Defecation Syncope Research Articles

IDF21-0446 Diabetes mellitus with micturition and defecation syncope: Etiology or chance association?

Background: Syncope is a transient and abrupt loss of consciousness with complete return to pre-existing normal neurologic function. Defecation and micturition syncope are types of the situational syncope, which occur immediately after precipitating situations, such as defecation and urination respectively. Situational syncope are considered forms of neurally mediated syncope with reflex-mediated vasodilation and bradycardia, but possibly other mechanisms can also be involved. Micturition syncope is commoner than defecation syncope which is rarely described. Aim: We describe a case who presented with episodes of both micturition as well as defecation syncope. To the best of our knowledge, this is the first description of both types of syncope occurring in a single patient. Method: A 42 year old male, known case of diabetes mellitus since 10 years and on irregular blood sugar control presented to neurology department with complaints of episodic unconsciousness since last 5-6 years. History revealed total 5 episodes of syncope out of which 2 occurred while micturition and 3 while defecation. There were no associated signs suggesting seizure. There was no history of any drug intake except metformin and no history of chronic constipation. He denied history of angina, dyspnoea, palpitations and symptoms suggesting transient ischemic attacks. Results: Examination showed well-built individual with pulse 74 per minute (no arrhythmia), BP 134/76 mm Hg with no significant postural drop or tachycardia. ECG and ECHO were normal. 24 hour holter monitoring did not show any abnormality. Pelvic ultrasound was also normal. Discussion: Micturition syncope and defecation syncope are rare types of situational syncope. While all micturition syncope should be evaluated for bladder mass, defecation syncope should undergo testing for causes of chronic constipation if present. Autoimmune conditions like diabetes mellitus and hypothyroidism are also seen to be associated with these presentations. The exact mechanism of causation of these types of syncope in diabetes is yet unknown but future studies are needed to ascertain whether diabetes is an etiological factor in the causation of situational syncope.

Defecation Syncope; Digging Deep: A Case Report

Defecation syncope explains the exaggerated vasovagal response while defecating, which may result in unconsciousness and rarely cardiac arrest. It is underreported, mainly because of the patient's hesitation and inability to correlate the two, unless specifically probed by meticulous history taking; the importance of which cannot be over-emphasized. A 28- year old fieldworker with two episodes of syncope, the last of which culminated in a cardiac arrest requiring resuscitation by a bystander. Upon further questioning, it was revealed that both times, the patient had the urge to defecate followed by dizziness and warmth preceding the loss of consciousness. A head-up tilt table test was planned as a means to reenact the symptoms. Upon confirmation of diagnosis, the patient was counselled for lifestyle changes only. Defecation syncope leading to cardiac arrest is a rare entity but with high mortality ratio. Since vagal tone increases during straining effort, reducing physiological response may be helpful to avoid lethal results. Hydration, avoidance of constipation, and squatting position are among the important key risk-reducing factors.

Defecation Syncope: Two Cases of Post-Operative Cardiac Arrest

Introduction: The vasovagal response is a normal physiologic response that consists of sequential changes in blood pressure, heart rate, and contractility that resolves spontaneously in normal patients. This normal response can be problematic in patients with a compromised cardiovascular system who require surgery. Case Summary: We report two cases of defecation syncope with cardiac arrest. Both patients had preexisting cardiovascular disease and no premonitory syncope symptoms. Both patients were returned to spontaneous circulation following initiation of ACLS protocol, but died later in the hospital course secondary to complications of cardiac arrest. Conclusion: Promoting hydration, incorporating a stool softener into the medication regimen, and squatting during bowel movement may aid in reducing the risk for syncope and associated cardiac arrest with defecation.

Characteristics of Syncope in Japan and the Pacific Rim

As is true in the Western world, syncope of cardiac and non-cardiac origin is one of the common clinical presentations in daily medical practice in Japan and Asia. However, the underlying disorders and social backgrounds associated with syncope may differ, from those encountered in Western countries, particularly in Japan. While non-cardiac causes, neurally-mediated reflex faints in particular, are highly prevalent, out-of-hospital deaths by drowning due to syncope occurring during bathing at home are not rare in Japan, particularly in the elderly. Other underlying cardiac or non-cardiac disorders are also noteworthy, particularly Brugada syndrome and coronary vasospasm, which may present as isolated syncope. In addition, the characteristic clinical presentation of micturition and defecation syncope is not uncommon. This review is focused on these specific underlying diseases in the light of the guidelines issued by the Japanese Circulation Society regarding the diagnosis and treatment of syncope.

