Constipation

Ah, poop! Oh crap! Shit! When did those phrases come to signify something negative? If you have constipation, a poop, crap, or shit can literally lighten your day.

Hi, Bestie—if you didn’t guess it, we’re talking about poop today…or rather a lack thereof. Let’s talk all things constipation and how this relates to the pelvic floor.

What is constipation?

You probably know the bare basics of constipation. It’s when you can’t poop. But what is medically deemed to be constipation? If you miss a day or two of regular pooping, are you constipated? It is considered “normal” to have as many as three bowel movements (BMs) per day to as few as three bowel movements per week. More than three BMs per day would fall on the side of diarrhea, while fewer than three BMs per week would constitute constipation. Even if you have slightly fewer than three BMs per week (say, two), this can still be considered within the “normal” range if it is not uncomfortable and is your regular rhythm.

Stool is further examined on a scale of hardness. This is called the Bristol Stool Chart (1) (see image). The scale runs from 1 (very hard) to 7 (entirely liquid). Stool is considered to have “normal consistency” if it is graded as a 3, 4 or 5 on the Bristol Stool Chart (1). The softer the stool, often the quicker it transits through the intestines, and therefore the higher frequency of defecation. Contrastingly, the harder the stool, the slower it transits through the intestines and the lower the frequency of defecation. This means, harder stool is more likely to be associated with constipation.

Bristol Stool Chart (1)

There are more specific criteria relating to the different types of constipation experienced, including functional constipation (FC), constipation relating to Irritable Bowel Syndrome (IBS-C), Opioid-induced constipation (OIC), and bowel obstruction. We’ll talk about these in detail at a later date.

What are the symptoms of constipation?

This may seem obvious—not pooping—but there are other symptoms associated with constipation. These could include discomfort in the lower abdomen, abdominal bloating, decreased energy, decreased appetite, or discomfort in the pelvic region. Straining to pass hard stool could also result in hemorrhoids or anal fissures.  

What causes constipation? 

Constipation is interesting because it can be experienced at any time in life, and affects all types of people. Young children can experience constipation, as can adults, as can the elderly. People with neurologic disorders can experience constipation, as can pregnant folks. Constipation really doesn’t discriminate, and because of this there isn’t always a clear cause of someone’s constipation. It is often due to many factors occurring at once. Your therapist or other healthcare professional can work with you to get to the core of the issue at hand in order to improve your symptoms.

A potential cause of constipation includes posterior vaginal prolapse. This occurs when the rectum or small bowel pushes into the back wall of the vagina, creating a little pocket (see image below). Stool can become trapped in this pocket, and leave you feeling like you are unable to fully empty yourself during defecation.

Another potential cause of constipation is poor inability to relax the pelvic floor muscles. As we know, the pelvic floor muscles are in charge of providing support to the organs of the pelvic cavity, including the bladder, uterus, and rectum. The pelvic floor muscles lift up during coughing, sneezing, or exercising to aid in continence and help you to avoid urinary or fecal leakage. However, the pelvic floor muscles need to lengthen and lower during urination and defecation. This movement of the pelvic floor muscles helps to reduce pressure on the structures of the pelvis and allow urine and stool to move out. If the pelvic floor is tight or tensed, it becomes difficult to pass stool. In fact, some folks experience pelvic floor contraction (lifting) while trying to poop. This is the opposite of what we want to happen and it is called dyssnergic defecation. 

Constipation can also stem from poor lifestyle habits. Lack of activity, poor diet, and decreased hydration can all contribute to difficulty passing stool.

Pelvic PT for constipation:

In your initial visit with your therapist, they should ask you the following questions:

-       How often do you have BMs?

-       What is your stool consistency?

-       What your stool color?

-       Do you have pain with passing stool?

-       Do you feel that you have to strain to pass stool?

-       Do you ever lose stool or gas without wanting to?

-       What position do you defecate in? (ie do you use a stool, feet flat on the floor, squat, etc)

-       How much fiber are you eating in your diet?

-       How much fluid are you typically drinking per day?

-       What do you do for exercise?

-       What medications or supplements do you take?

If your constipation is due to a posterior prolapse, your therapist can suggest ways to reduce the prolapse and empty more completely. This might include position changes on the toilet, or use of external support to the tissues of the pelvis to improve the pathway of the stool.

If your constipation is due to tightness or poor pelvic floor relaxation, your therapist will work with you on improving your overall pelvic floor muscle motion. This could include breathing techniques, hip stretches, use of a dilator, pelvic floor lengthening exercises, biofeedback, and more.

If your constipation is related to poor lifestyle habits, your therapist will provide you with advice on how to improve these habits. This includes drinking the recommended amount of fluid each day, increasing fiber in the diet, potentially adding magnesium to the diet, and increasing physical activity throughout the day. You may also be referred to a registered dietitian if diet seems to be playing a large role in the symptoms of constipation.

Regardless of the cause of your constipation, your therapist may provide you with some basic tools that can help symptoms. These include positioning during defecation (ie using a stool under your feet), daily colon massage, increasing physical activity, drinking fluid, increasing fiber, and more.

Take Aways:

If you have constipation, whether it just started in the past couple of weeks, or you have been dealing with it since childhood, there are tons of options for improving your symptoms. Your pelvic health therapist should be well trained to help you combat your constipation. They will help you to get to the root of the problem and find solutions specific to you. Remember: in pelvic PT, really no topic is off limits. We are happy to chat about poop! Let’s beat constipation together and turn “oh, crap…” into “oh, crap!” (please note, this doesn’t really work unless you’re also using the right tone of voice for each version—I think you get it).

XOXO,

Your Pelvic Bestie

References:

1.     Lewis, S. J., & Heaton, K. W. (1997). Stool form scale as a useful guide to intestinal transit time. Scandinavian Journal of Gastroenterology, 32(9), 920-924

 *The information contained in this article is for educational and informational purposes only and is not intended as health or medical advice. Always consult a qualified health provider regarding any questions you may have about a medical condition or health objectives.