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Difficulty in defecation refers to the prolongation of the interval between bowel movements and the difficulty in passing stools. This condition is different from constipation, with three main distinctions: in this condition, stools can still be passed on their own, albeit 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, while in constipation, the stools are necessarily dry and hard; in this condition, even if there is no bowel movement for several days, there is little abdominal discomfort, whereas in constipation, abdominal symptoms are more pronounced.

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

bubble_chart Common Symptoms and Signs

1. Large intestine heat accumulation difficulty in defecation: difficulty in passing stools, dry or granular stools, abdominal distension, or distending pain that resists pressure, flushed face, dysphoria and thirst, yellow urine, dry tongue with greasy or yellow and rough coating, deep and strong pulse.
2. Dampness-heat accumulation difficulty in defecation: difficulty in passing stools, sticky and turbid stools or initially hard and later loose stools, or alternating diarrhea and constipation, lower abdominal distension, gastric stuffiness and chest tightness, heavy body, bitter mouth, no thirst, short and red urine, yellow and greasy tongue coating, slippery and rapid pulse.
3. Spleen-lung qi deficiency difficulty in defecation: difficulty and discomfort in passing stools, straining to defecate, sweating and shortness of breath, even panting, mental fatigue, limb fatigue, lack of energy and reluctance to speak, low voice, lower abdominal emptiness, or rectal prolapse, swollen and tender tongue or with tooth marks on the edges, weak and feeble pulse.
4. Liver-spleen qi stagnation difficulty in defecation: difficulty in passing stools, urgency and tenesmus, desire to defecate but unable to, more flatulence, relief of abdominal discomfort after flatulence. Hypochondriac region distending pain, mental depression, frequent belching. In women, menstrual distending pain of breasts, wiry or deep and wiry pulse.
5. Spleen-kidney yang deficiency difficulty in defecation: commonly seen in the elderly, difficulty in passing stools, dry or normal stools. Cold intolerance, mental fatigue, sore and weak waist and knees. Clear and long urine, increased nocturia, or difficulty in completely emptying the bladder after urination, pale and swollen tongue with tooth marks on the edges, white and moist tongue coating, slow or deep pulse.
6. Yin deficiency and blood deficiency difficulty in defecation: difficulty in passing stools, dizziness and blurred vision, palpitation and insomnia, pale complexion, or afternoon tidal fever, red cheeks, dry mouth and throat, red tongue with little coating, thin and rapid pulse.