Central Nervous System Involvement in Systemic Lupus Erythematosus: Cerebellar Infarctus /

Syncope is a symptom which is a transient loss of consciousness and very common in society and is one of the most important referral causes to emergency services. Micturition syncope (MS) appears as a rare cause of neurally-mediated syncope. MS is caused by reflex which results with vasodilatation and bradycardia, like defecation syncope. In the clinical setting, the MS is presented with transient loss of consciousness during supine position or micturition following after a sleep period mostly in otherwise healthy men. It is a reflex state in which standing triggers vasodilatation and bradicardia. MS covers 2-8% of all syncopes. There is still no consensus about treatment and outcome of MS. In this article two male patients with MS are presented. With these two cases, we aimed to give detailed information about micturition syncope which is a rare type of syncope.

Clinical Characteristics of Defecation and Micturition Syncope Compared with Common Vasovagal Syncope

Little is known about the clinical characteristics of patients with situational syncope such as defecation syncope (DS) or micturition syncope (MS) compared with those with common vasovagal syncope (VVS). Among 680 consecutive patients, who underwent a head-up tilt test between January 2006 and November 2010, 282 patients (40.4±16.7 years; 48.6% men) diagnosed as DS (n = 38), MS (n = 38), or common VVS (n = 208) were included. Ages at diagnosis (38.7±17.3 vs 48.3±14.1 vs 42.0±13.8, P = 0.004) and the first syncope (33.7±18.4 vs 44.5±15.3 vs 37.5±14.6, P = 0.002) were significantly less in patients with common VVS than those with DS or MS, respectively. The patients with MS were more likely to be men (73.7%, P = 0.036), whereas patients with DS were more commonly women (73.7%). No sexual preference was observed in patients with common VVS. Body mass index was significantly lower (P = 0.047) and syncopal episodes were more recurrent (P = 0.049) in patients with common VVS than those with DS or MS. The frequency of drinking alcoholbefore syncope was significantly higher in patients with MS (39.5%, P < 0.001). DS tended to occur in older women, whereas MS tended to occur in middle-aged men and drinking alcohol was an important precipitating factor for MS. However, common VVS was observed more in a thin and young population, which was more recurrent compared with those situational syncopes.

Clinical Characteristics of Defecation Syncope Compared With Micturition Syncope

Defecation syncope (DS) and micturition syncope (MS) are daily excretion-related syndromes that are both classified as situational. However, their clinical features seem to be very different, so the present comparative study aimed to clarify those of DS. The study population consisted of 20 consecutive patients with DS and 37 consecutive patients with MS. The DS patients were significantly older than the MS patients (63+/-15 vs 52+/-17 years, P=0.026). Gender was significantly different (P=0.026): women predominated in the DS group (60%) whereas men more commonly had MS (70%). The diurnal distribution of syncope differed (P=0.0054): 88% of MS episodes occurred between 6 pm and 6 am, whereas DS occurred almost equally throughout the 24 h. Syncope after drinking alcohol was less common with DS (10%) than with MS (60%) (P=0.0003), whereas gastrointestinal tract (GIT) symptoms as a premonitory sign were more common with DS (55%) than with MS (3%) (P<0.0001). Positive responses to head-up tilt testing did not differ between the DS and MS groups. DS tends to occur in elderly women and without any significant daily distribution. Alcohol-related syncope was uncommon in patients with DS, and preceding GIT symptoms may be important as predictors or triggering factors.

Gender Difference in Patients with Recurrent Neurally Mediated Syncope

PurposeThe gender difference of neurally mediated syncope is not well defined in a large patient population. The aim of this study was to evaluate the gender difference of clinical manifestations in patients with neurally mediated syncope who underwent head-up tilt test.Materials and MethodsThe medical records of 1,051 consecutive patients with two or more episodes of syncope, who were diagnosed as having neurally mediated syncope by head-up tilt test, were retrospectively reviewed.ResultsOf 1,051 patients, 497 (47.3%) patients were male and 554 (52.7%) patients were female. Female patients were experiencing syncopal episodes for longer periods of their lives (8.2 ± 9.5 years vs. 6.8 ± 9.2 years, p = 0.002) and more episodes of syncope prior to head-up tilt test (HUT) (7.2 ± 9.4 vs. 5.0 ± 6.4, p = 0.001) than male patients. Micturition syncope (20.0% vs. 5.2%, p < 0.001) was observed more frequently in male patients than in female patients. To the contrary, however, defecation syncope (16.3% vs. 9.3%, p < 0.001) was observed more frequently in female patients than in male patients.ConclusionFemale patients were experiencing syncopal episodes for longer periods of their lives and more episodes of syncope than male patients. Gender difference was also noted with regard to frequency of situational syncope.

