How Pelvic Floor Physical Therapy Helps Bowel Dysfunction

In Pelvic Floor Physical Therapy by Kim BuonomoLeave a Comment

By Kim Buonomo, DPT, PHRC Lexington

 

Did You Know….

 

  • Surveys have estimated that over four million people in the United States have frequent constipation. This is the most common digestive complaint in the United States and corresponds to a prevalence of about two percent. More Americans suffer from constipation than die from heart disease every year.
  • The impact of constipation on quality of life is significant and comparable with other common chronic conditions. In 92,000 annual hospitalizations, constipation was listed among the discharge diagnoses. 
  • About 75% of us will have at least one hemorrhoid at some point in our lives, and half of us will have had one before the age of 50. 
  • Among adults who are not in hospitals or nursing homes, between seven and 15 out of 100 have fecal incontinence, and it is suspected that this number may be under-reported. Fecal incontinence also occurs in about two out of 100 children.
  • Fecal incontinence severity scores showed significant improvement after patients completed biofeedback training. There were also improvements in quality of life scores including depression and embarrassment after biofeedback. 
  • In a study of biofeedback for pelvic floor dysfunction compared to laxatives (the usual treatment for constipation), nearly 80% of people undergoing biofeedback had improvement in constipation compared to 22% in the laxative group.
  • Pelvic floor rehabilitative techniques are effective and superior to pelvic floor exercises alone in patients with fecal incontinence who do not respond to conservative measures.

 

Pelvic Floor Dysfunction and Bowel Dysfunction

 

  • Symptoms patients experience include:
    • Straining with defecation
    • Fecal or flatulence incontinence
    • Abdominal bloating or distention
    • Fecal urgency or frequency
    • Pain or bleeding with bowel movements
    • Changes to width of stool (narrow, like being squeezed from a tube of toothpaste)
    • Excessive wiping after defecation
    • Irritation of the skin surrounding the anus
    • Upper GI symptoms including burping, reflux, difficulty swallowing
    • Emotional or social distress such as fear, embarrassment, social isolation, loss of self-esteem, anger, or depression

 

  • Associated diagnoses include:
    • Pelvic floor dyssynergia, paradoxical contraction
    • Rectocele (a kind of pelvic organ prolapse)
    • Rectal prolapse
    • Levator ani syndrome
    • Anal fissures or hemorrhoid
    • SIBO
    • Leaky gut syndrome
    • Irritable Bowel Syndrome 
    • Inflammatory Bowel Disease (Crohn’s disease, Ulcerative Colitis, etc.)
    • Anal or rectal cancer
    • Dehydration or nutritional deficits
    • Constipation
    • Diarrhea
    • Urinary Incontinence
    • Pudendal Neuralgia
    • Type 2 Diabetes

 

How does someone develop bowel dysfunction?  

There are many different kinds of bowel dysfunction so there are many potential things that can cause it. Some of these are listed below, but this is by no means an exhaustive list. 

 

  • Constipation can be induced by different kinds of medications, including: 
    • Oral contraceptives
    • Opioids
    • Iron supplements
    • NSAIDs
    • Antihistamines like benadryl
    • Tricyclic antidepressants 
    • Some medications for urinary incontinence
    • Selective serotonin antagonists, which can be used to treat nausea
  • While most people know the importance of adequate water intake, up to 75 percent of the American population are functioning in a chronic state of dehydration. When your body doesn’t have enough water, this can lead to firmer stools, which are more difficult to pass and cause more straining, which can lead to bowel dysfunction and even pudendal neuralgia. 
  • When your body repeatedly pushes ineffectively over the course of months or years, it can lose sensitivity to urge. Without voiding on a regular basis, your bowel wall can become overdistended, which can reduce its ability to contract effectively to propel stool out, leading to a vicious cycle of bowel dysfunction. 
  • Certain surgeries can trigger bowel and pelvic floor dysfunction, including surgery to remove cancer in the anus or rectum, remove hemorrhoids, or to treat anal abscesses and fistulas. 
  • Childbirth can also trigger bowel dysfunction. The chances are greater if:
  • Your baby was large
  • Forceps or a vacuum were used to help deliver your baby
  • The doctor made a cut, called an episiotomy, in your vaginal area to prevent the baby’s head from tearing your vagina during birth
  • You had a significant tear in the perineum while giving birth
  • When the nerves that control the pelvic floor muscles, bowel, or bladder are damaged, we can see dysfunction. Common neuropathic contributors to dysfunction include brain injuries, spinal cord injuries, multiple sclerosis, spina bifida, and neurogenic bowel or bladder. 
  • Hormonal changes can affect bowel function. In one study, thirty-eight percent of postmenopausal women reported altered bowel function, in contrast to fourteen percent of premenopausal women. And let’s not forget: Why Your Period Makes You Poop!  

 

  • Diagnostic Challenges
    • One of the biggest challenges of diagnosing bowel dysfunction is that people often don’t feel comfortable talking about it. This leads to a lack of awareness regarding what is “normal.” Did you know that it can be normal to poop as little as once every three days or as often as three times a day? Did you know that straining to get out a bowel movement is NOT normal? Another challenge is that people often aren’t aware that something can be done to address these issues so they suffer in silence. This is why we at PHRC write blog articles, just like this one! Because we know how important it is to have reliable, accurate medical information, and how difficult it is to find good information about pelvic floor conditions. 

