From NPR1 to Men’s Health 2, the right way to poop has become an increasingly hot topic for discussion. In fact “Put Your Constipation Woes Behind You,” is consistently our highest ranking blog every week. Oh, and if you haven’t seen the knight and unicorn bestowing the benefits of the squatty potty3, go watch it now! So, why is poop such a widely discussed topic and what really is the right way to evacuate?
According to a study by Shahid et al in 2012)4, “constipation affects up to 28% of Americans.” More Americans suffer from constipation than die from heart disease every year.5 While constipation may not be an imminent cause of death, you don’t need a medical degree to realize that if you don’t take out your trash regularly, the house is going to stink. And without doing a PubMed or google search for the prevalence of constipation in America, a walk into your local drug store will tell you that many Americans need laxatives to help them poop. Now we see why this is such a hot topic!
The constipation epidemic is significantly prevalent among children as well as adults. A study by Wald et al gathered data on 1,142 children and found that approximately 10% of children ages 5-8 suffered from constipation6. If the parents don’t know how to poop properly, how are they supposed to train their kids?
To understand how to solve a problem, it’s helpful to start at the source. So let’s go back to how constipation is defined! According to the Mayo Clinic7, “constipation can be defined as having less than three bowel movements per week or difficulty passing stool that can lead to excessive straining.” Constipation can be due to a blockage, nervous or musculoskeletal system dysfunction or hormonal imbalance.
And now for the solutions.
The Mayo Clinic suggests increasing your fiber, adding a laxative, exercising regularly, prescription medications, and surgery. Two other key solutions not listed by the Mayo Clinic include going to the bathroom only when you have the urge and avoiding the excessive straining that constipation induces. Here’s why this is so important.
By ignoring the urge to poop on a regular basis, you may be creating a vicious cycle that can lead to chronic constipation. This is the scenario: You get the urge to poop. Assuming you are an adult with an intact nervous system, and you are NOT having diarrhea (that’s a different story), you can override the reflex to poop. This reflex is triggered when your rectum is stretched and is known as the parasympathetic defecation reflex. By contracting the external rectal sphincter, you stop the reflex and movement of waste toward the anal canal and suppress the urge to poop8. If you do this repeatedly the body’s intrinsic poop train does 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. So when you do finally go to the restroom, now you have to strain because the signal, ie. peristalsis, has gotten quiet. Peristalsis is the body’s way of moving waste through the colon and it requires no conscious effort on your part.9 Therefore, as best you can, when you have the urge to poop, go!
Now let’s talk about how to avoid excessive straining. This topic has inspired footstools such as the squatty potty and research studies alike to find the best pooping alignment. Straining can lead to hemorrhoids, anal tears, rectal prolapse, pelvic floor dysfunction and pudendal neuralgia7, none of which are pleasant to say the least. Straining increases when trying to poop while using the modern day toilet. It’s simple biomechanics really. If you are trying to push something out of a tube that’s closer to a right angle than a straight line, it will be more difficult. However, when your knees are higher than your hips, what is known as the “anorectal angle” increases, helping the poop to get out.8 The anorectal angle is the angle between your rectum and anus – the final exit point. Normally our knees are level with or below our hips when we sit on the toilet – not helpful for the anorectal angle. We also have the research to prove squatting is helpful. A study by Dr. Sikirov demonstrated that people strain less when they squat versus when they sit. There is a statistically significant difference10.
It is evident and proven that squatting or a squatting position helps you poop. But what if you are squeezing when you think you are pushing? Extremely counterproductive. I have seen this repeatedly in my patients. I ask them to bear down or bulge like they are having a bowel movement and instead they squeeze. So let’s say you’ve done everything right. You poop when you are supposed to. You squat on the toilet. You eat well, take fiber and exercise daily. You’re not on any meds that would cause you to be constipated. And you’re still having trouble pooping. Well, maybe you are squeezing when you should be bulging. You’re not alone in this. But what to do?
A mirror is a great tool!
Recline in bed, place a mirror where you can see your perineum and anus. Try squeezing, you should see your perineum and anus lift. Then try bulging or bearing down, you should see your perineum and anus bulge. Or if you’re more adventurous, try using a finger in the shower. Insert a lubricated finger into your anus and practice squeezing and bulging. Squeezing will feel constricting. When bulging you should feel your finger moving down and out. It is important to be able to do both actions and to know the difference. The muscles in your pelvic floor need to go through their full range of motion to function effectively, just like any other muscle in your body. If you only knew how to lift your arm, how could you pick anything up? You need to allow your arm to extend to reach an object and only then do you bend your elbow to pick up the object. If you are still concerned about how to poop, consult with a pelvic floor physical therapist.
So, let’s recap. What did you learn in our poop lesson for the day?
- Go when you have the urge.
- Get into as close of a squatting position as you can
- Make sure you are bulging correctly.
Viola!
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http://www.npr.org/sections/health-shots/2012/09/20/161501413/for-best-toilet-health-squat-or-sit
http://www.menshealth.com/health/pooping-wrong
http://www.squattypotty.com/
J Clin Gastroenterol. 2012 Feb;46(2):150-4. doi:10.1097/MCG.0b013e318231fc64. Chronic idiopathic constipation: more than a simple colonic transit disorder. Shahid S1, Ramzan Z, Maurer AH, Parkman HP,Fisher RS.
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.
http://www.mayoclinic.org/diseases-conditions/constipation/basics/treatment/con-20032773
Herman and Wallace inc. Pelvic Rehabilitation Institute. Pelvic Floor Level 2A. www.hermanwallace.com
https://www.gutsense.org/gutsense/sensitivity.html
https://vw-squattypotty.storage.googleapis.com/uploads/2015/03/03/files/Straining-study.pdf
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 have pelvic floor dysfunction to were my bowels dont function. Will the nausea I have ever go away and eating has become an issue.My dr has me on 2 caps mirlax morning and 2 night, I still feel sick .I have lost alot of weight.Will this biofeedback help with any of this.
Stephanie Prendergast, MPT says:
Biofeedback and pelvic floor physical therapy should help. Often, SIBO or gut candida can also be present and contributing to the pain.