I am thrilled to have the opportunity to present TWO webinars over the next few months with Therapy Network Seminars! The first, “Introduction to Pelvic Floor Rehabilitation” will be next Thursday, 11/5 8:00 – 9:30 p.m. EST and will provide introductory information about pelvic floor anatomy and function, common diagnoses related to pelvic floor dysfunction, basic information on what pelvic PT really involves, how to screen for pelvic floor dysfunction in YOUR patients, AND most importantly, how you can begin to integrate the pelvic floor into treatment the very next day!
Then, on 12/10 8:00 – 9:30 p.m. EST, I will be presenting on “Pelvic Floor Dysfunction in the Adult Athlete.” This webinar will dive deeper into the role of the pelvic floor in stability and will explore the relationship between the pelvic floor and the other deep stabilizers around the pelvis. We will also discuss how to integrate the pelvic floor and the diaphragm within functional core stabilization, common diagnoses related to pelvic floor dysfunction in the adult athlete, and specific key components to be addressed for women returning to athletics postpartum.
I am super excited to be presenting these webinars, and I hope some of you will join me!!
Register today for the early bird discounted rate of $31!!
I’ll admit it… I like treating pooping problems. I know that grosses some people out, but it’s true. I think it’s because bowel problems really really impact people’s lives. I mean, pooping is a super basic human activity–so when it’s not working the way it should, it’s really awful.
I have recently had quite a few patients who are having difficulty evacuating their bowels. Now, there are multiple reasons why this could occur (I know, I’ve written about constipation a lot already, see here for evidence)–but today, we’re going to chat about one in particular, dyssynergic defecation or sphinctor dyssynergia.
What exactly is dyssynergic defecation?
Basically, your pelvic floor muscles work with your colon reflexively. When your colon is contracting to push the poop out, and you are sitting on the toilet ready to empty your bowels, the muscles should relax and open to allow this to occur. Sometimes, this relationship becomes dysfunctional, and basically, you think you are pushing and relaxing the sphinctor muscles, but instead, the muscles are contracting and closing the sphinctor. I know what you’re thinking– Jessica, I would know if I were actually contracting my muscles instead of relaxing them while I poop. But, no, you wouldn’t. In fact, many patients are shocked when I show them the actual coordination of their muscles.
Typically, incoordination of the pelvic floor muscles is paired with poor coordination of the abdominal muscles, and often impaired sensation of the rectum. Dyssynergic Defecation is diagnosed typically by an anorectal examination, and anorectal manometry/defecography testing (like this, with an MRI, or by assessing muscle activity with EMG while the person attempts to expel a balloon, or other testing options)
Why does it happen?
Dyssynergic defecation is very common in people who have constipation. In fact, this review suggested that close to 40% of people with constipation have this incoordination pattern. There are several factors that can contribute to dyssynergic defecation. This review estimated that close to 30% of adults with dyssynergic defecation patterns had constipation as children, and found that 46% had frequent straining to empty hard stool. But there are other factors that can contribute as well, such as:
low back pain
history of sexual abuse/trauma
poor behavioral habits related to bowel health
nothing (like many other things, we sometimes just don’t know why it happens)
What are the signs and symptoms?
As we discussed previously, dyssynergic defecation is extremely common amongst those struggling with constipation (typically meaning < 3 BMs per week, as well as symptoms of abdominal discomfort, bloating, and/or difficulty emptying bowels). This article looked at the most common reported symptoms of those with dyssynergic defecation, and found that many experienced the following:
Excessive straining to have a bowel movement
Feeling of incomplete evacuation after a bowel movement
Frequent hard stools
Frequently utilizing digital maneuvers to empty stool (this means, using a finger to either help pull stool out of the rectum, or using a finger to press inside the vagina to help empty)
What can you do about it?
The great news is that men and women (and kids too!!) with a dyssynergic defecation pattern can respond very well to conservative treatment! Pelvic physical therapists are typically the providers of choice when it comes to helping people with these problems, and work closely with GI and Colorectal Physicians to help these men and women. Treatment typically involves a few different components:
1. Developing amazing bowel habits. You know that has to be first on my list. If your bowel habits are not stellar, we can try to help your muscles all we want, but you will still have difficulties emptying. So, first things first, we need to make sure your dietary habits rock, you have a great bowel routine, and you know how to sit on the toilet in the most optimal way. Wondering what that toilet position is? Check out this sort of funny, mostly weird video by my favorite potty comedians and stool developers (pun intended), Squatty Potty.