 

What is Pelvic Floor Physical Therapy for Bowel Dysfunction and how can it help?

The bowels are a complex system and waste removal is managed by the muscles of the pelvic floor. Your pelvic floor physical therapist is an expert at understanding these mechanics and helping you keep your pelvic floor muscles working in tip-top shape. We also work with your gastroenterologist, colorectal surgeon, nutritionist (like our Integrative Functional Nutritionist, Jandra) and any other specialists that you may be seeing in order to provide the best program for you, considering any contributing factors that you have to your symptoms in addition to the muscles themselves. Keep in mind that since there are many potential causes of bowel dysfunction, there can be many different kinds of treatment that may help you specifically. For the most effective and individualized program, you should schedule an evaluation with one of our physical therapists. Some of the tools we use include:

 

  • Biofeedback training 

Biofeedback, or motor control training helps teach you how to effectively engage and relax your pelvic floor muscles. Learning how to use your pelvic floor muscles effectively is important in helping you control your bowels. You can contract to hold in a bowel movement, and relax to void without straining. While there are other tools like the Elvie that can help you learn, we find manual cues more effective. Your therapist will work one on one with you using different techniques to get you to understand how to effectively contract and relax your pelvic floor muscles. Biofeedback has been shown to be a safe and cost-effective tool for managing mild-to-moderate fecal incontinence associated with traumatic sphincter injury. If the pelvic floor muscles are super tight or if they are not able to appropriately relax down, it may be difficult to easily or completely empty the bladder or bowels. 

 

  • Balloon Training

A common tool that assists biofeedback training for bowel dysfunction involves the use of a small balloon inserted into the rectum. Inflating the balloon simulates the pressure of an impending bowel movement. Patients are taught to contract their pelvic floor muscles when they perceive balloon distention to hold the balloon in (to reduce fecal incontinence), and can be taught to relax in order to void the balloon out (to reduce constipation or straining). This kind of biofeedback therapy often improves rectal sensation and may enhance coordination between perception of rectal distention (improving an appropriate urge) and external sphincter contraction (ability to hold that urge) in patients with reduced rectal sensation. It has been studied that some types of patients have a high likelihood of improving their symptoms of disordered defecation when they are taught to relax their pelvic floor muscles with simulated defecation.

 

  • Myofascial work including abdominal massage

Restrictions of muscles and connective tissue throughout the pelvic girdle (anything from your belly button to your knees) can influence your bowel function. One study even showed that patients with chronic functional constipation had significantly more trigger points compared to their non-constipated counterparts. The people with constipation in this study also had a higher consumption of fat and dairy products and were less physically active than non-constipated participants. 

 

Internal manual therapy can also help address restricted rectal tissues. The rectum should be able to expand in order to accommodate stool. When there is damage to those tissues from things like radiation treatment for cancer, history of bowel surgeries, or things like perianal Crohn’s disease, the rectum can lose some of that flexibility. But we can often improve it with manual therapy. Sometimes working with dilators anally is also appropriate. Your therapist can teach you how to do this, if it is right for you. 

 

  • Diaphragmatic Breathing

Did you know that your diaphragm and your pelvic floor are linked like a piston? It’s true! As I mentioned in a previous article, 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). Our blog has a ton of great articles on everything from understanding pelvic floor movement to learning how to poop the right way and all of our therapists can help teach you how to breathe effectively. 

  • Education

If you haven’t figured it out yet, pelvic floor physical therapists know a lot about poop. And knowledge is power! Your physical therapist can teach you everything you never thought you needed to know about pooping. Some of these topics include:

  • Everything we talked about in this article! 
    • Diaphragmatic Breathing
    • Abdominal Massage
    • Balloon Manometry training
    • Dietary recommendations (appropriate water and fiber intake)
    • My favorite pooping aid, the squatty potty. 
    • Biofeedback training: How to use your pelvic floor muscles effectively 
  • Other products that can help with voiding mechanics, such as Femmeze, which helps patients to manage rectocele. 
  • Stress management- with increased stress comes increased cortisol levels, putting your body into fight or flight mode and out of rest and digest mode. This can negatively influence bowel health and pelvic floor function. Meditation and mindfulness practices can help improve your body’s homeostasis and keep everything functioning well.
  • Urge retraining- By ignoring the urge to poop on a regular basis, you may be creating a vicious cycle that can lead to chronic constipation. If you repeatedly ignore the urge to poop, your body’s intrinsic poop triggers do not get triggered as easily because the rectum is now less sensitive to the incoming signals. You’ve basically trained your body to “tune out” the incoming signal to void. We can teach you how to tune back in. 

 

Success Stories

 

Recovery After Rectocele Repair and How Pelvic Floor Physical Therapy Helps

 

Additional Resources

References

Sonnenberg A, Koch TR. Epidemiology of constipation in the United States. Dis Colon Rectum. 1989 Jan;32(1):1-8. doi: 10.1007/BF02554713. PMID: 2910654.

