Dyssynergic Defecation (or…when the poop just can’t get out)

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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.

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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:

  • pregnancy
  • traumatic injury
  • 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
  • Abdominal bloating
  • 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!!

~ Jessica

5 Ways to Decrease a Flare-up on Vacation

It never fails. Around this time of year, many of my patients are traveling, going on fun vacations (just like me! Yep, I was away last week– sorry for the lack of posts!), and the pelvic floor never seems to love that. Unfortunately, vacations for many mean a flare-up of symptoms–worsening of pain from sitting for long car or plane rides, constipation, or other unpleasant feelings. This seems to happen like clock-work. But the good news is, vacationing doesn’t have to be the start of a bad flare. You don’t have to be afraid to go on vacation. In fact, there are a few since steps you can take to reduce and manage the vacation blues.

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 1. Pack your toolbox.  One of the big ways you can reduce the likelihood of a flare, is to plan ahead and pack the necessary tools that normally help you.  Do you normally take a fiber supplement daily to manage the bowels? Pack it. Use an ice pack when you start feeling pain? Pack it. Listen to a progressive relaxation CD or youtube video before bed? Make sure you bring it along!  The more you plan ahead, the better it will be if you do start having pain or see a change in your bowel/bladder symptoms.

2. Keep your bowels in check.  Now, some of you are probably thinking, “I have pain Jessica– not bowel problems!” BUT, keeping the bowels in a routine is so important for ANY pelvic floor problem. A bout of constipation can increase bladder leakage or worsen pelvic pain. Unfortunately, constipation is very common while traveling.  One of the main reasons for this is that most of us significantly change our habits when we travel. For example, I normally start my day with a protein shake and a piece of fruit—but on vacation, I will have french toast, or a big omelet, cheese danishes, and other larger, richer breakfast options. Delicious, right? But the bowels don’t love the change. The best thing we can do for our bowels while traveling is to stay consistent. Remember, your bowels love a good routine, so try to eat similar meals that you normally eat at similar times! Keep up with fiber or supplements to maintain a good consistency, and don’t forget your fluid intake!! For more tips for bowel health, check out my previous posts here.

3. Stay consistent with your routines. Yes, we just hit on this with the bowels, but this is equally true with the other routines you use to manage your pain or other problems. Vacation is a great way to relax, but many people will find they drop their helpful habits while traveling.  Sometimes this may mean waking up a few minutes earlier in order to get your morning stretching in, or perhaps taking a break in the afternoon to use an ice pack, or maybe even setting an alarm to make sure you do your exercises–but these small steps can really do a lot to decrease the risk of a symptom flare!

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4. Pace yourself. This one is most important for those dealing with pelvic pain. We know that movement is medicine for persistent pain, and a vacation is often a very motivating time to move! That being said, it is important to gradually add movement and take breaks as needed to allow your body time to rest and adapt to a higher level of activity. I often will see men and women who may be very sedentary in their day-to-day lives, but then, go on vacation and want to be on-the-go 24-7! It is a much better alternative to try to slowly increase your activity, giving yourself adequate time to rest based on your prior activity level and what your body needs. For example, if you are normally inactive, it may be helpful to plan an activity for a few hours in the morning, but to plan for a resting period after that (great time to ice and do your stretches!). If you have several activities you would like to do, consider making a list and spacing those activities out over the days you are traveling.

5. Try not to freak out.  I get it. Flares are scary–especially when you’ve been seeing progress and have been feeling great! But, don’t let it get the best of you! Remember to see a flare for what it really is– a flare.  Keep your mindset positive, use the tools you have, and you will be back to vacationing in no time! And if you feel like you need a boost, contact your pelvic PT (we really don’t mind!). We’re always happy to talk through some strategies to calm things down, and are happy to help get you back to relaxing! 🙂

What strategies do you use to decrease a flare on vacation? PTs out there– are there any other tips you like to give your patients? Let me know in the comments below!

~ Jessica

Sex, drugs, and… no poop?

Really, I could have left off the “sex” at the beginning of the title… it would be more appropriate to the topic by saying “no sex” for reasons you will see…but I just couldn’t. The title was too great. So, there you go.

