The Missing Piece of the Constipation Puzzle

Let’s talk about the connection between bowel movements and the pelvic floor! It may not be the most glamorous conversation, but it’s real, and relatable. And if you have ever had to strain to have a bowel movement, or feel like you can’t fully empty your bowels: raise your hand!

Constipation is defined as: infrequent, difficult, or incomplete bowel movements.

Clinically, it is often defined by the following criteria:

• Having fewer than three bowel movements per week
• Experiencing hard or lumpy stools
• Straining during bowel movements
• A sensation of incomplete evacuation
• A feeling of blockage or obstruction

While there can be a variety of medical conditions and varying reasons contributing to constipation, there is a connection between constipation and the pelvic floor. This is not always discussed, but it is highly related and the good news: it’s treatable!

These conversations are not always the most fun and exciting, but if you have experienced constipation you know just how uncomfortable it can be.

Keep reading to learn how the two systems are related and how a pelvic floor physical therapist (or PT tips) can help you manage constipation.

Meet Your Pelvic Floor: The Unsung Hero of Digestion

The pelvic floor is a group of muscles and connective tissues that sits like a hammock at the bottom of the pelvis. These muscles stretch between the pubic bone (front) and the tailbone (back) and also attach across the sit bones.

The pelvic floor supports the organs above, plays a role in bowel and bladder function, supports hip, low back and pelvic girdle stability.

The primary muscles include:

• Levator ani group (puborectalis, pubococcygeus, iliococcygeus)
• Coccygeus
• Associated sphincter muscles (external anal sphincter)

Let’s go a bit deeper to discuss the pelvic floor’s role in supporting bowel function.

A healthy bowel movement depends on coordination between multiple systems, including the pelvic floor. Here’s how it works:

1. Storage Mode

At rest, the pelvic floor muscles maintain a steady state of activation, helping to maintain continence by keeping the rectum closed and supporting internal organs.

2. The Urge to Go

When stool moves into the rectum, it stretches the rectal walls, signaling the brain that it’s time to go!

3. Let it go!

When ready for a bowel movement, the pelvic floor muscles must relax to allow ease of passing stool.

4. Pressure Assist

At the same time, the diaphragm moves down, the abdominal muscles contract to provide a bit of intra-abdominal pressure.

5. After

Once the bowel is emptied, the pelvic floor muscles return to a slightly contracted state, maintaining organ support and preventing leakage.

How Pelvic Floor Dysfunction Can Contribute to Constipation

Next, let’s look at how pelvic floor dysfunction, or non-optimal function of the pelvic floor can contribute to constipation.

Overactive pelvic floor muscles can contribute to constipation since the muscles cannot fully relax and release during a bowel movement. This will often contribute to straining or “bearing down”.

Additionally, lack of coordination, or dyssynergic defecation, which means the pelvic muscles contract instead of relaxing when trying to poop.

If there is core weakness, or weakness of the abdominal muscles like following a surgery, c-section, or early postpartum, the lack of strength can contribute to difficulty with bowel movements or incomplete emptying. Our abdominal muscles must be able to provide a little bit of pressure to assist in bowel movements.

Sometimes, we have a history of pain with bowel movements or fear of pain (hello first postpartum bowel movement), which can contribute to a subconscious tensing of the pelvic floor muscles.

Posture, toileting habits, and lifestyle components such as poor diet can also contribute to constipation.

The good news is that working with a pelvic floor physical therapist can help to find the cause and provide great support to improve ease of bowel movements!

How Constipation Can Worsen Pelvic Floor Problems

Constipation and pelvic floor dysfunction can turn into a frustrating cycle.

Long term constipation or chronic straining, can contribute to further tension of the pelvic floor muscles, which can then contribute to pain, urinary leakage, or incomplete emptying.

Repeated straining can weaken the pelvic floor, which may contribute to future concerns such as hemorrhoids or pelvic organ prolapse.

Hard stool or stool withholding (this can be really common in kids or early postpartum) can contribute to muscle incoordination.

Overall, the end result is a frustrating cycle of constipation, pelvic floor muscle tension, and more constipation.

Break the Cycle with Pelvic Floor PT

The good news: we can break the cycle with pelvic floor PT.

Pelvic floor physical therapy is an evidence based treatment approach to addressing constipation, and underlying pelvic floor dysfunction.

Here is what to expect in work with a pelvic floor PT:

Comprehensive assessment:

• Posture
• Breathing strategy
• Pelvic muscle coordination, strength
• Core muscle assessment
• Toileting habits

After assessment, your treatment will likely consist of a variety of interventions including:

• Education: bowel habit health, dietary components and toileting posture
• Manual therapy: to release tight muscles and improve relaxation
• Biofeedback training: to retrain muscle coordination
• Breathing and pressure management
• Lifestyle factors: hydration, fiber, exercise and timing strategies

Key takeaway: Pelvic floor PT addresses both the muscle dysfunction and behavioral patterns contributing to constipation.

When to Seek Help

Talking about bowel movements can be embarrassing for many, but it’s imperative to discuss with your healthcare provider to ensure you are getting the best treatment!

As with many symptoms related to pelvic floor dysfunction, constipation is common, treatable, and nothing to be embarrassed about!

Here are some signs you may benefit from pelvic floor PT:

• Needing to strain or use your fingers to assist bowel movements
• Feeling incomplete emptying of your bowels
• Having less than 3 bowel movements per week
• Experiencing pelvic pain or heaviness

There are many reasons someone may experience constipation, and oftentimes it can be a very benign concern. But any new change in bowel movements and bowel health warrants a discussion with a medical practitioner.

The pelvic floor and digestive system are teammates, and when they fall out of sync, constipation may be an unwelcome side effect.

The good news is that pelvic floor physical therapy can help!

Keep Learning

• Rome IV Diagnostic Criteria: https://theromefoundation.org/rome-iv/rome-iv-criteria/
• Mayo Clinic – Constipation Symptoms & Causes: Mayo Clinic – Constipation
• American Gastroenterological Association (AGA): AGA GI Patient Center – Constipation https://www.ncbi.nlm.nih.gov/books/NBK539732/
• APTA Pelvic Health: Physical Therapy Management of Functional Constipation in Adults: A 2021 Evidence-Based Clinical Practice Guideline