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Rome IV Diagnostic Criteria for Functional Defecation Disorders

Official Rome IV criteria for the diagnosis of functional defecation disorders.

Patients who have symptoms consistent with functional constipation or IBS with constipation and in whom a defecation disorder is suspected. 

Do NOT use in patients:

  • Without age appropriate colorectal cancer screening.

  • With secondary intervenable causes for constipation (e.g. medications).

Must have the following:

For 3 months prior with symptom onset ≥6 months ago

a. Abnormal balloon expulsion test
b. Abnormal anorectal evacuation pattern with manometry or anal surface EMG
c. Impaired rectal evacuation by imaging

Additional criteria for inadequate defecatory propulsion:

Additional criteria for dyssynergic defecation:

Diagnostic Result

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Advice

  • If 2 tests are negative (e.g. BET and ARM negative): unlikely FDD.

  • If 2 tests are discordant (e.g. BET negative and ARM positive): possibly FDD.

    • Consider additional testing such as defecography

  • If ≥2 tests are positive: more likely FDD.

    • Refer to pelvic floor physical therapy for biofeedback, defecation, and/or sensory conditioning training.

Management

  • Anorectal biofeedback.

  • Defecation and/or sensory conditioning training.

  • Treatment of FC or IBS-C:

    • Start with secretagogues (e.g. linaclotide, Lubiprostone, plecanatide).

    • If bloating is present and/or slow transit constipation is associated: consider prokinetics (e.g. prucalopride, tegaserod).

Critical Actions

Recognize high rates of sexual/physical abuse in this population:

  • Educate about what is entailed in testing as can trigger prior trauma.

Understand that biofeedback therapy is time-consuming, can have poor insurance coverage, and trained personnel are limited:

  • Education prior to referral to pelvic floor physical therapy is crucial.

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