason may be surprisingly simple: constipation is not one disease.
“Two patients can use exactly the same word, constipation, and yet have completely different physiological problems,” says Dr Zubin Sharma. “If the mechanism is different, the treatment may also need to be different.”
For patients with difficult or refractory constipation, this distinction can be critical.
Constipation Is a Symptom, Not a Complete Diagnosis
Most people define constipation by how often they pass stool.
But frequency is only one part of the picture.
Some patients pass stool infrequently. Others go every day but experience excessive straining, incomplete evacuation or a sensation of blockage.
Some spend 30 to 45 minutes in the toilet.
Others repeatedly return to the washroom because they never feel completely empty.
According to Dr Zubin Sharma, these differences provide important clues.
“When I evaluate a patient with chronic constipation, I don’t only ask how many times they pass stool,” he explains. “The pattern of defecation can tell us a great deal about the underlying physiology.”
Modern GI motility science broadly recognises that constipation can arise through different mechanisms.
In some patients, stool moves slowly through the colon.
In others, the colon may move reasonably well, but the muscles involved in defecation fail to coordinate appropriately.
There can also be abnormalities of rectal sensation, overlapping irritable bowel syndrome or combinations of different mechanisms.
Calling all of these patients simply “constipated” may therefore hide important differences.
When the Pelvic Floor Works Against the Patient
One of the most frequently overlooked causes of difficult defecation is a problem with pelvic floor coordination.
Passing stool is an active physiological process.
The rectum generates pressure while the anal sphincter and pelvic floor must relax in a coordinated manner.
In some patients, this coordination is disturbed.
Instead of relaxing appropriately during attempted defecation, the muscles may fail to relax or may paradoxically contract.
The patient pushes harder.
But the harder they push, the more difficult evacuation may become.
This condition is commonly described as dyssynergic defecation.
Dr Zubin Sharma says such patients often arrive after years of laxative use.
“If the primary problem is the mechanics of evacuation, increasing the amount of stool or making it progressively softer may not completely solve the problem,” says Dr Zubin Sharma.
These patients may describe prolonged toilet time, excessive straining, a persistent sensation of incomplete evacuation or the need for unusual manoeuvres to pass stool.
Why More Laxatives May Not Be the Answer
Laxatives remain an important and effective treatment for many patients with constipation.
Dr Zubin Sharma cautions against interpreting physiology-based treatment as an argument against laxatives.
“The question is not whether laxatives are good or bad,” he says. “The question is whether we are treating the dominant mechanism responsible for that patient’s symptoms.”
For example, a patient with slow movement through the colon may require medicines that improve bowel movement or secretion.
A patient with pelvic floor dyssynergia may benefit more from specialised pelvic floor biofeedback.
Another patient may require treatment directed towards altered gut sensation or a disorder of gut-brain interaction.
The same symptom can therefore lead to very different treatment pathways.
This is where GI motility testing can become useful in carefully selected patients.
What Is Anorectal Manometry?
Anorectal manometry is a specialised physiological investigation used to assess the function of the rectum and anal sphincter.
The test can evaluate anal pressures, rectal sensation and the coordination of muscles during attempted defecation.
According to Dr Zubin Sharma, the value of the test lies not simply in generating numbers or colourful graphs.
“The manometry report has to be interpreted in the context of the patient’s symptoms and other physiological findings,” he explains.
In selected cases, additional investigations such as a balloon expulsion test or gastrointestinal transit assessment may be required.
Dr Zubin Sharma emphasises that not every person with constipation requires advanced testing.
However, patients with persistent symptoms despite appropriate treatment, significant evacuation difficulty or a clinical suspicion of pelvic floor dysfunction may require a more detailed physiological assessment.
Biofeedback Can Retrain the Defecation Process
Perhaps one of the most interesting aspects of pelvic floor dysfunction is that treatment may involve retraining the body.
Specialised biofeedback therapy helps patients understand and modify the muscle coordination required for normal defecation.
Using physiological feedback and structured training, patients can learn how to generate appropriate abdominal pressure while relaxing the pelvic floor.
Dr Zubin Sharma believes this is an area where India requires greater awareness and more structured services.
“Biofeedback is not simply asking a patient to perform Kegel exercises,” he says. “The treatment of dyssynergic defecation requires targeted training based on the physiological abnormality.”
This distinction is important.
Traditional pelvic floor strengthening exercises may not address a coordination disorder and, inappropriately prescribed, may even focus on the wrong physiological goal.
Dr Zubin Sharma Advocates a Physiology-First Approach
Through his work in GI motility and neurogastroenterology, Dr Zubin Sharma has increasingly focused on patients with complex constipation and evacuation disorders.
He believes difficult constipation should be approached through a structured clinical pathway.
The first step remains a detailed history and appropriate exclusion of secondary causes.
But when conventional treatment repeatedly fails, the question should change.
Instead of asking, “Which laxative should we add next?”
Doctors may need to ask:
“Why is this patient unable to evacuate normally?”
For Dr Zubin Sharma, this represents the broader direction in which gastrointestinal medicine is evolving.
“Symptoms are the starting point,” he says. “Physiology helps us understand the mechanism.”
A Different Future for Patients With Chronic Constipation
Chronic constipation can significantly affect quality of life.
Patients may plan travel around bowel movements, spend prolonged periods in the toilet and progressively restrict their diets.
Many quietly accept the problem for years.
Dr Zubin Sharma believes greater awareness of GI motility disorders could help selected patients reach the correct diagnosis earlier.
Not every constipation patient needs manometry.
Not every patient has pelvic floor dysfunction.
And not every laxative failure indicates a rare disease.
But when symptoms persist despite repeated treatment, understanding the mechanism may be more useful than simply escalating the prescription.
As Dr Zubin Sharma puts it:
“Before treating constipation harder, sometimes we need to understand constipation better.”
