By: Kim Buonomo, DPT, Lexington
Don’t hold your breath!
What do you do when you poo? It sounds like something from Dr. Seuss. It’s a strange question, and some of our patients don’t know how to answer it. Next time you have a bowel movement, try to think about the specifics. How are your feet positioned? Are they flat on the floor? Propped up on a stool (AHEM! Squatty potty!)? Or leaning against the bathroom sink for support? What are your abdominals doing? Are you curled up in a ball over your hips? Do you rock back and forth to stimulate some movement down there? Do you sit and play angry birds on your phone and lose track of time? (We’re all guilty of that from time to time!) And one last question… are you breathing?
Often, when I ask my patients to “pretend to have a bowel movement” in the clinic, they immediately hold their breath and strain. This is a major problem when you are trying to poo. As we remember from Katie’s stellar graphic in this post about the diaphragm and the pelvic floor, the two are linked like a piston. So if you actively stop your diaphragm from moving (AKA hold your breath), then you are effectively stopping your pelvic floor muscles from relaxing (AKA allowing you to poop). Stephanie also covered the right way to poop in this excellent article!
Holding your breath translates to more than just constipation and hypertonic pelvic floor muscles. Another concern here is something called defecation syncope. It’s been discussed in local news outlets and Men’s Health and basically it is when you hold your breath and strain so hard that you pass out on the toilet. We’ve all heard people joke about holding their breath so long that their face turns purple. When you hold your breath and use pressure to have a bowel movement, you are doing something called the Valsalva maneuver. We talked about Valsalva as it relates to exercise here. From that article, “the Valsalva maneuver is described as taking a breath and forcefully exhaling against a closed mouth, glottis (throat), and nose–and is often utilized when performing a task where we need abdominal and spine stiffness to help create more force. Baessler K. et al, 2017 examined the effects of the Valsalva maneuver versus straining on the bladder neck and the puborectalis pelvic floor muscle on continent and incontinent women. They concluded that valsalva and straining are two different tasks, and that the pelvic floor is stiffer when utilizing valsalva techniques.”
During a Valsalva Maneuver, the diaphragm is forced downwards by the increased pressure inside the thoracic cavity. If you are straining, but breathing, this should not happen. When you Valsalva on the toilet, you are trying to use that pressure to “cheat the system,” so you can poop without totally relaxing your pelvic floor muscles. There’s a couple problems with that! Problem one: it sends a message to your pelvic floor muscles that even though they were contracting, whatever they were doing was not enough to maintain continence. Of course, this was a conscious choice by your brain, but your body can get confused by that. This is one of the factors that can contribute to hypertonic (high tone) pelvic floor dysfunction, because you are telling these muscles they need to contract harder to maintain continence. This may also contribute to developing a pelvic organ prolapse. And problem two: all that built up pressure restricts blood flow to the heart and can actually cause you to pass out. Some studies have shown that passing out under these circumstances is not life threatening, but if you lose consciousness when alone in the bathroom it may take longer for someone to realize you need help, which may contribute to negative outcomes. So while it may not be life threatening, breathe easy; so you can pass stool, not pass out.
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Are you unable to come see us in person? We offer virtual appointments!
Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. The cost for this service is $85.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
References
Herman and Wallace inc. Pelvic Rehabilitation Institute. Bowel Function, Dysfunction and Pathology. www.hermanwallace.com
Men’s Health. Can you die by pooping? (2016). [online] Available at: https://www.menshealth.com/health/a19548528/death-by-pooping/
Sitting toilets: The secret very few know today. The Valsalva Maneuver – A Side Effect of Using Sitting Toilets. (2006). [online] Available at: https://www.toilet-related-ailments.com/valsalva-maneuver.html
CTV. Fainting on the toilet is a real medical problem – but doctors say it can be avoided. (2018). [online] Available at: https://www.ctvnews.ca/health/fainting-on-the-toilet-is-a-real-medical-problem-but-doctors-say-it-can-be-avoided-1.3895702
Mayo Clinic. Vasovagal syncope. (2018). [online] Available at: https://www.mayoclinic.org/diseases-conditions/vasovagal-syncope/symptoms-causes/syc-20350527
Bae MH, Kang JK, Kim NY, et al. Clinical Characteristics of Defecation and Micturition Syncope Compared with Common Vasovagal Syncope. Pacing & Clinical Electrophysiology. 2012;35(3):341-347. doi:10.1111/j.1540-8159.2011.03290.
Brophy C, Evans L, Sumpio B. Defecation Syncope Secondary to Functional Inferior Vena Caval Obstruction During a Valsalva Maneuver. Annals of Vascular Surgery. 1993;7(4):374-377.
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
I am 80 years old and wondering why I had to learn about rocking slowly and straining on the way up aids (greatly) elimination BY ACCIDENT!
Everyone should be taught this as a child!