By Kim Buonomo, DPT, PHRC Lexington
Introduction
Megan (mid-50 year old cisgender female) started seeing me in September 2021. She had a history of bowel dysfunction since giving birth to her daughter in the late 1990’s. She described her symptoms as a pattern of alternating constipation and diarrhea, associated with bloating, hemorrhoids and abdominal discomfort. She thought for a long time that she would just have to deal with it but last year her daughter was diagnosed with Celiac disease. Megan decided to go gluten free as well, and had an improvement in symptoms. She realized that she has been reacting to gluten. She established care with a nutritionist to see what other foods she may be reacting to and what else could be done to improve her bowel symptoms. After working on the nutrition side of things, her nutritionist recommended that pelvic floor PT may also help. Megan looked into pelvic floor PTs in her area and found PHRC in September 2021.
Symptoms
Megan described her primary symptom as bouts of pain and digestive distress similar to food poisoning, but it felt like “bowel poisoning.” Such an experience would cause a one to two day period of violent diarrhea, nausea, and excessive voiding (pooping). Once everything was out, she would feel better until her next episode. These episodes would happen every few weeks.
As she changed her diet, Megan noticed that she needed to wipe excessively after bowel movements, and had some stool staining her underwear (we call this fecal smearing). She felt that this had a lot to do with her constipation and straining. She would also get abdominal pressure and bloating, which made her feel like she needed to try to have a bowel movement two to four times per day but she would struggle to empty her bowels when she was in the bathroom.
Even when her stool felt like it was soft enough that she should be able to pass, she was straining to get it out. She told me that she imagined putting a corkscrew up there and yanking because it felt like that would finally give her the relief that she was hoping for. Every two weeks or so, she would have a good day and would be able to get it out, which provided significant relief of all of her symptoms, but that relief wouldn’t last long, and was gone as soon as stool built up in the colon again. She also had pain with bowel movements associated with hemorrhoids since giving birth.
My Findings
Megan had several key findings I thought would be important to address when considering her bowel dysfunction.
- Prolapse- Megan has a type of prolapse called a rectocele. With a rectocele, the back wall of her vagina isn’t adequately supporting her rectum. This can cause stool to sit or collect in the unsupported part of the rectum and make it more difficult to poop.
- Pelvic floor dysfunction (Motor control and tone) – Megan had been struggling for a long time to relax her muscles effectively enough to have a bowel movement. This led to her muscles getting tighter and tighter over time, and she needed to strain more and more in order to execute a bowel movement, which became a self fulfilling prophecy. Over time, those muscles became so tight that they were unable to relax entirely. This article talks about some of the key muscles that are responsible for helping us move our bowels. These muscles being restricted or uncoordinated is a major contributor to bowel related pelvic floor dysfunction.
- Diastasis recti- This is a separation of the “six pack” muscle, the rectus abdominis. This is common after pregnancy, after laparoscopic surgery, with sudden weight changes, and/or with chronic straining. Diastasis can contribute to constipation as the patient isn’t recruiting their abdominal muscles effectively to seal the abdominal canister and maintain pressure there to ease the stool down. We’ve talked about diastasis on our blog in several articles and treatment approaches for diastasis are continuing to change as we learn more about the diagnosis!
- Myofascial restriction through the glutes- She has spent years clenching her butt when she was feeling the urge to poop! Your butt muscles and your pelvic floor muscles are connected. Imagine trying to poop with your glutes clenched, or trying to pee with your inner thighs squeezed together. Pretty difficult, right? Helping her relax her glutes will actually help her relax her pelvic floor.
- Posture!!! – This is part of my all time favorite blog series of ours, and it explains why posture is so important when it comes to SO MANY of our basic functions! Altered posture affects breathing mechanics, pain, continence, intra-abdominal pressure, our ability to lift, and so much more!
Assessment
Based on my evaluation, I knew that the factors I listed above were contributing to Megan’s presentation and I knew that we could do something about it! Given how long she had been experiencing symptoms, the severity of her dysfunction, and the fact that so many things outside of PT (like diet) can influence her symptoms, I knew it would take us a couple of months of working together consistently to make a difference, but I knew that we could address many things that would go a long way toward improving her quality of life.
Digestion is achieved by a complex system that is affected by countless other functions of our body such as hormones, different kinds of bacteria (the gut microbiome), our muscles and nerves, our gynecological and urinary systems, our food choices and how well we are hydrated. I was glad that she was working with a good interdisciplinary team to address these areas in combination with the work we were doing in PT.
At our evaluation, I set the following goals for Megan:
In eight weeks…
- I wanted to see an improvement in the coordination of her pelvic floor muscles, thereby allowing her to relax and poop more effectively.
- I wanted her diastasis (that separation of her abdominal muscles) to reduce. This would improve the closure of her abdominal “canister” and allow her to use her abdominal muscles more effectively to relax to poop.
- As a result of these things (as well as the manual therapy we did in our sessions), I wanted the amount of muscle tension and pain in her pelvic floor to reduce.
In 12 weeks…
- I wanted her to have an improved ability to poop, so that she was able to go to the bathroom without straining at least half of the time.
