Tag Archives: Bowel Problems

Clinical Expert Interview with Susan Clinton, PT on Sensory Balloon Retraining for Bowel Dysfunction

In continuing my video series with clinical experts, I interviewed Susan Clinton, PT, DscPT, OCS, WCS, COMT, FAAOMPT (Yes, those are a TON of initials!!) regarding balloon training as a treatment for bowel dysfunction. Susan is well-known in our profession as an expert on bowel dysfunction, and her video definitely did not disappoint!

Curious about this treatment? Check out the interview below! If you want to learn more, here are a few research articles that mention balloon training as a treatment tool (this one and this one) Hope you enjoy!

Your bladder and bowels need a diary.

This past weekend, I had the wonderful experience of assisting at Herman & Wallace’s Level 1 Pelvic Floor Course, held here in Atlanta. I have been assisting at these courses for the past 4 years now, and I absolutely love it. There’s nothing better than helping clinicians who are new to the field of pelvic health learn and grow in this fantastic specialty. I love the excitement, the slight fear (I mean, many of these folks are doing their first vaginal exams at these courses), and the growing passion for helping men and women with pelvic floor problems. And the most exciting thing is knowing that they are going out in their communities to begin offering this service to people who really need it. And, now you know how much that really means to me. 

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Cathy Neal (an awesome PT who assisted with me), Susannah Haarmann (an awesome PT who instructed the course), and myself! 🙂 We’re just missing Amanda Shipley and Pam Downey! Photo courtesy of Susannah!

The initial level 1 course covers an introduction to pelvic floor dysfunction (all diagnoses), and covers bladder dysfunction in more detail. One of the prerequisites of the course is for all participants to complete a bladder diary which is then evaluated in the class. So, why keep a bladder or bowel diary? 

First, let’s be honest, we are all horrible historians. Many of us can barely remember what we ate for breakfast, let alone remember all the details of our bathroom habits! Let me ask you this:

  • How many times did you urinate yesterday?
  • How much fluid did you drink? What exactly did you drink?
  • What did your poop look like? When did you poop?

If you’re like me, it’s probably tricky to recall these exact details. (Well, you may be slightly better at recalling than I am, now that my pregnancy brain is in full effect!). And, if you are having any problems with your bowels or bladder, these details really do matter. Here are a few examples:

Patient #1: Mary (obviously not her name) was a lovely 65 year old retired nurse experiencing urinary leakage on her way to the restroom several times each day. She had tried exercises, dietary changes, and medications, and her problem kept persisting. Her bladder diary was eye opening for both of us! We learned that she only leaked urine when she would hold her bladder for over 6 hours! After years of holding her bladder for entire shifts, she got into some pretty bad habits. Once we changed this, her leakage went away completely! 

Patient #2: Sara(also, not her name) was a 10 year old girl having bowel accidents daily. Once we did a diary, we found out the problem! Her mother was a hair stylist who saw clients out of her home. Sara was afraid to have a bowel movement while her mom’s clients were there, and had started having accidents from getting too constipated! The three of us quickly determined a “code word” for Sara to tell her mom when she needed to go, and within 2 weeks, the problem was solved! 

So, as you can see… these little diaries can be oh so powerful! So, let’s get into the details!

Who should do a bowel or bladder diary? Well, in my mind, everyone should try it at some point! It’s so cool to see what your patterns really are… but for sure, anyone who is having problems like urinary urgency or frequency, urinary leakage, constipation or bowel leakage.

How long should you keep one?  Typically, I like people to track for at least 3 days. Preferably, two of those days should be “regular” and one can be “different.” For example, if you are working, you may choose two days to be work days, and one to be over the weekend.

What should you look for?  The best thing to do if you are having problems is to bring your diary to your health care provider. He or she will be able to analyze it completely, and give you insight into what may be happening. However, I do think there is some benefit in doing a little sleuthing yourself. Here are a few things to identify:

  • How often are you going? Normal bladder frequency is typically around 5-8 times each day, and less than 1 time each night. Normal bowel frequency varies quite a bit from 1 time over 3 days to 3 times each day.
  • How strong are your urges when you go? Generally, I recommend grading urges on a 0-3 scale (from no urge –> gotta go right now!). Were most of your urges very small? Were you running to the bathroom all day?
  • How much did you urinate? The best way to track this is to actually measure your output (usually a cheap plastic cup or a dollar tree measuring cup works well). Normal output of urine is 400-600 mL per void. You can also try just counting the seconds of your stream, however, this does tend to be less accurate. We generally tell people that each stream should be at least 8 seconds.
  • What did your poop look like? Was your stool soft and formed? Little rabbit pellets? Did you have to push hard to empty your bowels or did they come out easily? Did you have any discomfort or pain?
  • What was your diet like? Do you notice any trends in what you eat or drink? Were you drinking some well-known bladder offenders (like caffeinated drinks, soda, coffee, artificial sweeteners or sugary drinks)? Did you eat at really regular intervals? (You know I love my bowel routines!)
  • Did you notice any trends? Did you always go to the bathroom when you had the littlest urge? Was most of your leaking with coughing or sneezing? Does running water send you running to the bathroom? Did you always have a bowel movement after your morning coffee?

As you can see, so much wonderful information can be gleaned from these diaries, so if you’re having problems, get started today! Knowledge is power, and once we become aware and identify trends in our habits, we can make the changes needed to really help us get the most out of our bodies!

If you want to get started today, try using one of these free templates available online (John Hopkins’ Bladder Diary, Continence Foundation Diary, or Movicol’s “Choose your Poo!” Diary) There are also wonderful apps available now for tracking bowel/bladder function! This is a sample of a diary I frequently use in the clinic (see below).

Bladder Diary

So, get tracking! And, on a serious note– don’t forget that these diaries can also help to determine if you are having a more serious problem, so please, please please, see your health care provider for an evaluation if you are having the types of problems we discussed today!

Happy Wednesday!

~Jessica

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

Great photo, right? Click on it to link to a wonderful article by my colleague and friend, Jenna Sires, written for the amazing group ShareMayFlowers, “Are you pooping properly?”

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.

Click on the image to go to the blog post I pulled the image from. Great info from a supporter of squatty potty 🙂

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 proble4m. (See this article, this one, that one, and this one!)

Click on this picture to go to the open access article I pulled this from. Basically, this shows that after biofeedback, the person was able to still generate the right pressure, but the anal muscles relaxed and opened rather than contracting.

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