Q&A: Understanding Bowel Dysfunction

By Stephanie A. Prendergast, DPT, MPT, Cofounder, PHRC Los Angeles

A few weeks ago we published a blog about How Pelvic Floor Physical Therapy Helps Bowel Dysfunction. In it we discussed how one might develop a bowel dysfunction, symptoms, associated diagnoses and how pelvic floor PT can help in recovery. This week, we asked our social media audience to submit their own questions about bowel dysfunction. Below are the most commonly asked questions and their answers!

Q: How can my pelvic floor affect my bowel movement?

A: The pelvic floor muscles keep stool in when we need to and are responsible for letting it out when we decide the time is right. There are a number of reflexive and voluntary movements that allow both to happen! Ti simply slightly we included one example below.

In order to have a bowel movement, the pressure of the stool in your rectum should be greater than the pressure in your pelvic floor. This is why your pelvic floor has the ability to contract and relax, so that you can contract and maintain continence when you want to, and relax to allow passage of stool when you want to. At PHRC, we often see patients who have trouble relaxing their pelvic floor muscles. This results in things like straining, incomplete emptying, and holding your breath when you have a bowel movement, which all reinforce those bad habits. Pushing against a contracted muscle is like pushing against a closed door. Nothing will get through! An indepth blog about the anatomy & physiology of our anal sphincter, is available on our website to further your self-education!

Q: How can Vulvodynia and constipation be related?

A: Studies show that people with constipation are more likely to develop pelvic floor dysfunction and pelvic pain because repetitive straining can lead to an overuse injury of the pelvic floor muscles and/or pudendal nerve irritation, both of which can cause pelvic pain, including vulvodynia. Medications that are therapeutic for vulvodynia symptoms, such as the tricyclic antidepressants, can cause constipation. Pelvic floor PT can help with all of the above!

Q: When I pass, it’s like pebbles and has been since October. I’ve tried every remedy, what is next?

A: Multiple factors can result in changes in the shape of your stool. Two pelvic floor factors include the ability to relax the pelvic floor muscles to initiate a bowel movement and the ability of the pelvic floor muscles to remain relaxed to allow all of the stool to empty. Many times people have a problem in one of these areas, or both, and have difficulty with complete emptying and passing a more formed stool. Factors such as rectoceles can also play a role. “Pebble Stool” is a symptom that there is something going on with the pelvic floor muscles and can be effectively evaluated by a pelvic floor physical therapist.

Q: Is taking laxatives once a week bad if you struggle to have bowel movements?

A: Struggling with bowel movements is a symptom. Sometimes the issues with bowel movements can be due to GI issues, sometimes pelvic floor issues, sometimes both. While laxatives can help we recommend getting to the root cause of the issues and correcting them. When used correctly laxatives are not ‘bad’ and can be part of someone’s health routine.

Q: How can we help our constipation?

A: Constipation plays a major role in pelvic pain. It can cause existing pain to flare or can be a contributing factor responsible for the pelvic pain to begin with. Whatever its cause, it is essential to put an end to constipation. So, what can you do if you suffer with constipation? This is going to depend on what type of constipation you have. We have an entire blog dedicated to helping you, Put Your Constipation Woes Behind You (quiet literally!).

Q: Can IBS contribute to endometriosis?

A: In those with endometriosis, it is estimated that 90% have IBS, or at least GI symptoms, the most common being bloating, followed by changes in bowel movements (diarrhea, constipation, or both).

THINKING OUTSIDE THE GUT: Could Endometriosis be the culprit behind your Constipation or Bloating?

Q: I know having to urinate in the middle of the night is bad, what about bowel urges?

A: Urinating in the middle of the night is not necessarily ‘bad’, but it can be a symptom of PFD. Under normal circumstances we do not get bowel urges at night on a regular basis. If this is happening we recommend seeing a medical provider for an evaluation.

Q: Why does your period make you poop?

A: You have a shift in your hormones during your period, just before your period, your estrogen and progesterone drop to stimulate contraction of your uterus to shed the lining if pregnancy does not occur. As you start menstruating (bleeding), your estrogen begins to rise; at the same time, your uterus is driven to contract by the release of prostaglandins (lipids or fats that are hormone-like). These also can act on your GI tract causing an increase in contraction or motility. Contractions of the bowel (also known as peristalsis) are important and are important for what we call GI motility. Those with slow motility may report issues with constipation and those with fast motility tend towards loose stool or diarrhea. So an overall increase in prostaglandins, necessary for uterine contractions, can cause one to also have increased bowel movements during this time. For some this means relief from constipation, for others this is too much and causes diarrhea or loose stools during their period.

We have an entire blog dedicated to this question! Along with a 3 part series about Period Health (Everything you should have learned in 6th grade, but didn’t).

Q: Do you recommend using a squatty potty?

A: Yes! A not-so-fun fact is the height of our toilets actually results in less than optimal pelvic floor biomechanics. A squatty potty raises our knees higher than our hips which allows better pelvic floor relaxation, assisting with evacuation of stool.

Q: I am eating a high fiber diet and drinking all the water, but still constipated. What do I do? See a pelvic floor PT or GI referral?

A: Multiple providers can help with constipation. Going to the bathroom is more complicated than it seems! Integrated health providers, GI doctors, pelvic floor physical therapists, nutritionists and acupuncturists can all be helpful.

Q: What can I do to reverse change in bowel habits due to too many antibiotics last year?

A: Antibiotics can result in changes to the gut and this can lead to bloating, pain and constipation or diarrhea. It is best to get to the root cause of the problem, stool tests such as the GI Effects test can be helpful to help you better understand what is going on in your gut and your provider can help you figure out what to do about it.

Q: How to tell if it’s your pelvic floor or just your diet?

A: In general, if you have difficulty with the actual execution of a bowel movement, meaning you have to strain to evacuate you may have a pelvic floor problem. People often have diet and pelvic floor problems together. If you have bowel trouble and pelvic pain or urinary dysfunction chances are there is pelvic floor involvement too.

Thank you to all that contributed to the Q&A! If you didn’t see your question answered here, please drop a comment below or follow us on social media to be the first to know when we do another Q&A!

Additional Resources:

Anatomy and Education

Pooping Mechanics

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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

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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.