Did you know that even the Queen has to deal with bowel motions? I don’t mean that in a disrespectful way at all- I am reminding us all about that fact because many women (and men) are very reluctant to discuss their bowel problems until they are almost at the Calamity Stage on the Bowel Richter Scale because they are embarrassed or mortified about bowel talk. It’s almost as though they are the only person in the world that may be having this problem when in fact bowel dysfunction is common. Bowels can preoccupy your thoughts when you are suffering with difficult evacuation and we can all relate to the satisfaction felt when you are able to completely evacuate a stool after some period of constipation. I even had a patient exclaim the other day: “Sue I did a bowel motion on a plane toilet!!” and we know that deserves a trophy.
Constipation is a frequent and debilitating problem worldwide. It affects twice as many women as men.
Now I was prompted to write this blog on bowels by the recent visit of the Duchess of Sussex to Australia. Meghan Markel – who (in case you have been living in a bubble devoid of social media or the magazine New Idea) is pregnant and boy (Has Sue been told the sex of the child?) can bowel function change during pregnancy! The good thing it can sometimes change for the better, but it can sometimes also change for the worse. Constipation affects up to 38% of pregnancies with rising progesterone levels in pregnancy contributing to slow gut motility. (1)
As for pregnancy, a prospective study demonstrated that pregnant women are most prone to developing constipation in the first two trimesters. The prevalence of functional constipation in the first and second trimester varies between 35% and 39%, is 21% in the third trimester and 17% peurperium. (1)
But bowel problems are more than constipation and incomplete evacuation. Anal flatus, bloated bellies, sneaky gas, borborygmus (a rumbling noise produced by the movement of gas through the intestines), faecal incontinence, rectal prolapse, posterior wall prolapse and anal pain are all things that may be experienced by women before, during and after pregnancy as well throughout their lifespan. They are not routinely on a GP’s checklist (or in small talk like ‘How are your bowels?’) because it’s literally like opening the proverbial can of worms. The conversation cannot be finished in under half an hour and does not fit in with the 6-minute model that GPs are paid under by the government. Who can blame them? There are many fabulous GPs who do ask about bowels but when it takes a pelvic health physio perhaps an hour to cover the relevant education and pelvic floor/vaginal/rectal examination to find the extent of the problem, how can a GP possibly do much more than say: ‘Here take these laxatives’ if they have 6 minutes?
Hence this blog. I have written a previous blog called All About Bowels years ago and so have reposted some of the content here with a few added nuggets (having just been to another fabulous three-day Explain Pain Course with AssProf Dave Butler, Prof Lorimer Moseley and Prof Peter O’Sullivan where Nuggets <of Information> are chucked around every 5 minutes, I felt it entirely relevent and appropriate(2) to appropriate(3) the word ‘nugget’ for this blog).
The blog on All About Bowels (with some additions) follows:
Nothing causes more misery in people’s lives than bowel problems. Whether it be constipation, incomplete evacuation, faecal incontinence (FI), sneaky gas, rectal prolapse, haemorrhoids, pain from anal fissures or haemorrhoids, solitary rectal ulcer, recto-vaginal fistula or proctalgia fujax – and sadly, some people can have some or almost all of these conditions. One of the more famous people who reportedly suffered with major constipation was Elvis – his personal physician writing in his book that he had obviously a huge redundant bowel, that he sometimes soiled when performing and claimed he in fact died of constipation. Who knew!
I’ve said it before that for many kids, toilet training for ‘poo poos’ means being plonked on a potty with Mum and/or Dad making lots of grunting noises. Not a lot of science. (I have added a short new chapter on The Early Years in the new edition <Edition 3> of Pelvic Floor Essentials with info on toilet training, bed-wetting, FI, daytime wetting and childhood constipation to help).
There are 3 key elements to effective evacuation: Firstly the ideal position, secondly the best dynamics for emptying your bowels and thirdly optimising stool consistency. It’s a lot like Maths and Physics – getting the angles right (maths) and the coordination of the abdominal and pelvic floor muscles (external anal sphincter and pubo-rectalis) to release the stool (the physics bit) will make it easier to completely evacuate the bowel motion. In both my Pelvic Floor Recovery books, I go through in detail these three elements for effective, pain-free and complete evacuation. I have included the diagram for the position below.
Defecation dynamics means gaining effective coordination between the abdominal muscles and the pelvic floor muscles. Instead of pulling your tummy in and pushing down with your pelvic floor (ie straining), the idea is to gently bulge the abdominal wall which causes an opening and relaxation of pubo-rectalis and the external anal sphincter (ie.creates a funnel to release the stool).
One of the obvious problems with pregnancy is that the bowels are getting quite compressed by the end of 40 weeks.