Neurocardiogenic Syncope and Related Disorders of Orthostatic Intolerance

Received September 14, 2004; revision received January 31, 2005; accepted March 9, 2005. “We shall not cease from exploration and the end of all our exploring will be to arrive where we started and know the place for the first time” — —T.S. Eliot, Four Quartets Syncope, defined as transient loss of consciousness and postural tone with spontaneous recovery, has both challenged and perplexed physicians since the dawn of recorded time. The earliest written accounts come from Hippocrates, and the word syncope itself is derived from an old Greek term meaning “to cut short” or “interrupt.” Recurrent episodes of syncope may result from a large number of different disorders, all of which cause a transitory reduction in cerebral blood flow sufficient to disturb the normal functions of the brain. Over the last 2 decades, considerable attention has been given to types of syncope that occur due to a centrally mediated (or “reflex”) fall in systemic blood pressure, a condition that has been referred to as vasovagal (and later neurocardiogenic) syncope. However, research into the nature of this disorder revealed that it is but one aspect of a broad and varied group of disturbances in the normal functioning of the autonomic nervous system (ANS), each of which may result in orthostatic intolerance, hypotension, and ultimately syncope. Continued investigations into the nature of these similar yet different disorders has led to the development of a system of classification that attempts to more accurately reflect our understanding of these conditions and their interrelationships.1 The present system of classification has proven both functional and clinically relevant and includes a group of disorders that most investigators have thought to be principally autonomic in nature. Because both the cardiologist and the cardiac electrophysiologist frequently are expected to both diagnose and treat these conditions, the following …

New approaches to the treatment and prevention of neurally mediated reflex (neurocardiogenic) syncope.

Neurally mediated reflex syncope (sometimes referred to as neurocardiogenic syncope), encompasses a group of disorders of which the best known and most frequently occurring forms are the vasovagal (or common) faint, and carotid sinus syndrome. Postmicturition syncope, defecation syncope, cough syncope, and other situational reflex faints are also included among these conditions. With the exception of carotid sinus syndrome in which cardiac pacing is effective, treatment of most neurally mediated reflex faints is shifting from reliance on various drugs to greater emphasis on education and nonpharmacologic therapy. Initial management should include counseling of patients regarding recognition of early warning symptoms, and avoidance of precipitating factors. Volume expansion with salt tablets or electrolyte-containing beverages and patient education on how to perform isometric arm contractions and/or leg crossing in order to abort impending syncope are also important. Thereafter, tilt-training has demonstrated benefit in several clinical studies. When symptoms remain despite the above-noted interventions, pharmacologic therapy with midodrine or a nonselective b-blocker can be considered. In the case of most neurally mediated reflex faints, permanent cardiac pacing should be reserved only for those older patients with significant bradycardia or asystole at time of syncope when all other interventions have failed.

Abnormalities of sympathetic and parasympathetic autonomic function in subjects with defaecation syncope.

Defaecation syncope is defined as blacking out at, or around, the time of defaecation. It is associated with increased mortality; however, patients rarely voluntarily report symptoms. We have examined autonomic function in a cohort of patients with defaecation syncope. We prospectively identified all subjects referred to our unit with symptoms of defaecation syncope or presyncope on direct questioning. All subjects had autonomic function tests using beat to beat blood pressure measurement synchronized with R-R interval allowing real time assessment of autonomic function. Seven patients were identified who presented with defaecation syncope. Compared with age and sex matched controls, subjects had abnormalities of both sympathetic and parasympathetic autonomic function consistent with mild-moderate autonomic failure. On specific intervention syncope stopped in all subjects: 3 had culprit medication withdrawn, 3 received medication to increase blood pressure and 1 in whom cardioinhibition was demonstrated improved with permanent pacemaker insertion. Two subjects who had colonoscopy had profound haemodynamic changes during the procedure associated with syncope. Symptoms of syncope on defaecation are associated with autonomic failure. With appropriate therapeutic intervention our subjects all improved.

