A PT's Guide to Constipation
Listen, everybody poops. And, unfortunately, not all poops are created equal. Constipation is one of the most common defecatory debacles, with about 16% of adults in the U.S. experiencing constipation at any given moment. To give you a better idea of what this looks like, this means that anytime you’re on a run-of-the-mill domestic aircraft, about 30 of the passengers around you are constipated. Probably more, honestly, because who isn’t constipated after flying?
But what do you do when you’re constipated? Conventional wisdom says drink more water, grab a cup of coffee, go on a walk, maybe try a stool softener, and oh—have you tried chocolate cake? While these are great options, what happens when you’re chronically constipated or frequently straining on the toilet? What do we do then? We talked to Dr. Corey Hazama, DPT of Beyond Basics Physical Therapy to get the (poop) scoop.
What is constipation?
Pretty sure we’ve all been here and are intimately aware of what constipation is—but let’s just go over it real quick! Constipation, as defined by the Bristol Stool Chart, is when poops are hard and lumpy or are straight up rabbit pellets. This is usually accompanied by straining—which, as we’ll discuss later, is a big no-no. But for now, think about where your poop normally falls on this scale and whether you’re working really hard to have that BM.
What causes constipation?
As Dr. Hazama says, constipation is “anything that slows down transit time.” The more time your poop spends hanging out in the body, the more fluid is absorbed and the harder the poops get. So what causes these… arrival delays?
- Diet: we all know water and fiber are super important for pleasant pooping—and I’m sure we’re also all familiar with holiday/vacation eating and the gastrointestinal discomfort that follows. What goes in… must come out.
- Digestive conditions: Irritable bowel syndrome is a prime example of this—while there’s no concrete cause, scientists think the gut microbiome (aaaall the many bacteria that live in the digestive tract) is a big factor here.
- Stress: As Dr. Hazama says, “stress increases activation of the sympathetic nervous system, which often means no poop.” Can’t be pooping while you’re fighting off or fleeing from a bear! While stress can cause constipation, it can also cause diarrhea. What a joy it is to be human.
- Pelvic floor muscle dysfunction: Under normal circumstances, “the pelvic floor contracts to tell the colon to store the poop (now is not the time because I’m in the middle of a presentation, etc.), and when the pelvic floor relaxes this signals to the colon, ‘Ok, send the poop down! We are relaxed and on a toilet so a-ok!’” But in the case of pelvic floor muscle dysfunction and constipation, those muscles aren’t relaxing to allow for poop to pass—hence the constipation.
- Physical blockages: This might look like a bowel obstruction or pelvic organ prolapse. When there’s something physically in the way, poop has a hard time getting past which can cause us to become constipated!
- Neurological conditions: Some of these conditions include Hirschsprung's disease, MS, and spinal cord injury. Changes to the amount of neural input our bowels are getting can change how quickly food moves through the colon.
Constipation has maaaaany more potential causes, but we’ll let Mayo Clinic fill you in on those. We don’t need to reinvent the wheel here.
Why is constipation bad for you?
Well, first and foremost, constipation doesn’t feel so great. It can lead to bloating, the stools are painful to pass, and—if you’re super constipated—you might start to feel nauseous. But other than feeling not-so-great, chronic constipation can come with some complications.
- It’s rough on your pelvic floor: “Straining taxes the pelvic floor muscles,” Dr. Hazama explains. “Usually when people strain they are contracting the pelvic floor muscles instead of relaxing.” A healthy poop usually means relaxing the pelvic floor and opening those anal sphincters—the “pushing” should be coming from the downward pressure of our oblique abdominal muscles and diaphragm. The AIRBAG technique can be really helpful for getting the hang of pooping without straining. Dr. Hazama also says, “Frequent straining can overstretch the pudendal nerve [a nerve that supplies a lot of the feeling in your butt and genitals] because the pudendal nerve is stretched around the ischial tuberosity [your sitz or butt bones] when you bear down really hard in a slumped, posterior pelvic tucked position.”
- It can cause painful sex: Dr. Hazama says, “If you are constantly contracting your muscles to poop and they become tense and develop trigger points, then sex can become painful. The pelvic floor needs to open to poop, the same is true for penetrative intercourse. Muscles need to be relaxed to allow something in (or out).”
- It can contribute to pelvic organ prolapse: Pelvic organ prolapse is when one or more of your pelvic organs isn’t super well supported and begins to slump downwards. When it comes to chronic constipation and straining to poop, the most common type of POP that can follow is something called a rectocele—where the rectum (poop storage chamber) bulges into the vagina.
- It can cause hemorrhoids and anal fissures: With all the pushing and straining that often comes with constipation, hemorrhoids (swollen veins in the anus or rectum) and fissures (tears or cracks in the anus) are common complications.
What are some ways you can alleviate constipation?
At this point, we now know that constipation isn’t all that great for us—for a variety of reasons. So how do we treat it and avoid it? Here are the top recommendations from a pelvic PT:
- Diet: Right in line with conventional wisdom, drink more water and get more fiber in your diet (soluble and insoluble). Common soluble fiber sources are black beans, avocados, and oats. Some common insoluble fiber sources are whole-wheat flour, potatoes, and green beans.
- Exercise: Dr. Hazama says, “moving the body helps to move the guts, also mechanically speaking your hip flexor muscles are right behind your ascending and descending colon so sometimes their contractions can help stimulate things to happen.” And by things… we mean pooping.
- ILU massage: This is a little belly massage you can perform on yourself! It “stimulates the parasympathetic system to increase peristalsis,” says Dr. Hazama. Peristalsis is the fancy word for the squeezing and relaxing your intestines do to move food through your system.
- Stimulate the vagus nerve: The vagus nerve is one of the main regulators of our parasympathetic nervous system—meaning it’s important for digestion, the immune system, and heart rate. “Getting the vagus nerve more active can help with ‘rest and digest.’ Gargling, deep breathing, and using a vagus nerve stimulator are all ways to help activate it,” Dr. Hazama explains.
- Get a squatty potty: Okay okay, so Dr. Hazama didn’t mention this one but I’d be remiss to not talk about toilet stools. When we poop on a western porcelain throne, our rectal angle isn’t in the optimal position for easy emptying. The squatty potty helps to increase this angle by getting the body into a squatting position, leading to easier poop-vacuation. Nice.
- Pelvic PT: We will scream it from the mountaintops forever and ever. Pelvic floor PT is great. “I recommend pelvic floor PT for abdominal massage and to release, relax, and retrain the pelvic floor muscles to make pooping more efficient,” says Dr. Hazama.
If constipation is something you’ve been struggling with for a while and can’t be managed with lifestyle changes, we definitely recommend seeing a physician to discuss additional treatments and/or medications.
Now that we’ve reached the end, let’s recap! Constipation is as common as it is unpleasant, but there are lots of lifestyle changes you can make to avoid it or deal with it when it does come up. Just remember: eat well, drink water, move your body, get a squatty potty, and when in doubt pelvic PTs and GI docs have got your back—er… your butt.