Using a product to obtain a Bristol Stool 3 or 4 bowel motion is critical whether you are helping constipation or faecal incontinence. (Aiming for Bristol Stool 5 for children with constipation and anyone with an anal pain condition or who has had recent gynaecological or colorectal repair surgery). When doing Maths or Physics we often collect data and it is important to do this data collection to crudely see what your transit time is. Doing something simple like a corn test to see what your transit time is like, is an important first step when assessing the correct potion to take. To do the corn test, have no corn for a week, then a eat a whole cob of corn, making sure you don’t chew it very well (as opposed to advice normally to always chew your food well) and then no more for another week. You are looking to see when you first see the corn and when you last see it. If it takes longer than roughly 2 days to see all the corn, then you have some slow transit time happening in your bowel.
Addressing the fibre content of your diet is the first step when looking at how to optimise bowel function. 30 grams per day is the standard recommendation but interestingly many of the fruit and vegetables that would boost your fibre intake may also be the culprits causing excessive gas and bloating. Many people have now read about the FODMAPS diet and sometimes follow the advice on some internet sites by themselves. FODMAPS stands for Fermentable Oligo-saccharides, Di-saccharides, Mono-saccharides and Polyols and they can have a wide range of effects in the gut because they can be incompletely digested in the small intestine. This undigested food continues on to the large intestine (colon) where for some people with IBS they can get:
- Fermentation by bacteria which results in gas production and contributes to bloating and abdominal pain or discomfort
- Gas production (methane and hydrogen) can slow movement through the bowel and contribute to constipation
- Increased water delivery into the bowel (osmotic effect) may contribute to diarrhoea. (4)
Getting proper supervision from a dietician is important with FODMAPS so you don’t significantly reduce important food groups because you have instituted a blanket ban on all FODMAPS foods.
If diet doesn’t achieve an adequate texture and volume of stool then added products can be tried.
Remember this is a guide only- please discuss any use of products with your pharmacist, GP or other specialist doctor especially if you are pregnant.
Initially products such as fibres may be used to soften the stool. Some common brands include Normafibe* (which is also very helpful if your stool is too loose (each of the Normafibe pellets swell to 60 times their size and assist with binding the stool which helps with faecal incontinence), Benefibre*, Metamucil* and many others. The next stage if fibres are not working well may be an osmotic laxative such as Osmolax* or Movicol* which help bring more water into the bowel to soften the stool.
Adult Glycerol suppositories* are a wonderful help if the rectum is loaded and difficult to evacuate – to assist with defaecation and prevent the patient from straining (remember avoiding straining is the best advice particularly if you have rectal or vaginal prolapse, anal fissures, proctalgia fujax, haemorrhoids or have had gynae or colorectal repair surgery………actually never strain is the best motto). Remember all products have different names in overseas countries so you need to check with your pharmacist going by category – fibre (soluble/insoluble), osmotic laxative, stimulant laxative and so on.
Proctalia fujax can be considered a chronic or persistent pain condition so once the mechanics of defaecation have been corrected to especially decrease any tractioning of the pudendal nerve that occurs with straining, then sometimes a medication like Endep* (prescription item definitely discuss with your doctor) can help to decrease the constant messages from the pelvic region. It is also important to give good persistent pain education to help the patient understand why the persistent pain is present and how to decrease or eliminate it.
Poor gas control and faecal incontinence is distressing and can lead to people leaving their chosen employment, becoming very anxious and even agoraphobic. I have covered in a previous blog the importance of dietary management, regular pelvic floor exercises (particularly the external anal sphincter) and Imodium to help control any anal incontinence. Overeating can also cause excess gas production and having just emerged from a notoriously bad time for overeating (a three-day conference at the MCG with amazing food by Epicure) it may pay to look at portion size as one of the strategies to help excessive gas production.
Simple strategies such as using flushable wipes (restricted to a final wipe in these times of environmental concerns-they live in the toilet roll aisle and come in a large size for the home toilet and a purse or pocket-size) to complete the cleaning phase on the toilet, often assists when post-defaecation soiling is a constant issue. There are also new types of pads for patients with faecal soiling which have odour control qualities and it is important to use barrier creams to protect the skin (such as Sudocrem) if soiling is a daily problem.
I hope some of these hints are helpful to all those who may have issues and be noted by those who have yet to encounter problems.
*Please discuss the taking of any preparations/medications with your GP, medical specialist or pharmacist.
(1) Verghese T, Futaba K, Latthe P (2015) onstipation in pregnancy https://doi.org/10.1111/tog.12179
(2) Meaning of appropriate: suitable or proper in the circumstances.
(4) Taken from a handout prepared by Dietician Jocelyn Hunter-Clarke