2. Surface EMG Biofeedback training to improve muscle coordination: Biofeedback training uses surface electrodes placed at the anal sphinctor muscles and the abdominal muscles to identify the type of pattern a person uses to expel a bowel movement. Once we identify the pattern you currently use, we can work together to improve the pattern so that your sphinctor muscles relax when you generate abdominal pressure to empty your bowels. Seems pretty basic, right? But the right biofeedback training can make a HUGE difference–and the current research really supports this treatment for anyone with this problem. (See this article, this one, that one, and this one!)
3. Making sure your pelvic floor muscles are strong, FLEXIBLE, and well-coordinated. So, we’ve talked in detail about the pelvic floor muscles on this blog. Remember, we all want muscles that can contract AND relax. And, for dyssynergic defecation patterns, the relaxation component is extremely important! Often times, people who have difficulty relaxing their muscles to have a bowel movement tend to have tender, overactive pelvic floor muscles to begin with. So, treatment will also focus on improving awareness of the pelvic floor muscles, learning to relax the muscles (dropping and lengthening them), and often will include some manual therapy (yes, internal vaginal or rectal) to help reduce the tenderness and improve the mobility of the muscles.
4. Balloon retraining. People love hearing about this one… but it really is an awesome and effective treatment for so many men and women!! (Research supports it also– see here and here!) This treatment basically uses a small balloon that is attached to a catheter and is inserted into the rectum, and slowly inflated. Often times, people with dyssynergic defecation patterns have decreased sensitivity in the rectum, so they will not feel the presence of stool (or a balloon!) in the rectum when they typically should. Based on what we find initially, we can use the balloon to improve the sensation in the rectum. We can also use a slightly filled balloon to work on proper expelling techniques. I know what you’re thinking, Wow Jessica, this sounds like a super fun and awesome treatment. I know, but honestly, it’s very very helpful for people who need it!
Now, this just scratches the surface in terms of what all we pelvic PTs do to help with dyssynergic defecation. But, I wanted to get the conversation started! This tends to be a topic many people don’t talk about… in fact, I have had men and women travel SO far just to get the initial diagnosis! And, I need that to stop… hence this blog post today. Lastly, if you are having problems with constipation and think you may have this problem– Go see a GI/Colorectal Physician! Honestly, make an appointment today! And, contact your local pelvic PT. If you live in Atlanta or the surrounding area, give me a call! It’s time to get your bowels back in order (or even in order for the first time!).
I always look forward to hearing from you! So please, ask any questions or make any comments below!!
A few years ago, I participated in a Women’s Health Fair with my pelvic health team from Greenville, SC:
If you notice in the photo, we had a “Test Your Women’s Health IQ” game at our booth. The premise: 10 True/False questions… with an awesome prize if you get them all right. So, we had a group of about 4 or 5 guys (mid 20s-30s, all working for some tech company, I believe) come up to our booth, and confidently ask to take our test. The test was going pretty smoothly, and they were actually doing surprisingly well….until we reached this question:
True or False. It is normal for women to have discomfort/pain during sexual intercourse.
The guys chatted among themselves briefly, then confidently said, “Yeah, that one’s true… not always, but sometimes, yeah.”
Seriously guys?? In that moment, I felt a mixture of annoyance that there really are so many people out there who believe that women should have pain during sex, and also a whole lot of compassion for the poor women who may or may not have these guys as sexual partners.
Unfortunately, I hear this misconception frequently. Pain during sexual activity is fairly common (up to 1 in 5 women have pain during sex!), and somehow, women became convinced that this is “normal” and they just have to “deal with it.” But, I’m hear today to tell you that is not true!! There really are so many things that can cause pain or discomfort during sexual activity, and there are so many things that you can start today to help!
