Author: Kimberlie Landers PT, DPT at N2 Physical Therapy Swedish Medical Center
Bowel movements are often a subject that is kept to ourselves and not talked about, especially if you are having problems. However, the quality of a bowel movement can tell a lot about your health and well-being.
Through analysis of your stool you can gain vital information on your diet, hydration, overall GI health, and even levels of stress and anxiety.
How does a healthy GI system work and how are pelvic floor muscles involved?
Mouth, Esophagus and Stomach
Food passes from the mouth and immediately the body begins to break down the food particles into chyme, a mushy substance that can be digested. This substance then travels down the esophagus to the stomach. The body absorbs important nutrients, and the leftover waste products then enter the digestive tract.1
The bowel collects the waste products and absorbs water thus dehydrating the stool. At this point feces consist of
water, indigestible fiber, undigested food (such as corn and small seeds), sloughed-off dead cells, living and dead bacteria, intestinal secretions, and bile. The worn-out red blood cells in bile give stool its distinctive brown color. The colon collects feces until it is full enough and then empties into the rectum.1
The rectum and anus
The rectum is a chamber that connects the large intestines to the anus. It collects and stores feces until there is enough feces that cause a stretch reflex. This sends a message to the brain giving you the urge to have a bowel movement. The anus is the last part of the GI tract. This area consists of pelvic floor muscles and the internal and external anal sphincter.1
The Pelvic Floor and the Brain
The brain decides whether it is time to have a bowel movement. If you choose not to have a bowel movement, the pelvic floor and sphincter muscles contract and the rectum relaxes so that the urge to have a bowel movement temporarily passes, and stool moves back up the digestive tract out of the rectum.1
The pelvic floor muscles are normally contracted against the anus and rectum which creates an angle that prevents feces from emptying when you do not want them to. If your brain decides it is time to have a bowel movement, your pelvic floor and sphincter muscles relax which straightens the anorectal angle, and the rectum contracts expelling the feces.2 The best position for straightening the anorectal angle to allow easier passage of stool is a “squatting” position on the toilet. Place your feet on a stool while sitting on the toilet to improve ability to empty your bowels.
What is the pelvic floor?
The pelvic floor consists of three muscle layers that work together to support the pelvic organs (bladder, rectum and uterus), assist in urinary and fecal continence, stabilize the pelvis, and work as a pump for venous and lymphatic drainage.3
- Superficial perineal layer: innervated by the pudendal nerve
- Superficial transverse perineal
- External anal sphincter
- Deep urogenital diaphragm layer: innervated by pudendal nerve
- Compressor urethra
- Uretrovaginal sphincter
- Deep transverse perineal
- Pelvic diaphragm: innervated by sacral nerve roots S3-S5
- Levator ani: pubococcygeus (pubovaginalis, puborectalis), iliococcygeus
- Obturator internus
Types of bowel dysfunction:
Constipation, defined as infrequent bowel movements (less than 3 a week) and difficulty passing stool, is estimated to affect up to 42 million Americans per a 2015 US News and World Report article titled “8 Myths About Constipation.”4 One study by the Women’s Health Journal of Physical Therapy reported 30% of the population at any given time experiencing symptoms of constipation.5 Although there are many medical reasons for constipation, physical therapy can treat changes in a person’s musculoskeletal system that may cause or contribute to it.
Pelvic floor dyssynergia is the tightening, or lack of relaxation, of specific pelvic floor muscles, including the external anal sphincter, during attempted defecation. According to a 2013 Mayo Clinic Clinical Update, “as many as 50% of people with chronic constipation have pelvic floor dyssynergia.”6 Non-relaxation as described here can make it difficult or impossible to pass bowel through the rectum, as well as contribute to loss of coordination and muscle changes over time.
