Chronic constipation is frequently a cause of damage to the pelvic floor muscles and fascial support (ligaments). Chronic constipation can cause stretching of the pudendal nerve due to prolonged and repetitive straining (leading to pelvic floor weakness secondary to nerve damage).
Constipation also creates more pressure on the bladder and urethra which may cause increased urinary frequency or retention.
When you are constipated, diet recommendations, toilet habits and positions, and exercise and bowel mobility exercises such as the “I Love You” massage all need to be considered and addressed. These modifications should be made before laxatives or stool softeners are used.
- Fluid intake should be ½ oz. per pound of body weight of non-caffeinated fluid. This does not include alcohol. Most of your fluid intake should be water, and should not include sweetened beverages. Refined sugar contributes to constipation.
- Fibre intake should be approximately 30-40 grams/day. If you are quite a bit below this recommended level of fibre, increase your fibre slowly so as not to cause bloating and pain.
- Exercise: walk daily for at least ½ hour per day
- If you are constipated, minimize your caffeine and alcohol intake
- It is important to eat insoluble fibre. This includes lots of leafy green vegetables. This gives looser more fibrous stool. (Please note that some medication absorption is affected by increased fibre. For example, Calcium, Potassium, Iron and Thyroxin are more poorly absorbed when taken with a high fibre meal because it attaches to the fibre and is expelled. Take these medications at a different time than when you eat food which is high in fibre.) Eating foods such as spinach, rhubarb and prunes can be helpful in stimulating the intestines. When you are constipated, you should not have any white rice.
- Use the “I Love You” (ILU) massage 1-2x/daily to increase the processing speed of your food through your intestines. Sluggish bowels can contribute to constipation. Just like leaving a cake too long in the oven can cause the cake to dry out, the motility (movement of food) of your bowels can also contribute to your constipation. If the waste materials are left in your bowels for longer periods of time, more water is extracted, and you become constipated.
- Use Knee to chest stretches to stimulate bowel motility (movement of food and waste materials). Do these stretches every morning to help stimulate your bowels. Lie on your back, straightening one leg, and drawing the other knee to chest, hold this position for 30-60 seconds; repeat on the other side. Then repeat the stretch by bringing both knees to your chest at the same time for 30-60 seconds.
Awareness Training for Fecal Urgency:
- You need to learn to be aware of the reflexes that create an urge to empty the bowels (usually 10-30 min after a meal; occasionally, it can take up to 60 minutes)
- This urge may occur 1-2x/day after a meal, or every 2 days depending on the speed of transportation of the bowel contents to the colon (ILU massage may help if transit time is slow, as well as walking every day and drinking adequate fluids)
- The urge to defecate occurs each time a portion of the stool reaches the rectum
- This urge results in relaxation of the pelvic floor muscles (if the muscles are weak, you may become incontinent)
- If the reflex is suppressed because of rushing around and finding no time to go to the bathroom when the urge occurs, then the stool will dry out and become constipated (like a cake left in the oven for too long)
- To retrain this reflex, sit on the toilet 20 minutes after every meal, for 2-3 minutes, practicing deep breathing and relaxing the pelvic floor (see Reverse Kegels)
- Retraining proper bowel evacuation is a process which may take many months, but the result is gratifying and rewarding
Positions for Constipated Bowel Movements:
We never discuss with anyone how best to have a bowel movement. When you use the suggested positions below there will be less pressure on your pelvic floor, which will help with prolapse and pelvic pain. When sitting on the toilet to have a bowel movement, your feet should be supported and your knees should be above your hips (placing your feet on a foot stool will get you into this position). Squatting is the natural position for eliminating waste, and putting your feet on a footstool will start to mimic this position. While sitting on the toilet, it also helps to relax your mouth and your pelvic floor (see Reverse Kegels). Breathe slowly and deeply, in through your nose, and out through pursed lips, as if you are blowing through a straw. Instead of straining you can help the movement of stool, when your stool is starting to descend, by reaching over your right shoulder with your left arm, turning your trunk and head as well to the right. This will mechanically help you to evacuate your stool to minimize straining and placing further stress on your pelvic floor.
If you have a rectocele (bulge of the rectum into the vagina), use 1-2 fingers or a tampon to push posteriorly (backwards) against the back vaginal wall at the same time as you are evacuating. The tampon could be inserted prior to the bowel movement to support the posterior vaginal wall. You may also try maintaining pressure on the perineum with your hand(wrap your fingers in tissue first).
Some other things to consider:
- Your knees should be above your hip level with your feet supported on a stool. This mimics the position of squatting during a bowel movement, which is how we were intended to defecate. Toilets are a civilized luxury, but they are not kind to our pelvic floors because in sitting, the angle between the anus and rectum is too high, which makes it difficult for stool to get around the “corner”
- Do not force out bowel contents. It is better to activate bowel evacuation through movement. Turn your trunk to the left and right repetitively if it feels like you have to go but nothing is coming; or tilt your pelvis forwards and backwards gently and repetitively as you sit on the toilet
- Reach over the right shoulder with your left hand as the stool moves into the anal canal
DON’T strain; take a deep breath in, and breathe out slowly through pursed lips as you gently push using your diaphragm instead of your abdominal wall
- You can lean forwards with a book against your stomach to increase intra-abdominal pressure without straining
- Don’t stay on the toilet for more than five minutes; if you can’t go, get up and get busy; try again when the urge returns, or 20 minutes after your next meal
For urination, the pelvis should be tilted slightly forward. Slow deep breathing may help to relax the pelvic floor. Breathe normally without straining.
- Relax your jaw and drop your pelvic floor if you have difficulty with starting your stream (see Reverse Kegels)
- Breathe out slowly through pursed lips as if you are blowing through a straw
- Allow your bladder to contract to push out the urine; this is an action that we do not have direct control over.
- Allow it to happen. Actively pushing with your bladder will cause more pressure on your pelvic floor and can damage the involuntary muscle of the bladder, called the detrusor muscle. This may contribute to an overactive bladder.