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.
Have you read our book, Pelvic Pain Explained? To read more about it and order your copy click here.
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.
Herman and Wallace inc. Pelvic Rehabilitation Institute. Pelvic Floor Level 2A. www.hermanwallace.com