Fecal Incontinence varies in prevalence given different causes, and different research settings. At N2 Physical Therapy we engage in open discussions in a safe environment, and have learned that fecal incontinence is often experienced by people throughout different phases of life. Radiation for cancer, vaginal delivery, and tearing or episiotomies after delivery are all linked to fecal incontinence in varying forms.7
Other potential reasons for treatable bowel difficulties may be:
Low Anterior Resection (LAR) is a sphincter-preserving surgical technique performed for treatment of rectal cancer. This surgery allows for restoration of bowel continuity to avoid a permanent colostomy in about 50-80% of patients. Recent evidence demonstrates that pelvic floor rehabilitation is useful for improving functional outcome after a LAR, especially in regards to improved continence, stool frequency and quality of life.8
Rectocele: Also called posterior vaginal prolapse, a rectocele is a type of pelvic organ prolapse that occurs when some, or all of the rectum slides out of place due to the fascia between the rectum and the vagina weakening.9 This can occur due to pelvic floor muscle weakness, ligamentous weakness, or neurological changes. Signs may include an uncomfortable feeling of “fullness” or falling out, and symptoms include constipation and/or pelvic pain.10
Proctalgia fugax: Proctalgia fugax is defined as recurrent episodes of pain localized to the anus or lower rectum that
last from seconds to minutes, with no anorectal pain between episodes.11,12 Anal sphincter spasm is the most common proposed aetiology for proctalgia fugax, which corresponds to increased anal resting tone.13
Levator ani syndrome or chronic proctalgia presents as a vague, dull ache or pressure sensation high in the rectum that often feels worse when sitting and lasts at least 20 minutes.12
Pudendal nerve compression, irritable bowel syndrome, and increased stress or anxiety may be related to various bowel symptoms.
Anal Fissures: Anal fissures are cuts or tears in the lining of the anus. Often, the cause of anal fissures is unknown, but they are generally due to trauma or overstretching of the anal tissue. This may include childbirth, hard stool, and increased pelvic floor muscle tension (including the anal sphincter).14 Physical therapy will target pelvic floor muscle tension in order to increase the mobility of the tissue, as well as focus on dietary and behavioral modifications to help prevent further fissures.
The above diagnoses can be treated successfully with physical therapy through a number of interventions, including educational and behavioral recommendations, diet modifications, pelvic floor muscle relaxation techniques, dry needling of trigger points, biofeedback training for relaxation and coordination with the abdominal muscles, individualized exercise program, and manual therapy techniques, including abdominal bowel stimulation massage.4,5,8,15,16,17
What to expect at your first PT visit
We understand that you may be apprehensive when seeing a pelvic physical therapist for the first time. The therapists at N2 PT are good listeners and empathetic to what you are going through. A lot of time will be spent putting you at ease and explaining all steps of the process.
If you are uncomfortable with an internal examination there are alternate methods for evaluation, and you will work with your physical therapist to design a treatment approach that is comfortable for you.
- Part I: Conversation
- The physical therapists at N2 PT want to hear your story and listen to what you have to say. They will get a detailed history on your symptoms in order to develop a comprehensive treatment plan. They may ask about bladder, bowel, and sexual intercourse as everything is connected. They will explain how the pelvic floor could be contributing to your symptoms and educate you on anatomy and physiology along the way.
- Part II: The Examination
- The physical therapists at N2 PT will not only evaluate the pelvic floor, but any other part of the body that may be connected to your problem. We treat the whole person and will educate you on how everything may be connected. We will assess posture, range of motion, strength and perform special tests that help to determine the root of the dysfunction.
- External Exam: The skin, perineum and external genitalia will be assessed to determine if there are trigger points or tenderness as well as testing sensation and reflexes.
- Internal Exam: Due to the location of the pelvic floor muscles, the best way to evaluate them is to do an internal exam. This can be done through the vagina or rectum. Again, if you are uncomfortable with an internal exam on the first visit- don’t worry! The physical therapists will work with you to build a rapport and help you understand why this is the best treatment option. In the meantime the therapist can evaluate your back, hips and external pelvic floor.
- The internal exam consists of a single finger exam that differs a lot from what you are used to at your doctor’s office.
- We do not use a speculum or have to goal to evaluate the cervix, uterus or bladder. Our focus is on the pelvic floor muscles, ligaments, fascia, joints and soft tissue structures.
- With a single finger internal exam therapists are able to determine if you have pain, trigger points and/or muscle spasm.
- The therapists will test your ability to contract your pelvic floor (kegels) and relax or lengthen your muscles.
- Part III: Education
- Throughout the evaluation your therapist will be educating you on anatomy, your diagnosis and how physical therapy can help
- You will be started on an individualized home exercise program and a bowel program to help resolve your symptoms.
- At N2 PT we have open and honest communication and you should never feel embarrassed to ask questions!
Call us today to resolve your bowel symptoms and help you get your life back!