A04-5 Autonomic function in patients with defaecation syncope

A04-5 Autonomic function in patients with defaecation syncope

A04-5 Autonomic function in patients with defaecation syncope

A04-5 Autonomic function in patients with defaecation syncope

Recent Advances in the Classification and Management of Neurocardiogenic Syncope and Related Disorders

“Those who do not add to their learning, diminish it.”—The Talmud While a number of new and exciting developments in the ~eld of syncope have occurred in the last few years, there are several points of particular interest to the electrophysiologist. Over the last several years it has become apparent that sudden autonomically-mediated hypotension (with or without bradycardia) is an important cause of unexplained loss of consciousness, a phenomenon now known as neurocardiogenic (or vasovagal) syncope [1]. The development of head upright tilt table testing provided not only a way to induce and therefore diagnose the condition, but also allowed for detailed assessments of the pathophysiologic processes that were at work in this disorder. In the course of these investigations it also became increasingly apparent that neurocardiogenic syncope was but one of a group of related (yet different) disturbances in autonomic nervous system function associated with orthostatic intolerance [2]. More and more it is the electrophysiologist who is called upon to diagnose and treat these disorders, thus a working understanding of them is essential. While the system of classi~cation of autonomic nervous system disorders associated with orthostatic intolerance that has evolved is to some extent arbitrary (as is any such system) it is none the less an attempt to understand these disorders in an objective manner [3]. These disturbances are divided into four large groups: (1) Re_ex Syncope, (2) Postural Orthostatic Tachycardia Syndrome (or POTS), (3) Pure Autonomic Failure, (4) Multiple Systems Atrophy (Fig. 1). The re_ex syncopes are distinguished by a sudden rapid drop in blood pressure that is frequently accompanied (although not always) by a fall in heart rate. In between syncopal episodes patients have few other complaints [1]. These paroxysmal autonomic disturbances appear to re_ect a “hypersensitive” autonomic system that over responds to stimuli that are usually within the range of normal tolerance. A common mechanism between these disorders is that rapid activation of a bed of mechanoreceptors (in the heart, bladder, rectum, carotid body, etc.) results in a sudden surge in the amount of afferent normal activity to the brainstem [5]. This sudden increase in neural traf~c seems to mimic the conditions that are normally seen only during hypertension. This provokes an apparent “paradoxic” sympathetic withdrawal that leads to peripheral vasodilation and hypotension. This group of disorders includes not only neurocardiogenic syncope but also carotid sinus hypersensitivity, micturition syncope, and defecation syncope [6]. More detailed discussions of these disorders can be found elsewhere [1,7]. The Postural Orthostatic Tachycardia Syndrome (or POTS) is an increasing recognized cause of postural tachycardia, palpitations, lightheadedness, near syncope, exercise intolerance, cognitive impairment and lastly, chronic fatigue [8]. The hallmark of this disorder is an excessive increase in heart rate on standing or during tilt, that exceeds a 30 beat/minute increase during the ~rst ten minutes or a maximum heart rate of greater than 120 during the same time period [9]. These appears to be two distinct subgroups of this disorder. The most common is referred to as the “Partial Dysautonomic” form. This represents a failure of the peripheral vasculature to adequately vasoconstrict during upright posture. This is then compensated for by a large increase in heart rate and inotropy [10]. So opposed to “inappropriate” sinus tachycardia, the increase in heart rate is both appropriate and compensating in nature. This is an energy inef~cient form of compensation where the individual is “running in place” whenever he is sitting or standing. Standing for more than ~ve to ten minutes results in a bluish mottled appearance of the lower extremities. Many of these patients may be misdiagnosed as chronic fatigue syndrome. There also appears to be a central hyperadrenergic form of POTS, where there is excessive sympathetic activation in some neural distributions almost all the time. This appears to occur above the level of the barore_ex, and excessive sympathetic activity is not adequately dampened by the barore_ex. Although quite similar to the partial dysautonomic form of POTS, the hyperadrenergics have a high incidence of migraine-like headache and cold, sweaty extremities, and respond to different treatment modalities. The interested reader can ~nd further information elsewhere [10].

