A miracle called: pooping!

“Pooping is a miracle!” That is what one of my colorectal physician friends told me once.  And he could not have been more correct.

Many of us do not have the luxury of feeling the urge for a bowel movement, making it to bathroom on a timely manner, or sitting down and having a bowel movement without straining and bending and pushing in each and every way.

Frequency of normal bowel movement can vary from three times a day to three times a week, without any straining and with feces that looks like type 3 or 4 on the Bristol scale.

According to Black and Ford (2018), “Chronic idiopathic constipation (CIC) is one of the most common gastrointestinal disorders, with a global prevalence of 14%. It is more common in women and its prevalence increases with age.”

Hard, pebble-like feces could be related to a slow-moving colon (slow transit), poor diet, medication, and certain diseases, to name a few. In other instances, the colon moves appropriately and constipation still exists. And then there are those people with CIC who also have dyssynergic defecation (DD). These people have difficulty passing their stool due to mechanical issues related to pelvic floor muscles, the nervous system in the area, and/or a lack of synergy between the abdominal muscles, pressure system, and pelvic floor muscles. More than half of the people who have constipation suffer from DD (Rao, Patcharatrakul, 2016).

Due to variabilities of the underlying causes that lead to symptoms of constipation and difficulty with bowel movements, it is extremely important that one does not get a generic treatment based on their symptoms (Patcharatrakul, Rao, 2018). A thorough and detailed history, review of systemic diseases, physical and digital exam, and use of imaging (anorectal manometry, ultrasound, MRI) is absolutely necessary for an accurate diagnosis and treatment protocol.

Many people with the diagnosis of DD have exhausted various common treatment protocols of using stool softener, laxatives and increasing fiber.  In fact, many report  having type 3 or 4 stool on the Bristol scale, once they can defecate.  Their problem lies on the inability to effectively pass the feces through.

Mechanically speaking, there needs to be a sufficient amount of intra-abdominal pressure in combination with relaxation of pelvic floor muscles and postural positioning to improve the ability to have a bowel movement.  With chronic constipation, this synchronized synergetic and coordinated function becomes compromised and people lose their ability to recognize the flaws in their effort to have an effective bowel movement.

Pelvic floor physical therapists have the skills to create a treatment plan that would include behavioral modifications, proper positioning, change in food and fluid intake, manual techniques, and biofeedback to re-educate individuals about proper and effective evacuation skills without straining, bleeding, and/or pain. In a study by Patcharatrakul, Valestin, Schmeltz, Schulze and Rao, from 127 subjects who had been diagnosed with DD, more than 60% improved their symptoms with biofeedback treatment (2018).  Biofeedback has been proven to be more effective than the use of laxatives and other modalities without having any side effects.

If you have exhausted many treatment options or just have started your journey with difficulty with defecation seek out pelvic floor physical therapy for a consult, you too deserve a miracle!

Hypermobility, pelvic pain, and pelvic organ prolapse: a cluster of symptoms

Joint hypermobility syndrome (JHS) describes an abnormal increase in the range of movement in different joints of the body. JHS is a hereditary condition and people often experience recurrence of sprains, strains, bruising, and/or dislocations as a result. Those who have the condition often notice its effects in their fingers, knees, or elbows. When the soft tissues are more lax and mobile, however, the same pliability applies to the skin and the support system of our internal organs. Furthermore, Ehlers-Danlos syndrome (EDS) refers to the group of disorders that consequently affect the different organs. The only proper way to diagnose EDS is to be evaluated in an extensive history-taking and physical examination that includes orthopedic, neurologic, and dermatologic analysis, to name a few.

In their article, Colombi, Dordoni, Chiarelli, and Ritelli (2015) discuss the clinical spectrum of JHS and EDS. The spectrum expands to include the skin, joints (including flat footedness, ability to do the splits, bending the thumb to the forearm, bending and touching hands to the floor), muscles, gastrointestinal system, urogenital system, cardiovascular system and neuropsychiatric symtoms (fatigue, disturbed sleep, anxiety, etc.).

In addition to understanding the breadth of the disease, recognizing the co-mobilities is beneficial to properly diagnosing JHS and/or EDS.

There have been several studies that show the correlation between hypermobility and gastrointestinal symptoms, including irritable bowel syndrome (IBS). One study found that those who suffer from the constipation sub-type of IBS show much higher symptoms of JHS. This could be due to the biomechanics of the connective tissue that lead to slower transit, or, movement, in the colon, also known as colonic inertia (Zweig, Schindler, Becker, van Maren, Pohl, 2018).

In another study by Castori, Morlino, Pascolini, Blundo, and Grammatico (2015), the gastrointestinal indicators of JHS/EDS were broken into structural anomalies (hernias, organ prolapse, intestinal intussusceptions) and functional alterations (recurrent abdominal pain, constipation/diarrhea, reflux).  

Postural tachycardia syndrome (POTS) and other cardiovascular conditions both at rest and sudden positions changes (orthostatic) has been shown to be more prevalent in those with EDS (Roma, Marden, Wandele, Fancomano, Rowe, 2018).

As with many others who have chronic conditions, recognizing the psychosocial function of a patient with JHS/EDS is highly important because people with these conditions generally do not respond to typical biomedical approaches (Baeza-Velasco, Bulbena, Polanco-Carrasco, Jussaud, 2018).

There is evidence that women with JHS could be more prone to pelvic organ prolapse. Pelvic organ prolapse occurs when one or more pelvic organs, which includes the bladder, urethra, uterus, vagina, rectum, and small bowel, droop or descend into the vaginal opening. Additionally, many women with JHS/EDS tend to suffer from pelvic floor muscle tightness and shortening, causing pain with the use of tampons, intercourse and/or in a pelvic exam. This could be explained by the fact that hypermobility in other parts of body causes the pelvic muscles to tense up for better postural support.

The physical therapists who specialize in pelvic floor rehabilitation have the expertise to perform a complete evaluation of the mechanical and musculoskeletal systems, enabling them to better understand complex diagnoses for conditions like JHS and EDS. Their skills allow them to create a sustainable, effective treatment plan that aims to make everyday life more functional and pain more manageable.