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Constipation: Why, How & What Can Help!

Tell me – how long do you actually spend on the toilet trying to defaecate (not just soaking in the ambiance of your poop while you play on your phone)?

Constipation. This is a hard topic to understand, because of its complexities (pun drop in the first sentence, who am I?) But seriously, how long do you actually spend on the toilet trying to deafecate (not just soaking in the ambiance of your poop while you play on your phone)?

We should be able to effectively evacuate our bowels in about 60 seconds. From sitting down on the toilet, actively relaxing our external anal sphincter muscle, using a little effort if required (Not straining! Just a gentle increase in abdominal pressure whilst keeping our abdominal and pelvic floor muscles relaxed) and evacuating a type 3 or 4 stool (see Bristol Stool Chart below). We should then be able to wipe clean within 3-4 wipes. Voila, the perfect poo experience.

Now there are multiple reasons your experience may vary from the above mentioned “ideal”, too many for us to get into in just one blog post! So, we’re going to start by discussing the mechanics of how defaecation works, and some simple strategies you can use to improve your constipation.

Bristol Stool Chart - Constipation Education | The Healthy Peach Physio

How would you rate your Stools?

Introducing the iconic Bristol Stool Chart – the perfect way to summarise what types of stools there are, and which looks most like yours. The ideal stool is a Type 3 or 4!

First things first, we must have a need to defaecate before we can actually attempt it. Now I know this seems like an obvious statement, but in my time as a clinician, I’ve found that it’s a common misconception that we assume that defaecating and urinating are triggered by the same thing.

You know how when you’re about to leave the house you think, “oh, I might just quickly pee first” and then you can just sit down and pee? This is because our kidneys are constantly producing urine, which is being trickled into the bladder via the ureters. So, there is always something in the bladder to void, that when you sit on the toilet and relax to wee, you can.

Firstly, we don’t have a constant trickle of faeces into our rectum. What we have is a long colon, that works like a cement mixer, stirring up all the faecal matter and absorbing water out of the stool as it pushes it along. Until finally the formed stool reaches the rectum. This doesn’t happen in big waves all day either, we have a few big propulsive waves first thing in the morning when we wake up, that is doubled if we eat or drink coffee in this first hour of waking (hello, getting the urge to poo mid-way through my morning coffee!). After the first hour of waking and eating has passed, the chances of more big propulsive waves are small. We’re more likely to get stirring-like waves that just mix everything up, but don’t really push things along throughout the day, and basically, zero colonic activity while we’re sleeping.

So, maximising this first hour of the day is vital in achieving the “urge” to defaecate.

A Closer Look into the Poo-Pathways

Understanding how to best help cases of constipation, comes with a greater understanding of your body!

Second thing we need is adequate stretch on the walls of the rectum, that signal our brain there is something in there, that we need to evacuate. When the stool enters the rectum, it causes a rapid stretch on the smooth muscle tissue that lines our rectum. When this rapid stretch occurs, a reflexive relaxation of our Internal Anal Sphincter muscle occurs, and an opposite reflexive activation of our External Anal Sphincter muscle occurs. Our Internal Anal Sphincter muscle controls about 70% of our resting anal pressure that keeps us continent. When it is reflexively relaxed, we feel our External Anal Sphincter switch on, we then take conscious control of our anal squeeze and we think, “Ooop, I have to use the toilet!”.

This is how get our “urge to defaecate”.

So naturally, at this point, we go to the toilet, right? In the perfect world without breastfeeding babies, dogs throwing up in the laundry, having to be at the office by 6am, getting the gym at 5am for Pilates etc. Sometimes the urge comes at inconvenient times. So, what do we do? We ignore it. And after a little while (about 20-30 minutes), the urge passes.

Unfortunately, this is where our problem lies.

By ignoring the urge to defaecate, what happens inside our body is a slow stretch of the rectum until the smooth muscle gets so temporarily stretched that it no longer realises there is something in the rectum anymore! So, the brain stops getting the signal that there’s stool in the tank, and all the reflexive muscular actions are switched off. Our Internal Anal Sphincter muscle re-activates, taking on 70% of the resting anal pressure, thereby taking over control of continence for us. And our External Anal Sphincter that we were consciously squeezing when we felt the urge, will relax as there is no more need for it to assist so greatly with continence.

No more “urge” to defaecate.

So then what happens, is we get to work, we finish breastfeeding, our Pilates class finishes etc. and we think, “Alright, I’ve got time to go now”, and you go to the toilet and strain to try and pass the stool that you know is there, but can’t necessarily feel anymore.

We can’t easily defaecate at this point, because our Internal Anal Sphincter is still active. Unlike our External Anal Sphincter which we have conscious control over, the Internal Anal Sphincter is not controlled by “us”, and can only be told what to do by reflexive actions or “triggers” (like the rapid stretch of the rectum). So, trying to defaecate without the “urge” is like trying to push a firm sausage out of a 70% closed hole. It ain’t gonna be easy, and it’s gonna take a lot of straining, probably ending with an unsatisfactory poop (which is just the worst), and maybe also prolapse or haemorrhoids (nasty!)

So, what should we take away from this? We really have two options.

1. Maximise the first hour of the day, by being available to defaecate when the urge comes, and further stimulating it by eating breakfast and having a coffee (if coffee is your thing).

2. Figuring out how to re-trigger the urge (Definitely not easy, and not a great option, but is sometimes possible)

If you’re struggling with constipation, and you’re falling into the above-mentioned category of “ignoring the urge”, start by trying to make more effort to go on the “urge” and not waiting.

If this still hasn’t fixed your constipation issue (which, like I said can be caused by a multitude of things!) and you’re morning routine is fine, book in to see a women’s health physiotherapist, and dig a little deeper into your constipation issue.

 

Feeling like you need an expert on your side?

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