Defecation Syncope Secondary to Functional Inferior Vena Caval Obstruction During a Valsalva Maneuver

This report describes a case of defecation syncope secondary to functional inferior vena cava (IVC) obstruction. Preoperative hemodynamic assessment revealed a marked decrease in blood pressure and IVC obstruction when the patient performed a Valsalva maneuver. The intraoperative approach included continuous hemodynamic monitoring as well as transesophageal ultrasonography to assess IVC patency during surgical mobilization of the IVC. Functional obstruction of the IVC at the diaphragmatic hiatus was identified, and this obstruction was relieved with extensive mobilization of the IVC and right crural myotomy. This report describes an effective surgical approach to a rare functional disorder involving the IVC.

Defecation Syncope Caused by Pulmonary Embolism

Letters and Corrections1 July 1990Defecation Syncope Caused by Pulmonary EmbolismMarin H. Kollef, MD, David T. Schachter, MDMarin H. Kollef, MDSearch for more papers by this author, David T. Schachter, MDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-113-1-86_2 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptTo the Editors: Defecation syncope accounts for approximately 5% of all patients who present with syncope (1-4). Pulmonary embolism presenting with syncope is reported in 17% of patients (5). Pulmonary embolism as a cause of defecation syncope has not been well described in the medical literature. We report the cases of four patients with this entity who presented to us over a 12-month period.A 60-year-old man had a brain tumor surgically removed. On the sixteenth postoperative day after the completion of defecation, he lost consciousness, fell from the commode, and died. Autopsy showed a saddle embolus to be the...

Cardio-vascular events at defecation: Are they unavoidable?

Cardio-vascular events at defecation are to a considerable degree the consequence of an unnatural (for a human being) seating defecation posture on a common toilet bowl or bed pan. The excessive straining expressed in intensively repeated Valsalva Maneuvers is needed for emptying the bowels in sitting position. The Valsalva Maneuver adversely affecting the cardio-vascular system is the causative factor of defecation syncope and death. The cardio-vascular system of a healthy man withstands the intensive and repeated straining at defecation, while the compromised cardio-vascular system may fail resulting in syncope or even death. The squatting defecation posture is associated with reduced amounts of straining and may prevent many of these tragic cases.

Defecation Syncope

• To our knowledge, there is no previous clinical description in the literature of patients with defecation syncope. We evaluated 20 patients with this disorder who were a subgroup of a larger, prospective study of syncope, 13 women and seven men, with a mean age of 59 years. Eleven patients had had one episode and nine had experienced multiple episodes. Fourteen patients were recumbent before the urge to defecate, nine of these asleep. The diagnostic evaluation disclosed that two patients had gastrointestinal tract problems, three had cardiac diseases, and one had transient ischemic attacks. Three additional patients had marked orthostatic hypotension. No identifiable cause for defecation syncope was found in 11 patients, but new medical problems were noted in four of those patients. In follow-up at two years, syncope had recurred in ten patients, but the majority of recurrences were unassociated with defecation. Seven patients died during the follow-up period

Syncope in institutionalized elderly: The impact of multiple pathological conditions and situational stress

We conducted a prospective study to identify clinical factors which predispose institutionalized elderly to syncope. Over 3 years, 97 patients (mean age = 87 ± 6 y) developed syncope. On clinical evaluation, diagnoses fell into two categories: specific diseases including myocardial infarction (6%) and aortic stenosis (5%); and situational stresses including drug-induced hypotension (11%), postprandial syncope (8%), defecation syncope (7%) and postural hypotension (6%). Clinical variables derived from the history, physical examination, and laboratory evaluation of these patients were compared to those of 118 non-syncopal age-matched subjects evaluated in similar fashion. Multivariate analysis identified five independent statistically significant correlates of syncope: coronary artery disease ( p = 0.0003), functional impairment ( p = 0.006), postural blood pressure reduction ( p = 0.003), aortic stenosis ( p = 0.008), and insulin therapy ( p = 0.03). Syncope patients were more likely than controls to have two or more coexistent factors ( p = 0.0001). Syncope in institutionalized elderly is often due to the interaction of multiple coexistent clinical abnormalities which impair cardiovascular compensation for common situational stress.

Defaecation syncope.

Defaecation syncope is recorded in seven female and two male patients aged between 63 and 78 years seen over a period of nine years. The tendency for defaecation syncope to occur at night contrasts with the rarity of nocturnal defaecation in most old people. The close similarity with micturition syncope is noted.