Overlooked and Undertreated: National Shortfalls in Anorectal Evaluation for Gastroparesis-associated Constipation and Defecation Disorder

Background: Gastroparesis is a chronic motility disorder often accompanied by constipation. Defecation disorders are a common, treatable cause of refractory constipation; however, recognition and management in gastroparesis remain unclear. We assessed real-world rates of defecation disorder diagnosis and use of anorectal manometry (ARM) and pelvic floor therapies in gastroparesis with constipation, and related healthcare utilization outcomes. Methods: We conducted a retrospective cohort study using the TriNetX U.S. Collaborative Network (2000–2022). Adults with gastroparesis were identified, and rates of constipation, defecatory disorder diagnosis, ARM, biofeedback therapy (BFT), and pelvic floor physical therapy (PFT) were assessed. Among patients with gastroparesis and constipation, outcomes were compared between those with and without ARM after 1:1 propensity score matching. Outcomes included emergency department visits, hospitalizations, abdominal imaging, nasogastric tube (NGT) placement, gastrostomy tube placement, and total parenteral nutrition (TPN). Results: Among 295,016 patients with gastroparesis, 88,062 (29.9%) had constipation, but only 4,828 (1.4%) had a defecatory disorder diagnosis. Among those diagnosed, 1,291 (33.3%) underwent ARM and 147 (3.8%) received BFT. After matching, ARM was associated with lower odds of NGT placement (aOR 0.69, 95% CI 0.47–0.80), abdominal imaging (aOR 0.68, 95% CI 0.61–0.78), emergency department visits (aOR 0.80, 95% CI 0.78–0.85), and hospitalizations (aOR 0.58, 95% CI 0.44–0.76). No significant differences were observed in TPN or gastrostomy tube placement. Discussion: In this large, real-world cohort, defecatory disorders appear markedly under-recognized and pelvic floor–directed therapies underutilized in gastroparesis-associated constipation. Anorectal manometry was associated with reduced healthcare utilization, supporting earlier physiologic evaluation in refractory cases.