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Oranges in a net back to represent constipation and the pelvic floor

Constipated Again? Your Pelvic Floor May Be Holding Things Up

Everybody poops or, well, everybody should poop. Unfortunately, constipation is a problem that plagues too many of us, too much of the time. According to John Hopkins Medicine, every year in the U.S., about 4 million people report feeling chronically backed up, making constipation the most common gastrointestinal complaint.

Intermittent pooping troubles triggered by a change in your diet or daily routine are usually no big deal, but constipation that doesn't go away — or keeps coming back — is a more serious issue. Chronic constipation is typically due to two issues: slow movement in your gut and pelvic floor dysfunction.

Left untreated, chronic constipation can lead to more than just inconvenience and discomfort — it can contribute to even more complicated symptoms of pelvic floor dysfunction, including urinary incontinence, painful sex, pelvic organ prolapse, and rectal or anal pain.

The good news is that pelvic floor physical therapy can be a huge gut-saver. Using highly-effective treatment tools like pelvic floor biofeedback, a PT can help you poop easily, comfortably, and regularly again. Read on to learn more.

What does “normal pooping” look like?

When it comes down to it, poops are like snowflakes — no two are exactly alike. That's because your bowel health is a product of a myriad of factors including your diet, activity levels, health history, genetics, and even stress levels. Ideally, your bowel function will still fall within the normal range.

What's normal? If the following statements are true for you, most of the time, your bowel function likely just fine:

  • You have bowel movements somewhere between 3x/day, to 3x/week.
  • When you have a bowel movement, it's painless and easy — no straining or major pushing required.
  • Your poops are mostly brown and fall somewhere between type 3 and 4 on the Bristol Stool Chart (see below).
The Bristol Stool Form Chart

What are the symptoms of constipation?

Even if you know your bowel function is not normal, how do you know if you’re officially constipated? As it turns out, 29% of people are constipated without even realizing it. Luckily, there's a “cheat sheet” of sorts — aka the Rome IV criteria — which healthcare providers often use to help determine if you are.

Over the past 6 months, if two or more of the following symptoms have persisted for at least three months, it's likely that a doctor will diagnose you with functional constipation, or constipation that is not caused by illness:

  • At least 25% of the time, you have to strain when you poop.
  • At least 25% of the time, your poop is lumpy or hard (check out #1 and 2 on the Bristol Stool Chart above).
  • At least 25% of the time, it doesn’t feel like you've emptied your bowels – this is known as a sensation of incomplete evacuation.
  • At least 25% of the time, it feels like there is something blocking your ability to poop, aka a sensation of anorectal obstruction/blockage.
  • At least 25% of the time, you require some sort of manual assistance to help you poop — using your fingers to splint your pelvic floor or pushing near your anus to help you empty.
  • Each week, you have fewer than 3 bowel movements.
  • Loose stools are a rare occurrence unless you use a laxative.
  • Your poops don’t meet the criteria for irritable bowel syndrome.

Other than having difficulties getting stool out on a regular basis, it’s also common to experience the following symptoms when you have constipation:

  • Painful bowel movements
  • Abdominal pain or cramping
  • Abdominal bloating or nausea

How do pelvic floor muscles affect constipation?

While strong and healthy pelvic floor muscles are useful in helping to “keep things in” — bladder leaks, your organs, and accidental flatulence slips for example — it is just as important that your pelvic floor muscles are able to release and lengthen, at the right time and place, to facilitate things like sex, having a baby vaginally, and of course to poop.

Under normal circumstances, your pelvic floor muscles (along with your anal sphincter) act as the last line of defense and hold a small amount of tension to prevent stool or gas leakage as your rectum fills with stool, storing it until it is an appropriate time to use the bathroom. When you are ready to poop, you should be able to relax and open your pelvic floor muscles to easily and painlessly empty your bowels. A small amount of gentle pushing may help to facilitate this process, but you should never have to struggle and strain to poop.

