Constipation clarification and what can be done to address it?
Sara is 30-year-old mother of one who has noticed some fluctuations in her bowel movements over the past two years. She used to be “regular” but now feels she has to push at least every other day to make sure she “gets it all out”. She also has been noticing more urine leakage when she coughs and sneezes.
John is a 55-year-old man who changed jobs about 8 months ago. His new job is more lucrative but with more money, comes more stress. He sits at his desk for a minimum of 9-10 hours per day and often eats quick meals and energy drinks to keep himself focused during the day. He has noticed that he no longer has a bowel movement daily and instead it will sometimes take him 3 or more days before he gets the urge to go. He notices increased bloating and cramping the longer the time span between bowel movements, especially once it gets to day 3 or 4.
“Normal” Bowel Movement Habits
Before diving into the “abnormal”, it is important to keep in mind that variation between individuals is acceptable when discussing bowel movements. Typically, “normal” bowel movement frequency can vary between two to three bowel movements per day and three bowel movements per week. Stool should typically be a sausage or snake consistency that is smooth or cracked and a feeling of fully emptying. We should not experience overly dry or hard stool, especially in a pebble consistency, and should not feel it is painful or overly challenging to pass.1
Types of Constipation
Constipation is considered a primary or secondary condition. Primary, or functional, constipation is more common and simply means that the constipation problem is coming directly from the gastrointestinal (GI) tract. It can be divided into categories, including normal transit, slow transit, or outlet obstruction. Primary constipation is determined by the presence of at least 2 symptoms over 12 weeks within the previous 6 months. These symptoms include: infrequent bowel movements, straining (pushing) greater than 25% of bowel movements, lumpy or hard stools greater than 25% of the time, using hands or fingers to help with defecation on greater than 25% of bowel movements, sensation of incomplete bowel emptying greater than 25% of the time, and sensation of anorectal obstruction or blockage greater than 25% of the time.2
Secondary constipation means that the constipation is a result of factors outside the gastrointestinal tract, including bowel obstruction, illness, or medication. If you have recently started a new medication, including NSAIDs like ibuprofen, diuretics, calcium supplements, channel blockers, or anticonvulsants, and have noticed an increase in constipation, discuss this finding with your physician to determine if a change in medication or dosage would be helpful.2 Hormones can also play a role so you may notice a change while pregnant or in the pre-menstruation phase of your cycle.3
Risk Factors for Constipation
Factors that can increase the risk of constipation include non-white ethnicity, advanced age, female, low education level, low socioeconomic status, certain medications, decreased physical activity and depression.2,4
Ways to Address Constipation
Constipation can be addressed and improved without initial use of medication. Daily exercise, adequate fluid intake, slowly increasing dietary fiber, and going to the bathroom with the first urge for a bowel movement are all important. Typically, individuals should be drinking half of his or her body weight in fl oz per day with the vast majority of that being water. A probiotic may also be helpful for regularity and gut health.2,5 While it may seem unrelated, managing stress can help to improve constipation as constipation can be increased from stress or emotional strain.2
Additionally, a squatted position with a forward lean allows for the pelvic floor muscles to lengthen and relax for improved emptying of the bowels.3 Our pelvic floor muscles, specifically a muscle called puborectalis, loops around the rectum and pulls it at an angle to help keep us from pooping our pants every time we move. However, when it is time to have a bowel movement, if that angle does not straighten and the muscles do not relax enough, it can cause difficulty with having a complete bowel movement or cause us to feel like we have to push.
Have you ever heard of the Squatty PottyTM? It is easy to store in your bathroom and helps to achieve a supported squat position; however, you don’t have to rely on a store-bought device. There are plenty of objects that can be used within your home, such as stacking toilet paper rolls or using a stool. Just remember, the goal is to have your knees slightly above your hips with a relaxed forward lean.
Finally, abdominal massage is an excellent non-invasive way to potentially stimulate peristalsis, which is the contractions or squeezing your intestines perform to move food or stool through the gastrointestinal tract. Massage can increase frequency of bowel movements, decrease pain, and decrease discomfort.6-7
Constipation Affects the Bladder
While you may not experience constipation or it may not be your primary concern, keep in mind that constipation can influence stress urinary incontinence (think leaking with laughing, sneezing, or coughing) and overactive bladder (think having the urge to urinate less than 2 hours and having discomfort, pain, or leakage, when you have to hold it). The bladder and the rectum develop from the same tissue when we are in the womb and share a nerve. Overactive bladder has been linked to constipation and fecal leakage. Similarly, constipation and straining with bowel movements has been linked to urinary incontinence.3 Because the bladder and rectum are very close together, pressure or filling in one area can stimulate pressure or filling in another area. If you see a healthcare provider, particularly a pelvic floor physical therapist, they should be screening your bowel AND bladder habits.
Remember, there are many causes of constipation and multiple factors that can be addressed before more invasive medical testing or intervention is needed. Food, particularly fiber, fluid intake, specifically water, exercise, stress management, and positioning on the toilet are all great places to start. If you are finding it difficult to manage on your own, reach out to a healthcare provider, particularly a pelvic floor therapist, for an evaluation and personalized plan of care!
Written by Jordan Schmidt, PT, DPT
References:
U.S. Department of Health and Human Services. (2018, May). Definition & Facts for constipation. National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved February 27, 2022, from https://www.niddk.nih.gov/health-information/digestive-diseases/constipation/definition-facts
Dunlap, J., Dunlap, J., & Dunlap, B. (2021). CONSTIPATION. Gastroenterology Nursing, 44(5), 361-364.
Rane, A., & Dilgir, S. (2017). Defecatory Dysfunction and the Pelvic Floor. Current Obstetrics and Gynecology Reports, 6(3), 237-242.
Mukherjee, S.M., & Marwill, S. (2021). Constipation. In F. Domino, R. Baldor, J. Golding, & M. Stephens (Eds.), The 5-minute clinical consult (27th ed., pp. 216-217). Philadelphia, PA: Wolters Kluwer.
Botehlo, P.B., Ferreira, M.V.R., Araujo, A.M., Mendes, M.M., & Nakano, E.Y. (2020). Effect of multispecies probiotic on gut microbiota composition in individuals with intestinal constipation: A double-blind, placebo-controlled randomized trial. Nutrition, 78, 110890.
Sinclair M. The use of abdominal massage to treat chronic constipation. Journal of Bodywork and Movement Therapies. 2011;15(4):436-445
Zoorob, D., & Anderson, S., (2020). Pelvic Floor Physical Therapy and Women’s Health. Physical Therapy Effectiveness.
