Controlling Constipation

Think you are constipated or not so sure?

Let’s start with what is “normal” when it comes to poop: 

• Frequency: 3x per day to 3x per week, less than 3x per week is considered normal if unchanged from person’s usual frequency and isn’t associated with any discomfort ^{1, 2}
• Color: brown (black or blonde stools, or stools with red blood warrant medical consultation)
• Consistency: Bristol stool chart type 3-5^{2, 3} (see chart below)⁴

What is “constipation”?

A functional gastrointestinal disorder that is symptom-based, characterized by infrequency of stools, difficulty with evacuation of stool, or both^{5, 6} – associated with:

• needing to strain
• incomplete evacuation of stool
• sense of difficulty with passing stool
• increased time to have a bowel movement
• need for digital/manual assisted maneuvers to pass stool

The true percentage of how common constipation is, is unknown⁷, however is believed to be 14% worldwide and 20% among individuals in North America⁸

Factors that can contribute to constipation are metabolic problems, fiber deficiency, anorectal problems such as anal fissures (tears in the anal mucosal tissue) or colorectal cancer, body mechanics and poor management of intra-abdominal pressure, pregnancy and early postpartum, sedentary lifestyle, and travel. Individuals with pelvic abnormalities, such as pelvic organ prolapse, are at an elevated risk.⁹

Constipation can be due to motility issues within the gastrointestinal system itself or mechanical difficulty with evacuating stool from the rectum. Risk of development of hemorrhoids, anal fissures, and rectocele (pelvic organ prolapse involving the rectum) is elevated in individuals who experience chronic constipation. 

So, now, what can you do about it?

• Increase your daily activity to assist in digestion, motility, and muscle activity
• Make sure you are staying plenty hydrated
• Performance of self-abdominal massage to assist in motility 

• Adjust your toileting posture with use of a stool or a Squatty Potty^(R) to assist in pelvic floor relaxation and decrease need for straining.
  • Squatty Potty 20% Off Discount Code: HC-HealingMotionPT20

• Try increasing your fiber – adults should be consuming 20-35 g of fiber/day^{10, 11}
  • From high fiber foods, such as: beans, legumes, whole grains, fruits, vegetables
  • Over the counter fiber supplements – consult your medical professional on what type would be best for your individual symptoms and increase dosing gradually to decrease risk of abdominal cramping, bloating, and gas

• Consult your medical provider about:
  • Use of over the counter stool softeners, lubricating agents (such as mineral oil), osmotic agents (such as magnesium), or laxatives 
  • Enemas
  • Prescription medication options
  • In dire situations, surgical options are available to address anatomical issues that could be at the cause – however, all conservative options should be exhausted before this option
• Attempt pelvic floor physical therapy!!

What would pelvic floor physical therapy for constipation look like?

• Assessment of your general health and wellness, activity levels, dietary and hydration status, bowel habits, breathing, abdominal function including presence of scars or diastasis recti, and pelvic floor muscle function
  • Assessment of pelvic floor muscle function can be intravaginal or intrarectal, however, intrarectal assessment is the preferred method to be able to truly assess the involvement in anal sphincter function in your symptoms
• Interventions could involve:
  • Patient education on general advice regarding behavior modification to address dietary, hydration, and activity level considerations
  • Adjusting toileting posture with use of breath and proper pressure management strategies
  • Sensory retraining of the rectum and anal sphincters
  • Instruction on manual perineal support during bowel movements if necessary
  • Abdominal massage
  • Pelvic floor muscle retraining and rehabilitation based on outcomes of physical examination
  • Use of biofeedback
  • Sympathetic nervous system (stress response or fight/flight system) downtraining to assist in promotion of parasympathetic activity (rest, digest, and restore system)

Constipation can seem complex and sometimes involves more invasive management strategies – however, most of my patients see improvements with addressing activity levels, maintaining a healthy diet, staying hydrated, adjusting toileting posture, and incorporating some abdominal massage into their daily routines. 

We are here for you if you are needing assistance in management of your constipation! You can schedule your appointment here.

You can learn more about other common pelvic health and women’s health problems in our Pelvic Health and Tips Resources.

References

1. McCrea, G. L., Miaskowski, C., Stotts, N. A., Macera, L., & Varma, M. G. (2008). Pathophysiology of constipation in the older adult. World Journal of Gastroenterology, 14(17), 2631–2638.
2. Walter, S. A., Kjellström, L., Nyhlin, H., Talley, N. J., & Agréus, L. (2010). Assessment of normal bowel habits in the general adult population: the Popcol study. Scandinavian Journal of Gastroenterology, 45(5), 556–566.
3. Longstreth, G. F., Thompson, W. G., Chey, W. D., Houghton, L. A., Mearin, F., & Spiller, R. C. (2006). Functional bowel disorders. Gastroenterology, 130(5), 1480–1491.
4. https://stock.adobe.com/images/bristol-stool-chart-with-faesces-form-classification-slow-and-rapid-transit-different-type-of-poop-excrement-from-constipation-to-diarrhea-flat-design-vector-poo-scale-infographic-illustration/503785958?as_campaign=ftmigration2&as_channel=dpcft&as_campclass=brand&as_source=ft_web&as_camptype=acquisition&as_audience=users&as_content=closure_asset-detail-page
5. Ford, A. C., Moayyedi, P., Lacy, B. E., Lembo, A. J., Saito, Y. A., Schiller, L. R.,…Quigley, E. M. (2014). American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation. American Journal of Gastroenterology, 109(1), S2–26. doi: 10.1038/ajg.2014.187
6. Gallegos-Orozco, J. F., Foxx-Orenstein, A. E., Sterler, S. M., & Stoa, J. M. (2012). Chronic constipation in the elderly. American Journal of Gastroenterology, 107(1), 18–25. doi: 10.1038/ajg.2011.349
7. Quigley, E. M., & Neshatian, L. (2016). Advancing treatment options for chronic idiopathic constipation. Expert Opinion on Pharmacotherapy, 17(4), 501–511.
8. Pinto Sanchez, M. I., & Bercik, P. (2011). Epidemiology and burden of chronic constipation. Canadian Journal of Gastroenterology and Hepatology, 25(Suppl B), 11B–15B.
9. Li, M., Jiang, T., Peng, P., Yang, X. Q., & Wang, W. C. (2015). Association of compartment defects in anorectal and pelvic floor dysfunction with female outlet obstruction constipation (OOC) by dynamic MR defecography. European Review for Medical and Pharmacological Sciences, 19(8), 1407–1415.
10. Eswaran, S., Muir, J., & Chey, W. D. (2013). Fiber and functional gastrointestinal disorders. American Journal of Gastroenterology, 108(5), 718–727. doi: 10.1038/ajg.2013.63
11. Harris, M. S. (2012). Evaluation and treatment of constipation. Retrieved from http://www.ogdengastro.com/wp-content/uploads/2014/03/cdb840d199c99374e054fd2ab6de2e8f.pdf