Leite FR, Lima MJ, Lacerda-Filho A. Early functional results of biofeedback and its impact on quality of life of patients with anal incontinence. Arq Gastroenterol. 2013;50(3):163–169.

 

Chiarioni G, Whitehead WE, Pezza V, Morelli A, Bassotti G. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology. 2006 Mar;130(3):657-64. doi: 10.1053/j.gastro.2005.11.014. PMID: 16530506.

 

Belsey J, Greenfield S, Candy D, Geraint M. Systematic review: impact of constipation on quality of life in adults and children. Alimentary Pharmacology and Therapeutics. 2010 April. https://doi.org/10.1111/j.1365-2036.2010.04273.x Accessed at https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2036.2010.04273.x on Feb 16, 2021. 

 

Birimoglu Okuyan C, Bilgili N. Effect of abdominal massage on constipation and quality of life in older adults: A randomized controlled trial. Complement Ther Med. 2019 Dec;47:102219. doi: 10.1016/j.ctim.2019.102219. Epub 2019 Oct 16. PMID: 31780015. 

http://www.cdc.gov/heartdisease/facts.htm

J Pediatr Gastroenterol Nutr. 2009 Mar;48(3):294-8. Bowel habits and toilet training in a diverse population of children. Wald ER1, Di Lorenzo C, Cipriani L, Colborn DK, Burgers R, Wald A.

Herman and Wallace inc. Pelvic Rehabilitation Institute. Pelvic Floor Level 2A. www.hermanwallace.com

 

National Institute of Diabetes and Digestive  and Kidney Diseases https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/hemorrhoids/Pages/facts.aspx

 

Health Line: Hemorrhoids http://www.healthline.com/health/hemorrhoids#Overview1

 

https://www.niddk.nih.gov/health-information/digestive-diseases/bowel-control-problems-fecal-incontinence/definition-facts#:~:text=Medical%20experts%20consider%20fecal%20incontinence%20a%20common%20problem%2C,in%20about%202%20out%20of%20100%20children.%204 

 

Whitehead WE, Palsson OS, Simren M. Treating fecal incontinence: an unmet need in primary care medicine. North Carolina Medical Journal. 2016;77(3):211–215.

 

Bharucha AE, Dunivan G, Goode PS, et al. Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. The American Journal of Gastroenterology. 2015;110(1):127–136.

 

https://www.niddk.nih.gov/health-information/digestive-diseases/bowel-control-problems-fecal-incontinence/symptoms-causes

 

Leite FR, Lima MJ, Lacerda-Filho A. Early functional results of biofeedback and its impact on quality of life of patients with anal incontinence. Arq Gastroenterol. 2013 Jul-Sep;50(3):163-9. doi: 10.1590/S0004-28032013000200029. PMID: 24322185.

 

The Big 8 Constipation-Causing Medications. Goodrx.com. https://www.goodrx.com/blog/the-big-8-constipation-causing-medications/

 

75% of Americans May Suffer From Chronic Dehydration, According to Doctors. https://www.medicaldaily.com/75-americans-may-suffer-chronic-dehydration-according-doctors-247393 

 

Atefe Ashrafi, Amir Massoud Arab, Saeed Abdi, Mohammad Reza Nourbakhsh.

The association between myofascial trigger points and the incidence of chronic functional constipation. Journal of Bodywork and Movement Therapies. 2021;26:201-206.

https://doi.org/10.1016/j.jbmt.2020.12.004. (https://www.sciencedirect.com/science/article/pii/S1360859220302412)

 

Dr. George Triadafilopoulos MD and DSc and FACP and FACG , Mary Ann Finlayson RN & Catherine Grellet MD (1998) Bowel Dysfunction in Postmenopausal Women, Women & Health, 27:4, 55-66, DOI: 10.1300/J013v27n04_04 

 

Wald, A., Bharucha, A., Cosman, B., Whitehead, W. (2014). ACG Clinical Guideline: Management of Benign Anorectal Disorders. Am J Gastroenterol, 109, 1141–1157.

 

 

______________________________________________________________________________________________________________________________________

Are you unable to come see us in person? We offer virtual physical therapy appointments too!

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. 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

PHRC is also offering individualized movement sessions, hosted by Karah Charette, DPT. Karah is a pelvic floor physical therapist at the Berkeley and San Francisco locations. She is certified in classical mat and reformer Pilates, as well as a registered 200 hour Ashtanga Vinyasa yoga teacher. There are 30 min and 60 min sessions options where you can: (1) Consult on what type of Pilates or yoga class would be appropriate to participate in (2) Review ways to modify poses to fit your individual needs and (3) Create a synthesis of your home exercise program into a movement flow. To schedule a 1-on-1 appointment call us at (510) 922-9836

Do you enjoy or blog and want more content from PHRC? Please head over to social media!

Like us on Facebook,

Subscribe to our YouTube Channel

and follow us on Twitter, Instagram, Tik Tok and Pinterest!

Leave a Comment