Easing the strain: put your feet up for constipation

In this guest blog, pelvic physiotherapist and comedian Elaine Miller tells us what we need to know to avoid constipation and when the going gets tough. This is the third blog in our new series Evidence for Everyday Health Choices.

Constipation is a miserable condition which can worsen co-morbidities like low back pain, muscle tone problems in people with neurological conditions and confusion in people with dementia. It is therefore a condition that needs to be understood and managed – but there is a dearth of research to guide us.

One of the main issues is encouraging people to seek help. Many people are simply too embarrassed to see their GP about bowel problems, which is a problem because one of the signs of colon cancer is a disruption in habits which lasts for longer than three weeks.

Therefore, I don’t discourage poo talk from my children, not even in front of Grandma (though, I draw the line at “Last Christmas, I went for a poo, and the very next day, I flushed it away. This year, to save diarrhoea, I’ll eat up my grains and fibre…” <proud mum>). The children’s continence charity ERIC has excellent resources for parents and for professionals in health and education, to try and normalise toilet talk.

What is normal?

Normal bowel function is:
When you first feel the urge to poo you can hold on long enough to get to a toilet without accident.
You do a poo within a minute of sitting on the toilet, it doesn’t hurt, and you don’t have to strain.
You completely empty your bowel, you don’t have to go back again, or have a feeling of some “left”.
It is normal for you to feel an urge to poo within about half an hour of eating.  This is the gastrocolic reflex and is what prompts people to want to go to the toilet in the morning. People’s normal pattern can range from several times a day to several times a week – it’s a good idea to pay attention to what your bowel habit is.

Here’s how it works

The indigestible parts of our food pass into the colon, which absorbs water and electrolytes. The large intestine is full of bacteria which change the food remnants into faeces. The time it takes for food to pass from one end of the digestive tract to the other is called “bowel transit time”, one to three days on average, and 90% of that time is spent in the bowel. A slow bowel transit time means the faeces spends longer in the large intestine becomes dehydrated and more difficult to pass.

The stool travels from the colon into the rectum, through the internal sphincter muscle and then through the external sphincter muscle on its way out of the anus. The internal sphincter muscle automatically relaxes the top of the anal canal, triggering nerves to signal that you need to go. The external sphincter is under voluntary control and can push the stool back out of the anal canal if there is nowhere suitable for us to go to the toilet. However, repeated withholding can cause constipation, particularly in children – it’s best to move your bowels when you feel the first urge.

Poo position

PlayDoh man on toilet 2PlayDoh man on toilet 1You can help reduce the stress on the tissues and reduce straining by squatting to pass a bowel movement. This position encourages the pelvic floor to relax. This can be mimicked on a Western style toilet by raising the feet on a low stool. A stool stool, if you will.

Sitting with hips at 90 degrees means the puborectalis muscle is not relaxed, which means the kink in the upper rectum does not straighten out. Raising the feet, so that the hips are flexed beyond 90 degrees straightens out where the colon and rectum join and allows poo to pass more easily. You can use a couple of toilet rolls to rest your feet on, or a children’s kick stool, or buy a specially made stool stool. Leaning on the elbows and making a “moo” (or other) sound reduces the urge to strain.
Physiotherapists commonly teach people to imagine they are widening their waist and pushing their tummy forward, like a barrel or like Shrek, and asking them to pay attention to their anus as they do so. Lean forwards and rest elbows on knees, almost like the crash position on an aeroplane. The anal sphincter should relax, and this basic biofeedback can be very helpful, and can save the person from assuming the recovery position post-poo. A motion-less position…

Why is straining bad?

Straining increases your intra-abdominal pressure and causes congestion of the soft tissues. So, you are more likely to develop piles, prolapse or vaginal varicose veins.   Cases of people fainting or having heart attacks when straining are well known. Ask Elvis.

Also, we know that a full bowel can irritate a bladder – many cases of incontinence are related to constipation. In my experience, deal with the bowel first.

What about diet?

Government guidelines published last year say we should aim for 30g a day of fibre. NHS Choices has some suggestions here for how you can get more fibre into your diet. Increase daily fibre gradually (5g a day) to avoid bloating. And, remember to drink plenty of water.

