Constipation Treatment
Oh, crap, we’re talking about constipation again today! Hey there, Bestie, and welcome back to another constipation chat. If you missed our last one, catch up here. Last time, we talked about the bare basics of constipation. Today, I wanted to discuss some of the common treatments for constipation and how your pelvic floor physical therapist can help improve your constipation symptoms.
First off, let’s review: what the bean even counts as constipation? It is considered “normal” to have as many as three bowel movements (BMs) per day to as few as three per week. Fewer than three BMs per week, typically signifies 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 it is your regular rhythm.
What we haven’t talked about yet, are the other symptoms that can signify constipation. And to be clear, when I say “constipation,” I’m talking about functional constipation (FC). FC is chronic constipation that is not due to secondary causes, such as medical conditions or medications. For example, opioid-induced constipation is constipation related to opioid medication. We’ll touch on that at a later date but for now, we’re just talking classic constipation!
So, what are the other criteria that help us to diagnose FC? For these, we turn to a set of guidelines termed the “Rome IV Criteria” (1). In order to be diagnosed with FC, one would have to meet two or more of the following criteria (1):
- Straining during more than 25% of defecations
- Lumpy or hard stools (Bristol Stool Form 1-2 in more than 25% of defecations
- Sensation of incomplete evacuation in more than 25% of defecations
- Sensation of rectum blockage in 25% of defecations
- Manual maneuvers to facilitate more than 25% of defecations
- Fewer than 3 BMs per week
- Loose stools are rare without the use of laxatives
These criteria should be fulfilled for three months with first symptoms starting six months prior in order to be diagnosed with FC.
What treatments for FC are available in pelvic floor physical therapy?
One of the most important things you can gain from talking with your pelvic health therapist about your constipation is education and information. Your PT might talk with you about any of the following:
- Diet: One of the biggest contributors to constipation is fiber deficiency (3). It is recommended that adults consume 25-30 grams of fiber per day, but a lot of folks have a difficult time reaching that amount of fiber in their diet (4). Your therapist might recommend integration of high fiber foods into your diet including beans, legumes, whole grains, fruits, and veggies. They might also recommend taking an over-the-counter fiber supplement. I personally recommend the Metamucil fiber capsules. They’re less gross than the powder you mix into your water and may be a good solution if you have trouble adding fiber to your diet. Start by taking one or two capsules and see how your body reacts. If you don't notice changes, add one capsule at a time until you reach your ideal poop consistency and frequency. A dose is up to five capsules, but I would start as low as possible and gradually increase as needed. Fiber has been shown to be effective for mild to moderate constipation (5).
- Exercise: Regular physical activity has been shown to improve pooping patterns (6). This is particularly true in middle-aged folks and those who are inactive. In people that exercise to a high level regularly, increasing exercise may not help with constipation.
- Routine: Believe it or not, the gastrointestinal (GI) tract has a circadian rhythm (7). This means it appreciates being on a set routine. This may be part of the reason constipation tends to flare up when traveling or when in a different environment than usual. Maintaining a regular routine of sleep and wake times as well as morning food and fluid intake can help improve constipation. Make sure to respond to the “call to stool” and defecate when your body is ready, rather than delaying the urge.
- Drinking Fluids: Fluid intake is essential to regular BMs. If you are struggling with constipation, be sure you are drinking the recommended amount of fluid for your body weight (half an ounce for every pound of body weight). Dehydration makes stool harder and more difficult to pass. Also, hot drinks (tea, coffee, caffeine) can help stimulate the bowels, but too much caffeine can have a negative effect on stool consistency.
- Colon Massage: Colon massage is a way to help the stool move through the colon. There are a bunch of different possible techniques, but my personal favorite is the ILU technique. Start by completing the “I” which is massage from left ribs to left hip. Next, create the “L” moving from right ribs to left ribs to left hip. Finally, complete the “U” by moving from right hip to right ribs to left ribs to left hip. You can work on this colon massage for 5-10 minutes at a time and it can be done lying down or in a seated position.
- Toileting Posture: Your therapist should teach you the ideal way to sit during defecation. You should have a flat back, with feet flat on a stool and knees raised above the hips. You want your legs to be relaxed. This posture allows for the pelvic floor muscles (PFMs) to relax and this makes it easier for stool to pass.
Toileting Posture
- Understanding how to push: During a BM, it is important to push without straining. This means you should keep the back of your throat open while pushing, rather than closing your throat and forcing air down into your abdomen. In other words, avoid using the Valsalva maneuver. It can help to focus on exhalation and contracting your abdominal muscles with each push. Also, it is important that the PFMs are relaxed during pushing. Your therapist can help you learn how to relax your PFMs in order to make stool passage easier.
During your therapy sessions, your therapist might also incorporate some of the following:
- Biofeedback: As we’ve discussed before, constipation can be the result of PFM tension. When the PFMs have trouble relaxing and lengthening, this makes it harder for stool to pass. Biofeedback can be used for “downtraining” the PFMs, or training them to lengthen more naturally. In fact, in patients with constipation due to dyssnergic defecation, a majority of patients saw improvement following biofeedback treatment (8).
- Transcutaneous Electrical Nerve Stimulation (TENS): This is less commonly used in physical therapy, but there is research to support its use (9). The use of a TENS machine has been shown to improve frequency of BMs. Your provider may have a TENS machine at their office that you can use during treatment sessions, but you may also want to buy your own TENS machine (for only about $30), have your provider show you how to set it up, and use it daily at home.
As you can see, there are tons of treatments for FC, and I only mentioned the basics! If you have been suffering from constipation, chat with your healthcare team to see what options you might have. It can be so debilitating and uncomfortable and you deserve to poop!
Happy crapping!
XOXO,
Your Pelvic Bestie
References:
1. Imran Aziz, William E Whitehead, Olafur S Palsson, Hans Törnblom & Magnus Simrén (2020) An approach to the diagnosis and management of Rome IV functional disorders of chronic constipation, Expert Review of Gastroenterology & Hepatology, 14:1, 39-46
2. 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.
3. Rao, S. S., Seaton, K., et. al (2007). Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clinical Gastroenterology and Hepatology, 5 (3), 331– 338.
4. Eswaran, S., Muir, J., & Chey, W. D. (2013). Fiber and functional gastrointestinal disorders. American Journal of Gastroenterology, 108 (5), 718– 727. doi: 10.1038/ajg.2013.63
5. Portalatin, M., & Winstead, N. (2012). Medical management of constipation. Clinics in Colon and Rectal Surgery, 25 (1), 12– 19.
6. De Schryver, A. M., Keulemans, Y. C., Peters, H. P., Akkermans, L. M., Smout, A. J., De Vries, W. R., & Van Berge-Henegouwen, G. P. (2005). Effects of regular physical activity on defecation pattern in middle-aged patients complaining of chronic constipation. Scandinavian Journal of Gastroenterology, 40( 4), 422– 429.
7. Andrews, C. N., & Storr, M. (2011). The pathophysiology of chronic constipation. Canadian Journal of Gastroenterology and Hepatology, 25 (Suppl B), 16B– 21B.
8. Lee, H. J., Jung, K. W., & Myung, S. J. (2013). Technique of functional and motility test: How to perform biofeedback for constipation and fecal incontinence. Journal of Neurogastroenterology and Motility, 19 (4), 532– 537.
9. Zhang, N., Huang, Z., Xu, F., Xu, Y., Chen, J., Yin, J.,...Chen, J. D. (2014). Transcutaneous neuromodulation at posterior tibial nerve and ST36 for chronic constipation. Evidence-Based Complementary and Alternative Medicine, 2014
*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.