When pelvic floor muscles become tight and overactive they can contribute to constipation in 3 ways:

1. Anal or rectal pain can make pooping scary.

Anal and rectal pain can be caused by a variety of issues including pelvic floor dysfunction, pelvic muscle trigger points, hemorrhoids, and anal fissures. If getting the poop out is painful, holding it may feel like the better and safer option. The problem is, holding it can further aggravate overactive pelvic floor muscles. And if you do it often enough, the natural sensation and pressure that helps you poop can go away (this is known as peristaltic dampening), making bowel movements even harder to come by.

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2. A tight pelvic floor can make it hard to squeeze out poop.

When pelvic floor muscles are overactive, they can lose flexibility and shorten, making it difficult to move stool out of a smaller anal opening. Plus, the longer your stool sits in your rectum, the harder and more difficult it is to pass. You see, your entire colon, including your rectum, absorbs water from your stool to keep it for your body. The longer it hangs out, the lower your Bristol Stool Chart number becomes. You will not only have to push harder to move dry, lumpy stool from your body, but it could be painful — which as previously mentioned, only adds to the problem.

3. Dyssynergia can stop you from relaxing at the right time.

Gently pushing while you poop can help to lengthen and open the pelvic floor and anus to facilitate a bowel movement. However, pelvic floor dysfunction can also show up as coordination loss. When you poop, this means you may contract your pelvic floor muscles and close your anus while you push, instead of relaxing your muscles and opening your anus (which allows the poop to come out). What's really tricky is that it can actually feel like you're relaxing when you're not. This is known as pelvic floor dyssynergia. Dyssynergic defecation is known to be the source of constipation in up to 50% of those who have chronic constipation.

Cure Chronic Constipation with Pelvic Floor PT

The good news is, pelvic floor physical therapy is highly effective in tackling constipation related to pelvic floor dysfunction. The following are a few of the reliable, evidence-based treatment strategies that pelvic floor physical therapists at Origin use to help those with constipation:

  • Adjustments in your diet: Dialing in your diet can be a huge source of improvement for your constipation. For example, pelvic physical therapy will help you focus on eliminating bowel irritants, increasing fiber intake, and drinking more water each day.
  • Manual therapy: For tight, overactive pelvic floor muscles, manual therapy techniques can help improve flexibility, minimize trigger points, and relieve pelvic floor muscle pain. Abdominal massage can also be a helpful tool in relieving discomfort associated with constipation and has even been shown to ease constipation by stimulating intestinal motility, which slows down bowel function in those with slow-transit related constipation. The good news is, your physical therapist will show you how to do these things on your own.
  • Biofeedback: Biofeedback has consistently been found to be a helpful therapy tool for those impacted by constipation. Pelvic floor biofeedback describes a variety of techniques that physical therapists can use to help teach you what your pelvic floor muscles are doing during bowel movements. Balloon-assisted biofeedback or electronic instrument-based biofeedback (using internal or external sensors) can help you retrain your muscles to coordinate more optimally for bowel function, as shown in this study.
  • Behavioral strategies: As they work on restoring your pelvic floor muscle health, there are some trusted behavioral strategies that physical therapists will often teach their patients, such as splinting, using a toilet stool, and making your belly big and exhaling when you push (instead of holding your breath).
  • Exercise: Being inactive may contribute to constipation, but constipation can make you feel like skipping exercise — so it’s a vicious cycle. Research shows that exercises like yoga may help to improve your gastrointestinal function. A physical therapist can help you find a safe exercise routine that works for you.

When you have trouble pooping, particularly if things aren’t getting back on track with your usual DIY strategies, it's always best to check in with your healthcare provider. They will be able to rule out any medical causes of your constipation. After other health conditions are crossed off the list, pelvic floor dysfunction is most likely to blame.

If your pelvic floor is making it hard to poop, don't hesitate to schedule an evaluation with one of our highly trained pelvic floor physical therapists. We'll have you pooping smoothly again in no time.

Ashley Rawlins Headshot
Dr. Ashley Rawlins, PT, DPT

Dr. Rawlins is a physical therapist at Origin who specializes in the treatment of pelvic floor muscle dysfunctions including pelvic pain, sexual dysfunction, pregnancy related pain, postpartum recovery, and bowel and bladder dysfunction. In addition to being a practicing clinician, she is a passionate educator and author.

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