Bowel diary

Stool chartIt’s a good idea to keep a bowel diary, or, to make the obvious joke, a log log. Note down when you poo, whether there was any straining or leaking of gas or faecal matter and what the poo was like, as measured by the Bristol Stool Scale, a simple medical tool used to classify poo and monitor bowel health and function. Types 1-2 indicate constipation; types 3-4 are ideal; types 5-7 indicate diarrhoea or urgency.

Adjust diet and fluid intake with the aim to be a 3-4 if you are prone to diarrhoea, a 4-5 if you are prone to constipation.

Massage

The first record of abdominal massage as a treatment for chronic constipation was in 1870. Interest has resurfaced and we know it can help move stool along and relieve cramping or bloating symptoms. Many non-randomized studies have suggested that it is an effective intervention for constipation and has no known side effects. A Cochrane review on abdominal massage for chronic constipation is currently being prepared.

People can learn to self massage to good effect – and what mammal doesn’t like the idea of a tummy rub? Start on the right side by the hip bone. Rub in a circular motion up the right side to the rib cage, across the abdomen to the left side and then down to the left hip bone and across the pelvis to the umbilicus. Always massage in a clockwise direction as this is the direction of digestion.

Medication

Best get advice from your GP or pharmacist. For instance, we don’t want people buying themselves over-the-counter bulk forming laxatives if they have chronic constipation. If you are already bunged up, you don’t need any more volume.

Pregnancy, childbirth and bowels

Pregnancy is particularly challenging because the growing uterus squashes the colon and the hormonal changes make it sluggish. Many pregnant women are prescribed iron supplements which increase the risk of constipation. Fear of post-delivery pain from tear or episiotomy sites can cause anxiety around bowel movements.

These issues are often missed in antenatal appointments and classes because of time constraints. It is very important, however, that women get good information about good bowel management – particularly if she has had a tear or episiotomy. You are going to nurse that first postnatal poo along and have to resist the urge to put a bonnet on it and give it a name…(ask me how I know).

Worry and discomfort are going to have a negative impact on maternal happiness and breastfeeding. Improved education might reduce the need for medication in this population. Toilet straining places stress on pelvic tissues and is associated with vaginal prolapse, rectal prolapse and piles. None of which are remotely funny.

What does the research say?

Not an awful lot. Much of the research is poor quality and little of it includes the Bristol Stool Chart, measures of pain or quality of life.

This Cochrane review on interventions for treating constipation in pregnancy compared bulk forming with stimulant laxatives in pregnant women. Data was poor but they concluded there was evidence that increasing fibre formed a better stool. The review states there is a need for further randomized controlled trials (RCTs) in different settings with a range of types of laxative and measurements of pain as well as stools.

mum holding new baby to chest

There’s a lack of evidence on how best to prevent or treat constipation after childbirth

A Cochrane review published last year evaluated effectiveness and safety of interventions for preventing postpartum (after childbirth) constipation. They included five trials, and, again, reporting was poor and none of the trials included pain, straining, incidence of constipation or quality of life. All trials did measure time to first bowel movement. They did not, however, record what the woman’s normal, pre-delivery pattern was. They recommended future trials should include behavioural and educational interventions and measure pain, straining and quality of life as well as time to first post-natal bowel movement.

Another Cochrane review, by the same team, looked at interventions for treating post-partum constipation. They excluded nine studies on the basis that they did not meet the inclusion criteria. They recommended rigorous and well conducted large RCTs.

There are some studies looking at adults with neurological problems, who often have problems with faecal incontinence or constipation. There are lots of papers examining the cause of neurogenic bowel disorders, but, few looking at the management of them. A Cochrane review on this included twenty trials, mostly poor quality, but they suggest that a good bowel routine (using laxatives, suppositories, enemas, diet, exercise and digital evacuation) is important and should  be based on the needs of the individual. Massage and even one education session with a nurse may help reduce constipation, but more and better research is needed before we can say that with confidence. The reviewers commented that there was “remarkably little research on this common problem” and repeated the call for more, good, randomized studies.

Until that happens, we will all just have to continue trial and error. With our knees above our hips.