First things first, if you or your partner is having discomfort or pain during sexual activity, it is very important to be medically evaluated. Pain can be caused from urinary tract or vaginal infections, STDs, ovarian cysts, low estrogen, endometriosis, vulvodynia/vestibulitis, overactive, tender pelvic floor muscles**, abdominal scar immobility (yes, that c-section can play a role!)…and many other things! So, your first step is to call your medical doctor and get evaluated. I know that for some people, talking with a health care provider (HCP) about sexual problems can be very uncomfortable–but just remember, we’re professionals. We hear these things every day, and guess what? It’s very very unlikely that you will surprise or shock us by what you say. So, try to get past the embarrassment you may feel, and talk with your HCP. I think you’ll be very very happy you did.
**See note at the bottom of this post
Once you have been evaluated , here are 5 tips to help to improve pain during sexual intercourse!
1.Communication is Key. Yes, between you and your health care provider–but more importantly, between you and your sexual partner. I often treat men and women who will tell me that their partners have no idea that they are having discomfort during sex. It’s easy for people to see sexual pain as a “me” problem–but if you are having pain with sexual activity with a partner–it really is an “us” problem. Approaching the problem together can be so so helpful! It tends to be much less isolating, and often, people will find that they can have more enjoyable sex with better intimacy in the process.
2.Lubrication. Lubrication. Lubrication. There is absolutely no shame in using lubricant during sex. In fact, I recommend it for everyone! Using a quality lubricant can reduce pain significantly! Typically, I recommend a water-based lubricant like Slippery Stuff or Sliquid–but I have had good success with my clients using Coconut Oil or even Olive Oil (be careful if using condoms though or if you are prone to infection). Several gynecologists I know especially recommend a natural oil for women who have vulvodynia or vestibulitis/vestibulodynia.
3.If At First You Don’t Succeed…Try A Different Position. Seems pretty basic, right? But many couples will get in habits of using the same positions, and sometimes, position alone can make all the difference in the world. A different position changes how anatomy interacts, so depending on why you are having pain, a new position may be much more comfortable. If you’re having pain while on top, try switching to the bottom or on your side. And, pillows are your friend. Use them to support your legs or back to help you be more comfortable.
4.Foreplay. Pain can really impact the mood. Many times, couples who are struggling with pain during sex will find that sexual desire and arousal become significantly impacted. Setting the mood, and making time for romance and foreplay can help to improve arousal. Arousal is really so important as there will be more natural lubrication and overall body relaxation which should help to improve the experience.
5.Don’t be afraid to ask for help! These little tips are meant to be helpful suggestions–but they won’t necessarily be a fix for many people who are having pain! If you or someone you know are struggling with pain during sexual activity, it really is important to get some help! Pain during sexual intercourse should not be something you have to “just deal with.” I don’t care if you’ve 1) had a baby 2)have a partner who happens to be larger 3) have some dryness as you’ve gotten older 4) have any other excuse for why YOU having pain is normal. Pain is NOT normal. Take the first step–do something about it today!
There are so many wonderful resources out there for people who are experiencing pain during sexual intercourse! Here are a few books I recommend:
Sex Without Pain, by Heather Jeffcoat, PT
Excellent resource by Heather–who happens to be a Duke alum! This book is a self-treatment guide for those experiencing pain with sexual activity.
To Bed Or Not To Bed, by Steve and Vera Bodansky
This book is one I often recommend for those struggling to experience pleasure with sexual activity. Although explicit (**warning), this book does provide step-by-step recommendations to make sex more pleasurable– and also covers other information on romance, foreplay, etc.
Reviving Your Sex Life After Childirthby Kathe Wallace, PT,
This book recently came out about a year ago, and is based on tons of wonderful research by my friend and colleague Kathe Wallace. Kathe has taught pelvic floor education for professionals for years, and this book is awesome!
As this is my first post dedicated to sexual dysfunction, this post is just scratching the surface of a HUGE topic! What else should we learn about? Let me know in the comments below!
**Yes, tender pelvic floor muscles can significantly contribute to pain or discomfort during sexual activity. Remember, the pelvic floor muscles stretch to allow for penetration and contract to provide pleasure. If the muscles are tender, hypervigilant, or overactive, they can contribute to pain or discomfort. If you believe your muscles may be a factor in the pain you are experiencing, it is definitely worth your while to seek out evaluation and treatment by a physical therapist trained in treating pelvic floor muscle problems. Give me a call if you live in the Atlanta area, or feel free to shoot me a message if you need help finding someone near you!