3 years ago, I wrote a post on dyssynergic defecation that over time has become the most viewed post I have ever written. Y’all, people are struggling with pooping. Bowel health is something we all tend to take for granted until it stops working right. So, what is dyssynergia? Basically, dyssynergia refers to a state where your muscles are working against you when you have a bowel movement. Instead of the muscles coordinating well to open and relax to allow the stool to come out, the muscles will contract and fight against the stool coming out. This is a big problem for people struggling with constipation. In fact, this review suggested that around 40% of people with constipation have this problem.
How do you properly poop?
“Why aren’t we ever taught these things?!” I hear this all the time from patients after we discuss the often basic techniques to improve bowel and bladder health. In reality, these habits should be learned and passed down through families, but the reality, more often than not, is that that majority of people do not learn proper habits until problems start happening. So, let’s get started, and get to healthy pooping.
Step 1: Use Optimal Pooping Posture & Positioning
Yes, how you sit on the toilet really does matter. The optimal toilet positioning is one that will allow the muscles around the rectum to relax. This helps to open the angle between the rectum and the anus, and will allow stool to pass more easily. Our friends at Squatty Potty have made major $$$ on this concept with their handy stool. They do have some great videos, and this one listed here gives a nice overview on why a squatted position is more optimal for defecation.
Now, as an aside, should everyone sit with their knees elevated that high on the toilet? That’s going to be a big NO. The optimal position for you may not be the optimal position for the person next to you. The key here is that you need to be as comfortable as possible while sitting on your throne. If your hips hurt, or your back feels tight, etc. when you are squatted like this, change the angle until you find the best position for you.
Step 2: Take Your Time
We all know those people who grab a book and head to the bathroom, only to be seen 30+ minutes later, right? Well, they actually do have the right thought process. Many people get into a pattern of sitting on the toilet and immediately straining and pushing to empty their bowels. This is not often necessary, and actually overrides the normal processes of your colon and rectum. The best habit is actually to 1) Head to the bathroom as soon as you can when you feel the urge to have a BM and 2) Sit and relax on the toilet, giving your body at least 5 minutes to get things moving on its own. If you do need to push or help the body in the process, move on to the next step.
Step 3: If You Need to Push, Push Properly.
Is it ok to sometimes need to push a little to get the poop out? Absolutely! Our bodies are made to be able to do this when needed to assist in getting the stool out. Did you know your GI system actually has several reflexes that aid in pooping? The intrinsic defecation reflex is a reflex that is stimulated when stool enters the rectum. This reflex will trigger the sequence of events that leads to defecation. When this reflex is suppressed (via another reflex, the Recto-anal inhibitory reflex), the colon will be helping you less in getting the stool out. This means that you may need to do a little pushing to assist in the process. So, how do you push?
Proper pushing requires a few things 1) abdominal muscle activation 2) pelvic floor muscle relaxation and 3) breathing. So, if you are holding your breath when you push, that is NOT proper pushing. Before we get started, it can be helpful to test yourself and see what your current habits are. To do this, place your hands on your belly while you sit on the toilet. Perform a fake “push” and see what happens. Did you hold your breath? Did your belly push out into your hands or pull in away from the hands? What did you feel happen at your pelvic floor?
So, now, let’s talk about how to push properly. First, be sure you are in your optimal toileting position. Now, place your hands on your belly and relax your belly forward. Do you feel how relaxing your abdominal wall allows your pelvic floor muscles to also relax? Interestingly enough, the pelvic floor and the transverse abdominis muscles have a neurological relationship. Thus, for the majority of people, these muscles contract together. So, since the transverse abdominis muscle will pull the belly in (leading to pelvic floor muscle contraction), we want to do the opposite–> keep the belly out. Next, with your “belly big,” take a deep slow breath in. Then, as you blow out, think about blowing into your belly, gently tightening the muscles of your abdomen without allowing the belly to draw in. We call this “belly hard.” Lastly, as you are doing this breathing, think about relaxing, lengthening and opening your pelvic floor as you gently bear down (“pelvic floor drop”). So, in summary, this is what we are aiming for:
- Belly Big— relax the belly forward and take a breath in.
- Belly Hard— As you exhale, push into the belly, tensing the abdominal muscles, but not shortening them!
- Pelvic Floor Drop— while you are exhaling, gently bear down, allowing your pelvic floor to open and relax
(Note- several amazing clinicians have developed these concepts and verbiage that best connects with people. Pauline Chiarelli has a great book called Let’s Get Things Moving: Overcoming Constipation, and she discusses this in detail there. “Belly Big, Belly Hard, Pelvic Floor Drop” is a phrase we teach in our H&W Curriculum, and I believe it is also a phrase used by Dawn Sandalcidi, an excellent pelvic PT and faculty member out in Denver, CO.)
Who knew pooping was so complicated?
Please let me know if you have any questions! If you’re a pelvic PT, I would love to hear from you–especially if you have other strategies you like to use to help people learn how to poop! Let me know in the comments!