Top bowel tips

-drink plenty of water

-avoid caffeine

-eat fibre

-exercise

-go when you feel the first urge

-after breakfast, sit on the toilet for 15-20 minutes and wait for the ejection reflex- which does exactly what it says

-take your time on the toilet

-raise feet on a stool, lean forwards

-don’t hold breath, ssss, grrrr, or moo

-do a pelvic floor contraction when the bowel movement is done to encourage complete closing

-congratulate yourself on releasing the poo hostage

Editor: This is the third of our daily posts this week to launch our new series Evidence for Everyday Health Choices. You can read more about it here. Join in the conversation on Twitter where you can find Elaine Miller @GussieGrips and us @ukcochranecentr #EEHealthChoices. 
Creative Commons License
Easing the strain: put your feet up for constipation by Elaine Miller is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.
Based on a work at http://www.cochranelibrary.com. The featured image and the image of mother and baby have been purchased for Evidently Cochrane from istock.com and may not be reproduced. The sitting man and log log are Elaine’s work so do ask her if you want to use them!

Links:

Leung L, Riutta T, Kotecha J, Rosser W. Chronic constipation: an evidence-based review. Journal of the American Board of Family Medicine2011;24(4):436-51. Available from: http://www.jabfm.org/content/24/4/436.full.pdf+html

Rome Foundation. Appendix A: Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders. C3. Functional Constipation: Diagnostic criteria. In: Rome III The Functional Gastrointestinal Disorders. 3rd ed. Raleigh, NC: Rome Foundation; 2006, October. p. 890. Available from: http://www.romecriteria.org/assets/pdf/19_RomeIII_apA_885-898.pdf

McClurg D, Hagen S, Dickinson L. Abdominal massage for the treatment of constipation (Protocol). Cochrane Database of Systematic Reviews 2011, Issue 4. Art. No.: CD009089. DOI: 10.1002/14651858.CD009089.

Harrington KL, Haskvitz EM. Managing a patient’s constipation with physical therapy. Physical Therapy 2006;86(11):1511-9. Available from:http://ptjournal.apta.org/content/86/11/1511.full.pdf   

Rungsiprakarn P, Laopaiboon M, Sangkomkamhang US, Lumbiganon P, Pratt JJ. Interventions for treating constipation in pregnancy. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD011448. DOI: 10.1002/14651858.CD011448.pub2.

Turawa EB, Musekiwa A, Rohwer AC. Interventions for preventing postpartum constipation. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD011625. DOI: 10.1002/14651858.CD011625.pub2.

Turawa EB, Musekiwa A, Rohwer AC. Interventions for treating postpartum constipation. Cochrane Database of Systematic Reviews 2014, Issue 9. Art. No.: CD010273. DOI: 10.1002/14651858.CD010273.pub2.

Coggrave M, Norton C, Cody JD. Management of faecal incontinence and constipation in adults with central neurological diseases. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD002115. DOI: 10.1002/14651858.CD002115.pub5.

Panayi DC, Khullar V, Digesu GA, Spiteri M, Hendricken C, Fernando R. Rectal distension: the effect on bladder function. Neurourology & Urodynamics 2011; 30(3): 344–7. doi: 10.1002/nau.20944.

 

 

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Elaine Miller

About Elaine Miller

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Elaine Miller is a pelvic physiotherapist in Edinburgh with a hobby of stand up comedy. She combined the two and wrote “Gusset Grippers”, a show about pelvic floors. It won the “weirdest show of the Fringe” award at the Edinburgh Festivals Fringe, which is, apparently, a compliment. Elaine believes that humour is the fastest way to break down the taboos which surround continence and sexual dysfunctions. She has written for Evidently Cochrane, Mumsnet, been featured in The Glasgow Herald, and spoken about continence on Radio Scotland and This Morning. Her aim is to go on Loose Women and make the obvious joke. You can follow Elaine on Twitter @GussieGrips

4 Comments on this post

  1. […] Evidence based pooping. […]

  2. […] dans la nature, et accroupi ! Le blog médical Evidentlycochrane publié un rapport expliquant que la constipation pouvait être évitée si nous faisions en […]

  3. a brilliant article and a great combination of humour and fact – toilet humour at its best

    Kathy Priday / Reply
  4. Hello! This post could not be written any better!
    Reading through this post reminds me of my old room mate!
    He always kept chatting about this. I will forward this page to him.

    Fairly certain he will have a good read. Thank you for sharing!

    Wendy / Reply

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