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. 

Page last updated 23 January 2023

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 (with feet raising on a raised stool) PlayDoh man on toilet (with feet on floor) You 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. The NHS website has some suggestions for how to 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 chart It’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.


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.

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.


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 (published September 2015) compared bulk forming with stimulant laxatives in pregnant women. Data were 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.

mother holding newborn baby
There’s a lack of evidence on how best to prevent or treat constipation after childbirth.

The authors of the Cochrane Review Interventions for preventing postpartum [after childbirth] constipation were able to include just five trials when they published the review in 2015 and found no more to add when they updated it in 2020. 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 (September 2014). They excluded nine studies on the basis that they did not meet the inclusion criteria and found none that they could include. 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. The Cochrane Review Management of faecal incontinence and constipation in adults with central neurological diseases (January 2014) 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’s note: The Cochrane Review Probiotics for treatment of chronic constipation in children (March 2022) found a lack of evidence on the effectiveness or safety of probiotics used to treat chronic constipation without a physical explanation in children.

Join in the conversation on Twitter with @CochraneUK and @GussieGrips or leave a comment on the blog. 

Please note, we cannot give specific medical advice and do not publish comments that link to individual pages requesting donations or to commercial sites, or appear to endorse commercial products. We welcome diverse views and encourage discussion but we ask that comments are respectful and reserve the right to not publish any we consider offensive. Cochrane UK does not fact check – or endorse – readers’ comments, including any treatments mentioned.

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.

References (pdf)

Easing the strain: put your feet up for constipation by Elaine Miller

is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International

35 Comments on this post

  1. […] Cochrane Regno Unito notato che è necessario piegarsi in avanti sui gomiti per ridurre la necessità di sforzarsi. […]

  2. […] Cochrane UK noted you need to be leaning forward on the elbows to help reduce the need to strain. Your elbows […]

  3. […] Cochrane UK noted you need to be leaning forward on the elbows to help reduce the need to strain. Your elbows […]

  4. […] Cochrane UK noted you need to be leaning forward on the elbows to help reduce the need to strain. Your elbows […]

  5. […] Cochrane UK noted you need to be leaning forward on the elbows to help reduce the need to strain. Your elbows […]

  6. […] Evidently Cochrane: Easing the Strain: put your feet up for constipation […]

  7. […] Easing the strain: put your feet up for constipation […]

  8. I am really benefited by this post and I got a chance to read it through Physiopedia Newsletter every Tuesday. Now I can give more better suggestions to my clients when they open up to me about Constipation issues. Thank you

    Sweety Joyce / Reply
  9. I have learned that the single largest cause of constipation is that we don’t drink enough water! With this type of constipation, things worsen, as the stool stays longer than it should in the large intestine and more liquid is absorbed from it, making the constipation worse.

    You did not mention natural stool softeners like mineral oil, which doesn’t get absorbed in the intestines, and therefore keeps the stool soft and easier to pass.

    A great way to naturally help prevent constipation is to eat a orange every morning, even with the pith. This increases fiber in a natural way, and contains enough liquid to prevent the problems you could experience with fiber laxatives and not enough fluids.

    Ange / Reply
  10. Hi Elaine, how are you? Congratulations on the blog, I follow it weekly. I tried this procedure and it didn’t work for me. I’m so tired, I’ve tried so many supplements, meds and exercises. I was referred to a new prebiotic supplement do you think I should try it? I’m suffering a lot, I have nothing else to do, I stay for 1 week if I even go to the bathroom.

    Mary J. / Reply
    • Hi Mary, We’re glad you follow the blog. I have taken the weblink out of your comment as we don’t allow links to commercial websites. Elaine is taking a break from social media while she is involved in an election campaign but you may wish to follow her on Twitter @GussieGrips or go to her website gussetgrippers.co.uk
      Best wishes,
      Sarah Chapman [Editor]

      Sarah Chapman / (in reply to Mary J.) Reply
  11. After reading this blog I can surely say that you have done a lot of research on this topic.

    I like how you have mentioned the excellent tips to prevent constipation and its causes here.

    I know many people who are unaware that constipation can be prevented because of this lack of knowledge, people tend to ignore it and have severe problems in their old age.

    Anyways, there were many causes here that I was not aware of. It provided me with value.

    Thank you again for writing on this. Highly appreciated.

    Mirza / Reply
  12. Shitty article, but I rather enjoyed it atop the stool stool here in the old stool shed.

    William Wallace / Reply
  13. I am 63 years old and have had constipation since childhood. Nothing seemed to work, except at times some small amount of licorice used as a laxative. .Then my sister said: “when you are on the toilet, lean back a little, and lean to the left side, try that”. And it worked wonderfully. It could be a last tactic to use, yet I’m happy with this.