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So, leaving out the “sex”- what do drugs and “no poop” have in common? Actually, a lot. Constipation is a common side effect or adverse reaction to many medications. I see this all the time when working with men and women for pelvic floor problems, as well as common orthopedic complaints. The problem is, many people do not really know how to handle it since stopping the medication would lose the benefits of the medication. Constipation is really the worst– pooping is one of those things many of us take for granted, but I’ll tell you, when things aren’t running smoothly, it truly impacts a persons quality of life. (see what I did there?) So, first, let’s go through what medications are known to have constipation as an adverse reaction/side effect:

  • Anticholinergics: These medications block the action of acetocholine in the brain, which basically decreases the involuntary movements of muscles. As a pelvic health PT, I generally see my patients with overactive bladder problems and urge related incontinence using these medications (detrol, ditropan, vesicare, oxybutnin, toviaz) as these medications can decrease the contractions of the bladder muscle. There are lots of other reasons a person may use other kinds of anticholinergics, and this website gives a good summary with a list of medications included in the group.
  • Opioids: Many people are familiar with these medications and know them as the strong pain medications (morphine, codiene, oxycodone). These medications block receptors in the brain, but also have strong constipating effects in many people.
  • Benzodiazepine derivatives: These medications impact the nervous system, and are commonly taken by people with anxiety/panic disorders and for sedative purposes. Some of the more common ones are xanax, valium, and ativan.
  • Antidepressants: These medications are of course taken for improving depression, but also can be used to help with chronic pain or certain pain disorders (like vulvodynia or fibromyalgia) due to the mechanisms of these medicines. Common antidepressants include cymbalta, amitryptiline (elavil), wellbutrin and effexor.
  • Propionic Acid derivatives (NSAIDS): Yep, this fancy name includes the common OTC medications ibuprofen and naproxen, as well as several other medications. Tricky thing here is that another more common adverse reaction of these medications is diarrhea– we see this type of thing happen all the time– so know that the GI system can be affected, one way or another. Constipation as a side effect happens more commonly in older adults.
  • Other: This is by no means an exhaustive list-– if you think your medication may be causing you some unwanted side effects, research the medication on a website like drugs.com. This website also has an interaction checker, which is SO important.

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So, what can you do if a medication is contributing to constipation? 

1. Talk to your prescribing physician: No, stopping the medication is not always the answer! If you just started the medicine and are noticing a change in your bowel function, I recommend talking with your prescribing physician to discuss the symptoms you are having and discuss alternatives medication options. I often will have patients who will stop a medicine if they notice side effects without allowing their provider the opportunity to help them! Remember, there are often several medications which can provide a similar benefit! You may not react as strongly to one vs. another.

2. Develop stellar bowel habits: We’ve talked about this in the past, and it’s always important, but I would argue it’s even more important when you have something working against you.

  • Eat a healthy diet with plenty of fiber-filled fruits and vegetables
  • Aim to get some level of physical activity each day– even a short walk around the neighborhood can help so much with bowel regularity!
  • Drink plenty of fluids, mostly water!
  • Keep consistent! Eat meals/snacks regularly and at similar times every day to help stimulate the normal colon reflexes.
  • Use optimal positioning on the toilet (squatting!) and make sure to relax, breathe, and spend a few minutes allowing your bowels the opportunity to empty.
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Image from my good friends at http://www.squattypotty.com–check them out!

3. Consider a little short-term help if you need it!  I’ll be honest– I don’t love long-term laxative use. My preference is always to try to help the body in a more natural way if possible. That being said, there are times when a short-term helper can be so important! I always recommend that my family members (names shall remain anonymous) use miralax (an over-the-counter osmotic laxative) during recovery from surgeries to help combat the side-effects of pain medications. A fellow pelvic PT used a laxative for a short period of time while she was pregnant because she had a difficult time getting the constipation under control. This can sometimes be super helpful! I always recommend talking with your physician and getting a good recommendation for something to try to help if it is needed.

I hope this is helpful! In conclusion, I just want to reiterate– communication is always SO important between the patient and ALL health care providers. If you are having undesirable side effects from a medicine, call your physician! Talk to your pharmacist! And develop amazing, awesome, and smooth bowel habits :).

Happy Wednesday!

~ Jessica

TBT: “Do you need to go potty?” 5 Tips to Improve Your Kiddo’s Bathroom Health

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Today’s throwback (yes, I know it’s Friday– I’m sorry, I was busy yesterday!) comes from a post I did a year ago on improving bathroom habits in children. This has been modified from my original post to reflect my most current thoughts and current practice patterns. Hope you enjoy! 

As you may know, I have advanced training in working with children with bowel and bladder dysfunction in pelvic physical therapy. Often times, this is shocking to many people to hear as most of us are somehow under the impression that children don’t have these sorts of problems. But the truth is, these problems are SO common in children! Amazingly, there are many easy things parents can do to make huge differences for their children!  I often here my adult patients say,

“But you don’t understand, I’ve been constipated since I was 5 years old– it must run in my family! ” 

What if we changed the habits of our children early to promote healthy bowel and bladder habits? Could we truly make a difference for them later on in their lives? Could we prevent them going in to their physical therapist and having to say statements like the one above? I believe we can do just that!

Here are your 5 tips to start making those changes today!