- I wanted her to no longer have fecal smearing or other loss of stool as a result of improved motor control and voiding mechanics. Did you know that constipation can actually cause a kind of incontinence called overflow incontinence?
- I wanted her to feel like she could evacuate her bowels more effectively. There are a ton of products that help patients like Megan. A few of these products are the squatty potty and femmeze. I knew that using these could help her get it out more effectively, so she would feel like she didn’t need to reach in there with a corkscrew to pull it out any more.
- I wanted her to have less frequent episodes of “bowel poisoning.” I suspected that this was happening because the prolapse was causing stool to collect in the rectum in a way that it couldn’t get out. Once it finally had a straight path to the exit, it would come out all at once and cause an episode where it would come out in an unrelenting way. If she could poop more regularly and more oten, I thought that we could avoid the recurring back-ups.
Plan
I decided to start seeing Megan weekly.
- We used different kinds of biofeedback strategies in order to improve her ability to voluntarily relax her pelvic floor muscles. This is a really hard thing to master, and it took her about six weeks before she ended up getting comfortable with it enough that she could do it successfully during bowel movements. Her breathing mechanics and posture were also important parts of this process.
- Education, education, education! We know a ton about how our body functions to have a bowel movement and there are many great resources we have to help patients poop more effectively, but so many people have no idea what is actually normal! We talked about the squatty potty, various toilet meditations, femeeze, and a few other strategies, and used these tools to improve her ability to poop.
- Manual therapy– Megan had been so tight throughout her pelvic girdle for so long that even with all the motor control training and biofeedback in the world, her muscles physically just couldn’t relax. They didn’t have the range of motion needed to do it! Working on these restricted tissues manually increased blood flow to these areas and reduced muscle restrictions and connective tissue dysfunction, which helped to relax the tissues, which in turn helped her control them better and overall improved her range of motion. She was able to do self myofascial release at home by rolling a tennis ball over her glutes, which she found to be very helpful in managing her symptoms.
- Outside of PT- I knew it would be important for her to continue to work with her nutritionist and keep up with her diet outside of PT. Our pelvic floor muscles don’t exist in a vacuum. They are influenced by what we eat, our stress levels, our sleeping habits, our pain, and all of the choices we make throughout our day. I knew that PT was only part of the puzzle, and that she would benefit from addressing all of those other puzzle pieces along with the work we were doing.
Success
I treated Megan weekly from September until November 2021. We worked on everything I mentioned above. Within the first month she didn’t see much of a change, which I expected since she hadn’t mastered her motor control training yet. When she finally got the hang of this (around week six), it ended up being a big turning point in her recovery and she started seeing a change in symptoms. She described her improvement around that time as feeling like the stool “falls” out without needing to push, and her stool was still soft and well formed. Even though relaxing was getting easier, she only felt like she was able to completely empty her bowels about 50% of the time. Even though this was still tremendous progress for her, I knew we could make even more gains.
We ended up seeing her twice during the month of December, and then once in January and once in February. She had a couple of setbacks in that time due to getting a stomach bug, and then COVID. These complications did cause a bit of a setback in regards to her symptoms, which made sense. Remember how I said the pelvic floor doesn’t work in a vacuum and it’s affected by the rest of our lives, and bodily functions? Well, when she had the stomach bug, she spent days with GI distress clenching her pelvic floor until she could get to a toilet to let it out. Of course this led her to fall into the old bad habit of clenching! Thankfully, she had developed such an awareness of her body by then that we only needed one session to get things back on track. When she had COVID a month later, she was quarantined from her family and spent two weeks in her bedroom without her foam roller. She was unable to eat her normal foods, do her normal routine, or continue with her exercises- on top of not feeling well from being sick. This caused another setback, which we were also able to work through quickly.
At her last visit with me in February 2022, she told me that she was doing great. Her stool was appropriately soft and easy to pass almost all of the time. She wasn’t bloated or constipated. She no longer had fecal smearing or abdominal discomfort. She hadn’t had a single episode of “bowel poisoning” unless she ate a food that she knew was on her bad list, and she had graduated with her nutritionist, only seeing them as needed. She did still have some right hip tightness and soreness, which was not terribly concerning to her.
From my perspective that day, it was clear that her coordination was much better. I did not identify any prolapse, and her muscular restrictions were also much better compared to her first day with me. She did still have a separation of the abdominal muscles, but this was less symptomatic as she was using her core more effectively and was no longer straining with bowel movements. Most importantly, she had met all of the goals we had set out for her! We decided to book a followup appointment for the end of March, just in case she felt she needed it, but she did not end up coming in for that because she was doing so well! As I write this, she is still doing great- about two months after her last PT visit!
I definitely got a bit emotional when she told me I changed her life, and I’m so happy that her quality of life has improved so dramatically with PT, the right education, and the right team of professionals!
Do you have issues with your bowel function? Not all patients know that prolapse can contribute to constipation, and that PT can help patients with symptoms like Megan’s. Contact one of our offices or schedule a telehealth consultation to see how we can help you!
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Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
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.
Melissa Patrick is a certified yoga instructor and meditation teacher and is also available virtually to help, for more information please visit our therapeutic yoga page.
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