    Janice Connelly / Reply
  14. Fiber makes ALL the difference!

    Have some soluble fibers. Try oats with hot water with some milk in the morning and your bowel movements will be the best thing in your life! The soluble fiber absorb water and add bulk and softness to your stool. Please try it.

    Anoop / Reply
  15. Can you have constipation and diarrhea at the same time

    Sadge Gowey / Reply
    • Yes. If you are constipated, liquid stool may be able go around the “clog” so you are still constipated.

      Pualani / (in reply to Sadge Gowey) Reply
  16. Hmm

    Sadge Gowey / Reply
  17. I find sitting on my hands helps (hands under thighs) as you can rock yourself into different positions, thus making it easier to poop. Also just as you are about to start to lower yourself on to the loo, start pushing a little bit before you get to sitting position. It makes a big difference. Also always go when you get the first urge.

    Graham Stamp / Reply
  18. Lifting my legs and moving forward on the toilet, totally works. Feeling much better now 😁 Thank you so much 👍

    Rosie / Reply
  19. I am 80 years old and I am having a prob with constipation just recently.i am drinking more water and I hope it will improve.

    James / Reply
  20. You may not need a stool. Lean forward and lean your body weight on tip toes. If position annoys your back, arch it if needed. That way you aren’t “carrying ‘two’ stools” to a restaurant restroom. Your tip toes do the job.

    Anonymous / Reply
  21. Very informative & great suggestions

    K. Moorer / Reply
    • I thought I was going to die ,I sent out Text to Ex wife forgiving and caring for i thought last moments of my life,,it was hard as a rock ,instead of toilet I poo on kitchen floor so 8 have counter to hold onto

      Sean / (in reply to K. Moorer) Reply
  22. Really, Really Thank You!!!!!!
    I am having chronic constipation and this is so far the best articel I have read and thanks a lot, it’s has helped me a ton. Great wishes to this author!!!!!!!

    Krishna Raut Pradeep Krishna / Reply
  23. This is the best piece of literature I have read in 60 years. It is so informative and straight forward. I am 70 years old and have sever different pooping problems. This will help me so much. Thank you!

    Brenda Allen / Reply
  24. You’ve never heard this one!!!!
    I would like to know if there’s any research showing why I become so anxious when constipated—-now this is the most important part——doctors always say it’s because I’m anxious about not being able to go. THATS NOT IT!!! I know that’s not it cuz I can wake up in a full blown anxiety attack before I even know I have to go!! It seems there’s an area in my large intestine where once the poo gets past it – whether it comes out or not – once it gets past this certain spot my anxiety is alleviated- believe me it has nothing to do with my feelings about not being able to go. I think when I’m constipated for a long time the toxicity level raise and that is what causes the anxiety. what do you think

    Wanda Witham / Reply
    • Crazy. I’m the same way!!

      Jared Morrisey / (in reply to Wanda Witham) Reply
    • I have been reading a book by Dr Jolene Brighten called “Beyond the Pill”. It covers much more than that though and explains how food and lifestyle work with your body’s natural cycles. There is a chapter on gut health, which explains that you must “always be pooping” as otherwise the toxins (including hormones, caffeine, alcohol) that your liver has filtered out go back into circulation in your body if your bowel movements are too infrequent. This then leads to other health issues from an imbalance in these hormones/chemicals ranging from mood swings, anxiety, aggression, hair loss/gain and whatever those hormones are meant to do, but on overdrive as you now have too much. This could be what you’re experiencing with anxiety getting high after you haven’t pooped for a few days. Perhaps take a look at her research.

      Aimee / (in reply to Wanda Witham) Reply
  25. Good blog on constipation. As a licensed massage therapist I have done MANY stomach massages for my clients over the years. It truly helps! I would suggest people eat more plant based foods .. more smoothies , fresh juices, raw veggies and fruit to help get rid of constipation 😁

    Melissa / Reply
  26. Good blog on constipation and what to do. As a massage therapist I swear by massages! They help all the impacted junk come out naturally. All my clients I have had who were constipated told me massage worked every time. 😃

    Melissa / Reply
  27. Very precisely and informative written blog.
    The blog has covered almost every aspect of healthy bowel.
    Remember constipation can be the cause of dangerous piles,so if you notice anything uncommon in your bowel movements, do get it diagnosed.

    Dr Jaya Maheshwari / Reply
  28. 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
  29. a brilliant article and a great combination of humour and fact – toilet humour at its best

    Kathy Priday / Reply

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