1. Encourage adequate fluid intake (mostly water!) and fiber intake!

The average person should consume 5-8 8-oz cups of fluid per day–and your child is no different! Fluid is SO important for both the bladder and the bowels! For the bladder, having adequate fluid decreases the risk of urinary tract infections, encourages normal bladder urges, and allows for a normal light colored urine instead of a dark concentrated urine. As an aside, taking in too many sweet sugary drinks, caffeinated drinks, and carbonated drinks will actually irritate the bladder and is something we want to try to avoid. (Note: Remember this if your child has difficulty with bed wetting!). For the bowels, adequate fluid allows for a soft stool that is easy to pass! If your child is not getting enough water, he or she will likely have a  more firm stool as the intestines have worked to absorb the fluid your child needs for normal bodily functions. Many a patient has been “cured” of constipation simply by drinking more fluid!

Fiber is also very important to encourage a good bowel consistency. The American Academy of Pediatrics recommends children take in between their age + 5 and their  age +10 grams of fiber per day (i.e. a 5 year old would need between 10 – 20 grams/day). There is some debate in this, so check with your pediatrician to get their recommendations. Good fiber sources include fresh fruits and vegetables, whole grains, oatmeal, granola, seeds and nuts! For good recipes for your kids, check out Gina’s recipes from Skinnytaste.com that are “Kid Friendly” here. Also, one of my favorite books for parents, Overcoming Bowel and Bladder Problems in Children, has a wonderful index of fiber-filled kid recipes!

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2. Encourage your child to listen to his or her normal body urges.

This goes for both the bladder and the bowels as well! Quick lesson on anatomy and physiology–We have a normal reflex in our colon that helps us hold our stool to empty at an appropriate time (Yay!). Unfortunately, if a person holds stool for too long, the normal colon response to help us poop is dampened–meaning it won’t work as well! For the bladder, over suppressing bladder urges can cause problems with emptying that bladder, daytime accidents and frequent urinary tract infections. Many times, children become distracted with playing, watching TV, etc. and will hold off on going to the bathroom when they do have that urge. Parents should try to be aware of how long it has been since their child has urinated, and try to encourage a frequency of at least once every 2 hours (this will vary some depending on the age of the child).

3. Get your kids moving! 

I’m sure you’ve heard it in the news these days that children need to get moving more! But, to take a new spin on it, encouraging your kids to move more will actually help keep their bowels more regular! Yes, it’s true, exercise is a stimulant to the bowels. So, encourage your kids to get outside and play, ride their bikes, do family walks and games– the more your kids move the better!

4. Help your child develop a bowel routine 

This one ties in perfectly with our last point. Here’s the scenario:

“8 year old Mary is not a morning person. Mom has a hard enough time getting Mary out the door in the morning, and this often means eating a bagel on the way to school. After Mary gets to school, she often needs to go #2, but is too embarrassed to go and holds it the whole day.”

Unfortunately, kids like Mary often develop constipation from over suppressing those urges! The sad thing with this is that if a child suppresses urges for bowel movements, the stool will often become hard and may even cause pain when the child does go to the toilet. Over time, children can end up with overly stretched colons and may even need to use laxatives/medication for a period of time to loosen the stool and help the colon return to it’s normal position. All of this can be minimized by building a routine for your kids in the morning (or evening) to help encourage a normal bowel movement.

This video from the Children’s Hospital in Colorado helps to shed more light on bowel problems in children:

We know that the colon LOVES consistency, so try to encourage your kids to spend some time (at least a few minutes) on the toilet at the same time each day. We also know that the colon loves fluid (hot especially), hot food, and exercise! So, a good bowel routine would look like this:

“To help Mary’s bathroom habits, Mom started waking Mary up 30 minutes earlier. Mary starts her day with a warm bowl of oatmeal, then plays with her pet dog.  After they play, Mary heads straight to the bathroom to have a BM.”

Yes, building a routine takes some extra time–but it is well worth it to prevent constipation in your kiddos!

5. Encourage proper toilet positioning and breathing on the potty

Yes, there is a right way to sit on the toilet. For children, most toilets are too tall and this makes it difficult for them to relax the muscles around the anal canal to help them poop without pushing hard. Kids will compensate by straining, but over time this can be very detrimental to their pelvic health. To help them out, get a small stool to go in front of your toilet seat which will help encourage them to fully relax their muscles. Encourage them to lean forward and relax on their knees. This will help straighten out the rectum to encourage easy emptying.

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Image from our good friends at squattypotty.com. Check them out!

Then, and most importantly, make sure they have time. Encourage them to read a book or magazine and give their colon a few uninterrupted minutes to “do its thing.” I recommend they spend this time doing slow breathing (Potty Yoga) and relaxing. If they feel like they need to push, encourage them to breathe while they push to avoid the typical valsalva maneuver we often see. Learning this will help them so much both now and in the future! For more information, read this excellent post from my colleague, Jenna Sires, called “Are you Pooping Properly?

What have you tried to help encourage good bathroom habits for your kids? Are your children having problems not addressed above? Feel free to comment below! Here’s to a healthy upcoming generation!

~ Jessica