Most of us are lucky enough to take our bodily functions for granted. However, for those who struggle with constipation, this supposedly normal function can become a real pain – literally.
When most people report having constipation, they are talking about functional constipation. To have functional constipation, you must have two or more of the following symptoms:
Around 8% of Australians are believed to suffer from functional constipation. This figure doesn’t include those who suffer from constipation related to IBS or medications, so overall constipation rates are even higher. We know women are more likely to suffer from constipation than men, and amongst pregnant women, rates can be as high as 25-40%.
Constipation is a problem I see really commonly and it is usually important to sort out when dealing with other pelvic health problems. For example, constipation can have a big impact on urinary urgency, as the loaded bowel will press on and irritate the bladder, making the symptoms worse. Similarly, constipation is believed to contribute to both the development of pelvic organ prolapse and aggravation of ongoing prolapse symptoms. Regular straining to empty your bowels is also not great for your pelvic floor muscles and can make them weaker, contributing to urinary or faecal incontinence, or cause other problems such as haemorrhoids or anal fissures. For people with pelvic pain, constipation can be another source of pain and contribute to spasm in the surrounding muscles.
Constipation not only has a big impact on our pelvic health, but also our general well-being. People who are constipated often report bloating, abdominal pain and nausea. More recent research on the gut even indicates constipation may be linked to lower immunity and an increased prevalence of depression and anxiety. This makes constipation a serious issue to address for many reasons.
A simple way to prevent or treat constipation can be to look after what goes in the other end – that is what you eat. Diets low in fibre are known to be a major cause of constipation. Fibre helps bind the bowel contents and draw water into the stool, to create a soft, formed sausage-shaped bowel motion. Ideally women should have 21-25g of fibre daily, and men 30-38g per day. Good sources of fibre include fruits and vegetables (leave the skins on for an extra fibre boost), wholegrains, legumes, nuts and seeds. If you cannot get enough fibre naturally in your diet, you may consider taking a fibre supplement. Commonly available ones are Metamucil and Normafibe. But if you prefer to keep things a bit more natural, psyllium husks (the main fibre in Metamucil) chia seeds or prunes can also be helpful. If you are really struggling with your diet, it is best to consult a dietitian.
Despite eating all the right food, if you are not drinking enough fluid, your bowel motions may still be too firm. About 2 litres of fluid a day is right for most people. However, I’ve certainly seen people who drink much more than that and still have constipation, so fluid and fibre are not the only issues.
Many people look at me strangely when I ask how they sit on the toilet to poo, but your position can make a big difference! Western toilets do not do us any favours. Eastern cultures which encourage squatting to defecate have really got the right idea, as this position helps to straighten out the kink in the end of the bowels and allows the pelvic floor muscles to relax and open. For most of us, this is impossible (and somewhat dangerous) to replicate at home. The next best thing can be to use a footstool, which will bring the knees slightly higher than the hips, then gently lean forward from the hips with a straight back. If you don’t mind a bit of toilet humour, the Squatty Potty commercial on YouTube demonstrates this nicely. However, you don’t have to buy an expensive footstool to do the job – books, bricks or even a toilet roll under each foot will do the job just as well. And don’t forget to “sit like a bloke” and position the feet wide apart too.
Once you get the right position, what you do when you’re there can also make a difference. Firstly, make sure you listen to your body and go when you get the urge, as this is when your bowels are helping by moving the stool down to the rectum. This most commonly occurs on waking or 15-30 minutes after a meal. Then once in position DON’T STRAIN! Straining hard can actually make the pelvic floor muscles tighten instead of relaxing and letting go, which is a bit like trying to squeeze out the toothpaste with the lid on. Instead, let your tummy bulge and waist widen to create more gentle pressure, and allow the muscles around your back passage to relax and widen. If you are struggling with this, your Pelvic Health Physiotherapist can show you how. Some people also find make a “Sssss” or “Ooodge” sound also helps. Yes, I know this sounds funny – but give it a try!
If you have tried all of this and still have constipation, it might be time to see a Pelvic Health Physiotherapist. There may be some other things going on.
Medications, including vitamins, may also be contributing to constipation. Some medications that commonly cause constipation include opioids (for pain), many medications for overactive bladder, iron and calcium supplements. If you are taking these medications, talk to your doctor or pharmacist about some alternatives which might work better for you.
If you experience pain around the back passage when trying to have a bowel motion this may also be making things harder. Pain can be caused by straining itself, but may also be the result of haemorrhoids or anal fissures. Pain may cause the anal sphincter muscles to contract – when we need these muscles to relax to empty effectively – causing more difficulty and a vicious cycle of symptoms. Haemorrhoids and anal fissures may also cause some bleeding when you wipe. Any bleeding should always be investigated by your doctor. However, if small haemorrhoids or fissures are the problem, you may be able to get some lotion to help. Learning to support the area and poo without straining can help too.
Even with the best technique, and optimal stool consistency, structural changes in the bowels can still make the process of emptying difficult. This may include a rectocele (when the lower part of the bowel pouches forward) or an intussusception (an internal telescoping of the bowel in on itself) which may cause the stool to be pushed in the wrong direction. There can be other causes for structural changes, so any recent or sudden change in bowel habits should be discussed with your doctor. If a prolapse is making evacuation tricky, your Pelvic Health Physiotherapist can show you some tricks to help. Strengthening the pelvic floor muscles may also make a difference.
The important message here is constipation is common, but an important problem to sort out. Quite often some simple changes can make a big difference. So, don’t waste your precious time straining on the loo. Come and see me if you’d like to sort out your bowel problems and get on with living.
Yours in pelvic health, Jenny