Kimberlie Landers PT, DPT
- NIDDK. Your Digestive System and How it Works. https://www.niddk.nih.gov/health-information/health-topics/Anatomy/your-digestive-system/Pages/anatomy.aspx. Last accessed 10/7/2016
- Squatty Potty or Correct Lavatory Posture. http://colonicvitalityuk.com/news.asp?page=2&id=25. Last accessed 10/7/2016
- Ritchie, Laura. Physiopedia. Pelvic Floor Anatomy. http://www.physio-pedia.com/Pelvic_Floor_Anatomy, last accessed 10/7/2016
- Miller, Anna. 8 Myths About Constipation. http://health.usnews.com/health-news/health-wellness/articles/2015/04/08/8-myths-about-constipation, last accessed 09/23/2016
- Binford J. Physical therapy management of outlet dysfunction constipation and pelvic pain. J Womens Health Phys Therap. 2013; 37(2): 59-69.
- Mayo clinic staff, http://www.mayoclinic.org/diseases-conditions/constipation/basics/definition/con-20032773, last accessed 09/23/2016
- Mayo clinic staff, http://www.mayoclinic.org/diseases-conditions/fecal-incontinence/home/ovc-20166830, last accessed 09/23/2016
- Visser WS, te Riele WW, Boerma D, van Ramshorst B, van Westreenen HL. Pelvic Floor Rehabilitation to Improve Functional Outcome After a Low Anterior Resection: A Systematic Review. Annals of Coloproctology. 2014;30(3):109-114. doi:10.3393/ac.2014.30.3.109.
- Beck DE, Allen NL. Rectocele. Clinics in Colon and Rectal Surgery. 2010;23(2):90-98. doi:10.1055/s-0030-1254295.
- Wang Y, Hart DL, Mioduski JE. Characteristics of patients seeking outpatient rehabilitation for pelvic floor dysfunction. Phys Ther. 2012; 92(9): 1160-1174.
- Jeyarajah S, Chow A, Ziprin P, Tilney H, Purkayastha S. Proctalgia fugax, an evidence-based management pathway. Int J Colorectal Dis. 2010; 25: 1037-1046.
- Wesselman U, Burnett AL, Heinberg LJ. The urogenital and rectal pain syndromes. Pain. 1997; 73: 269-294.
- Bharucha AE, Trabuco E. Functional and Chronic Anorectal and Pelvic Pain Disorders. Gastroenterology clinics of North America. 2008;37(3):685-ix. doi:10.1016/j.gtc.2008.06.002.
- Mayo Clinic Staff. Anal Fissure. http://www.mayoclinic.org/diseases-conditions/anal-fissure/home/ovc-20168229. Last accessed 10/7/2016
- Harrington KL, Haskvitz EM. Managing a patient’s constipation with physical therapy. Phys Ther. Nov 2006; 86 (11): 1511-1519.
- Starr JA, Drobnis EZ, Lenger S, Parrot J, Barrier B, Foster R. Outcomes of a comprehensive nonsurgical approach to pelvic floor rehabilitation for urinary symptoms, defecatory dysfunction, and pelvic pain. Female Pelvic Med Reconstructr Surg. 2013; 95 (5): 260-265.
- Mayo Clinic Clinical Update, http://www.mayoclinic.org/documents/mc2025-0113-pdf/doc-20078947, Digestive DIseases Update, Vol 1, No. 1, 2013.
- Abdominal Pain. http://www.medicinenet.com/abdominal_pain_causes_remedies_treatment/article.htm. Last Accessed 10/19/2016
- Digestion. https://www.niddk.nih.gov/health-information/health-topics/Anatomy/your-digestive-system/Pages/anatomy.aspx. Last Accessed 10/19/2016
- Anorectal Angle. http://colonicvitalityuk.com/news.asp?page=2&id=25. Last Accessed 10/19/2016.
- Pelvic floor anatomy female. https://www.yogatuneup.com/blog/2013/10/16/pelvic-floor-dysfunction-no-more/. Last Accessed 10/19/2016
- Pelvic floor anatomy male. http://humanbodyanatomy.us/male-pelvic-floor-anatomy/ Last accessed 10/19/2016
- Levator Ani Trigger point. http://www.triggerpoints.net/muscle/levator-ani. Last accessed 10/19/2016
- Physical therapy. https://www.nyboneandjoint.com/conditions-treatments/physical-therapy/ Last Accessed 10/19/2016