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1. Large intestine heat accumulation and dampness-heat stagnation causing difficult bowel movements: Large intestine heat accumulation occurs when pathogenic heat invades the Yangming fu organ, leading to heat accumulation in the large intestine. This can also result from a diet heavy in spicy foods, causing heat accumulation in the Yangming and stagnation in the stomach, which depletes body fluids. As a result, the gastrointestinal tract becomes dry, leading to difficult and dry bowel movements. Although it may not reach the level of severe heat constipation, there is still dry stool stagnating in the intestines, manifesting as abdominal distension, abdominal pain that worsens with pressure, or palpable masses. Dampness-heat stagnation causing difficult bowel movements occurs when heat combines with dampness, obstructing the gastrointestinal tract. Dampness, being a sticky and greasy pathogen, hinders the smooth flow of qi. When qi movement is obstructed, the normal ascending and descending functions are disrupted, leading to difficult bowel movements. Since heat combines with dampness, symptoms such as chest tightness, gastric stuffiness, heaviness in the body without thirst, and a greasy tongue coating indicative of dampness obstruction are observed. Although both conditions involve heat-related difficult bowel movements and share the same disease location, their pathogenic mechanisms differ, and thus their treatments should be distinct. For large intestine heat accumulation, the treatment involves purging heat to promote bowel movements, and the formula Stomach-Regulating Purgative Decoction is selected. For dampness-heat obstruction, the treatment involves clearing heat and resolving dampness to promote bowel movements, using Minor Purgative Decoction with the addition of Anemarrhena and Phellodendron Bark.
2. Spleen-lung qi deficiency and spleen-kidney yang deficiency constipation: Both belong to deficiency pattern, with reduced conduction function, retention of waste in the intestines, difficulty in excretion, and mild abdominal discomfort. However, spleen-lung qi deficiency is primarily characterized by qi deficiency (facial puffiness, panting, spontaneous sweating, aversion to wind, reduced appetite, and fatigue). The lungs govern the qi of the entire body, regulate purification and descent, and are internally and externally related to the large intestine. The spleen is the source of generation and transformation, dominates the circulation of elemental qi, distributes essence, and when spleen deficiency occurs, the transformation and transportation functions weaken, leading to laxity of the large intestine muscles and retention of waste in the intestines. If lung qi fails to descend, the large intestine lacks the force to propel, resulting in difficult and dry stools. Spleen-kidney yang deficiency constipation is due to the decline of life-gate fire, which lacks the strength to transform and transport. Jingyue Quanshu·Miscellaneous Diseases: "Lower energizer yang deficiency leads to qi stagnation, and qi stagnation prevents transmission." The kidneys are the root of yang qi, the residence of life-gate fire, and the source of the body's dynamic force. Kidney yang deficiency leads to internal coldness in the lower body, stagnation of yang qi, and weak transmission, causing difficulty in passing stools, often accompanied by cold intolerance, cold limbs, and increased nocturia. Treatment: For spleen-lung qi deficiency, the focus is on tonifying spleen and lung qi, using Middle-Tonifying Qi-Replenishing Decoction with additions like Bitter Apricot Seed and Trichosanthes seed. Ye Tianshi's approach to intestinal obstruction emphasizes opening the lung and stomach, following Zhu Danxi's principle of opening the upper orifices to clear the lower. For spleen-kidney yang deficiency, warming yang and tonifying the kidneys are essential, as Zhang Jingyue stated, "By strengthening yang, yin stagnation naturally resolves." Prescriptions include Fluid-Replenishing Decoction or Right-Restoring Pill.
3. Liver-spleen qi stagnation constipation: Emotional disharmony, depression, and overthinking impair the liver's free-flowing and regulating nature, leading to qi stagnation in the liver and spleen, obstruction of qi movement, and disruption of ascending and descending functions, causing disordered conduction in the large intestine and difficulty in passing stools. Clinical features include tenesmus, inability to defecate, hypochondriac distension and pain, belching, and nausea, which are prominent symptoms of qi movement disorder, differing from large intestine heat accumulation characterized by abdominal distension, fullness, pain upon pressure, thirst, and greasy tongue coating. Treatment should focus on regulating qi and guiding stagnation, descending qi to promote bowel movement, using modified Liu Mo Yin.
4. Yin deficiency and blood deficiency constipation: Rebing damage to yin, prolonged pestilent qi without blood recovery, excessive postpartum blood loss, improper sweating or diuresis, or old age and weak constitution with inherent yin and blood deficiency can all lead to yin deficiency and blood deficiency, resulting in dry body fluids, lack of moisture and blood to nourish the intestines, and difficulty in passing stools. This pattern differs from spleen-lung qi deficiency or spleen-kidney yang deficiency constipation, as qi deficiency and yang deficiency involve zang-fu organ hypofunction, muscle laxity, and weak transmission, often accompanied by functional decline symptoms (fatigue, shortness of breath, spontaneous sweating, cold limbs, and cold intolerance). Yin deficiency and blood deficiency involve insufficient tangible substances, dry intestines, and lack of fluid to moisten, leading to difficult stools, often accompanied by dizziness, tinnitus, dry mouth and throat, palpitations, and insomnia. Treatment: For blood deficiency, nourishing blood to moisten the intestines is recommended, using Intestine-Moistening Pill with additions like Polygonum multiflorum and sesame. For yin deficiency, enriching yin and producing fluids is essential, as Zhang Jingyue stated, "By strengthening water, the channels naturally clear." Modified Intestine-Moistening Pill combined with Fluid-Increasing Decoction can be used.

Constipation is rarely seen in clinical excess pattern, and is mostly due to deficiency pattern. Excess pattern may result from large intestine excess heat, dampness-heat accumulation, or qi stagnation. Deficiency pattern may result from spleen-lung qi deficiency or spleen-kidney yang deficiency, but most are caused by yin deficiency, blood deficiency, and insufficient body fluids. Treatment should follow the principle stated in Suwen·Zhizhenyao Da Lun: "Carefully adhere to the mechanism of disease, each responsible for its category, seek what is present, seek what is absent, blame the excess, and blame the deficiency."