By: Kim Buonomo
Don’t hold your breath!
What do you do when you poo? It sounds like something from Dr. Seuss. It’s a strange question, and some of our patients don’t know how to answer it. Next time you have a bowel movement, try to think about the specifics. How are your feet positioned? Are they flat on the floor? Propped up on a stool (AHEM! Squatty potty!)? Or leaning against the bathroom sink for support? What are your abdominals doing? Are you curled up in a ball over your hips? Do you rock back and forth to stimulate some movement down there? Do you sit and play angry birds on your phone and lose track of time? (We’re all guilty of that from time to time!) And one last question… are you breathing?
Often, when I ask my patients to “pretend to have a bowel movement” in the clinic, they immediately hold their breath and strain. This is a major problem when you are trying to poo. As we remember from Katie’s stellar graphic in this post about the diaphragm and the pelvic floor, the two are linked like a piston. So 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). Stephanie also covered the right way to poop in this excellent article!
Holding your breath translates to more than just constipation and hypertonic pelvic floor muscles. Another concern here is something called defecation syncope. It’s been discussed in local news outlets and Men’s Health and basically it is when you hold your breath and strain so hard that you pass out on the toilet. We’ve all heard people joke about holding their breath so long that their face turns purple. When you hold your breath and use pressure to have a bowel movement, you are doing something called the Valsalva maneuver. We talked about Valsalva as it relates to exercise here. From that article, “the Valsalva maneuver is described as taking a breath and forcefully exhaling against a closed mouth, glottis (throat), and nose–and is often utilized when performing a task where we need abdominal and spine stiffness to help create more force. Baessler K. et al, 2017 examined the effects of the Valsalva maneuver versus straining on the bladder neck and the puborectalis pelvic floor muscle on continent and incontinent women. They concluded that valsalva and straining are two different tasks, and that the pelvic floor is stiffer when utilizing valsalva techniques.”
During a Valsalva Maneuver, the diaphragm is forced downwards by the increased pressure inside the thoracic cavity. If you are straining, but breathing, this should not happen. When you Valsalva on the toilet, you are trying to use that pressure to “cheat the system,” so you can poop without totally relaxing your pelvic floor muscles. There’s a couple problems with that! Problem one: it sends a message to your pelvic floor muscles that even though they were contracting, whatever they were doing was not enough to maintain continence. Of course, this was a conscious choice by your brain, but your body can get confused by that. This is one of the factors that can contribute to hypertonic (high tone) pelvic floor dysfunction, because you are telling these muscles they need to contract harder to maintain continence. This may also contribute to developing a pelvic organ prolapse. And problem two: all that built up pressure restricts blood flow to the heart and can actually cause you to pass out. Some studies have shown that passing out under these circumstances is not life threatening, but if you lose consciousness when alone in the bathroom it may take longer for someone to realize you need help, which may contribute to negative outcomes. So while it may not be life threatening, breathe easy; so you can pass stool, not pass out.
Herman and Wallace inc. Pelvic Rehabilitation Institute. Bowel Function, Dysfunction and Pathology. www.hermanwallace.com
Men’s Health. Can you die by pooping? (2016). [online] Available at: https://www.menshealth.com/health/a19548528/death-by-pooping/
Sitting toilets: The secret very few know today. The Valsalva Maneuver – A Side Effect of Using Sitting Toilets. (2006). [online] Available at: https://www.toilet-related-ailments.com/valsalva-maneuver.html
CTV. Fainting on the toilet is a real medical problem – but doctors say it can be avoided. (2018). [online] Available at: https://www.ctvnews.ca/health/fainting-on-the-toilet-is-a-real-medical-problem-but-doctors-say-it-can-be-avoided-1.3895702
Mayo Clinic. Vasovagal syncope. (2018). [online] Available at: https://www.mayoclinic.org/diseases-conditions/vasovagal-syncope/symptoms-causes/syc-20350527
Bae MH, Kang JK, Kim NY, et al. Clinical Characteristics of Defecation and Micturition Syncope Compared with Common Vasovagal Syncope. Pacing & Clinical Electrophysiology. 2012;35(3):341-347. doi:10.1111/j.1540-8159.2011.03290.
Brophy C, Evans L, Sumpio B. Defecation Syncope Secondary to Functional Inferior Vena Caval Obstruction During a Valsalva Maneuver. Annals of Vascular Surgery. 1993;7(4):374-377.