Can you Poop?

Constipation: Pelvic Floor Dysfunction

This is a topic that is usually uncomfortable to talk about. There seems to be some stigma about keeping bathroom related issues private. Do you have a bowel movement every 2-3 days? Do you feel like it should be more regular and daily? Have you been told that this is just YOUR normal and that is fine? Living in pain and worrying about your next bowel movement is NOT normal. Heading down a path of months to years to fix your "normal" is also abnormal. Health care today sends patients with GI issues down the typical path of medication, a multitude of tests and exams, and more medication to fix the issue with no real explanation. Going to the bathroom should not be something that consumes your life and should not take this long to fix. Learning to advocate and speak up during these doctor's visits is important. Learning which tests are more important than others for diagnostic purposes is key. The amount of patients that have come in with stories of ER visits ending in "You're FOS (full of $#!t)" is beyond unacceptable. This is no laughing matter. Taking medications just to clean you out only to have to take them again days later is not a solution to the problem. You become more frustrated in the health system and learn to start living with it. Take a look at how most patients start their GI voyage and how you should take a stance and change your treatment path to start getting real results.

Have you ever read the book “Everybody Poops”? It is usually read to children to teach them about bodily movements and what is normal. Why is it ok for society to talk to young kids about this topic but we find it humiliating to talk about adult related issues with going to the bathroom? Have you ever wondered why you used to have bowel movements regularly and now don’t? Do you go every so often versus every day? There are so many factors that play into constipation and finding what your cause is can be the factor limiting you from getting the appropriate treatment.

Everybody Poops By Taro Gomi

Let’s start with the typical story from a patient with pelvic floor dysfunction. Remember, not every patient is the same and stories can vary. However, you might find similarities throughout this blog when compared to your own. You wake up one day and can’t take it anymore. The suffering of stomach pain just won’t stop. It is limiting your daily life including being able to go to work, working out, hanging out with friends and family, and it changes your eating behavior to the point of skipping meals. The list goes on. The discomfort and worry consumes your entire life and you think about it non-stop.

Living in pain is NOT normal

You decide it is time to get help so you start down the path of your primary care, the “gate-keeper” of the medical world. They are suppose to help guide you to a specialist that can help. Or they start treatment themselves and prescribe medication that they think will take care of it first. Have you been told to take Mirilax? How about one step further. Have you been told to take one cap full of Mirilax? How about two caps, three, four, or how about “as much as you need to go”. These are inappropriate answers and not to mention Band-Aids to manage a situation that should be looked in to more. So you’ve tried the laxative route. Mirilax, e-lax, magnesium capsules, calm-magnesium in powder form, magnesium citrate, senekot, etc. You’ve either gotten addicted to a laxative and forced your body to rely on them to go to the bathroom or you’ve stopped because they stopped working and you are looking for more guidance. People can fall into both categories. With one being more of an issue with medication dependence. Traditionally people start with the recommended low dose of a medication that is OTC. When it starts to not work anymore you resort to taking more. Your dosage slowly grows until you are at a level you should not be at. This is not appropriate.

Feel like you are becoming dependent on laxatives?

After the laxative route most patients are shifted over to a GI doctor. Here you will go through testing of all sorts. Medication routes involve prescription versus OTC including Motegrity, Amitiza, Linzess, Trulance, and again the list goes on. These medications may help you to have bowel movements. They also may make you feel the complete opposite: you can’t get to the bathroom fast enough, you have a large bowel movement that is now all watery, you go multiple times within the hour. Does this seem to be fixing your underlying condition? Or is it just helping with your symptoms? Either way, most people feel like it doesn’t matter as long as your are now having a bowel movement. You go about life taking the medication(s) and eventually it also stops working, putting you back in the same place you were before.

You either end up sitting and straining for a long time or you can't get there fast enough....

Further testing starts up months later because you have come to find that the medication route did not work. You go in for a colonoscopy. You drink that gross formula of half laxative half water and poop your brains out. To some this is the best result ever! It feels good to actually empty out. Who would have thought a colonoscopy prep would be something you look forward to? Said almost nobody, except those with this issue. The colonoscopy shows up negative. You go in for an endoscopy, maybe it shows potential evidence of celiac disease, maybe acid reflux, but no real explanation for your bowel issues. Moving on, you have a CT scan or x-ray to show blockages, blood tests for other systemic or organ issues (in most cases thyroid dysfunction), colonic transit study to see how fast food moves through your colon, defecography (an x-ray of the rectum during defection), and lastly a balloon expulsion test and anorectal manometry (test that evaluates the function of your anal sphincter muscles). A lot of times these tests are performed and your are poked and prodded with no results. You spend high co-pays, hospital bills for expensive tests, time and frustration. It typically takes months if not years to progress through the array of doctors, second opinions, and all of these tests. The frustration grows and you continue to think this is just you and something you have to deal with. It is not. AGAIN, THIS IS NOT NORMAL, AND IT IS NOT IN YOUR HEAD. Your body should be able to have both bowel movements and urination without having to constantly struggle.

Have you seen multiple doctors for your issue and still don't have any answers?

Finding the right doctor for you that is going to listen and help you through these various tests is very important. With todays’ healthcare most patients are rushed through the system and placed on a medication regimen. When that fails the system fails. You are more likely to be ushered off to a pain clinic to manage symptoms with even more medications (often which add to the constipation issue), or you are referred out to a psychotherapist to help with the anxiety.  Any of this sounding familiar?

Don't Panic. There are specific exercises and routine changes that can help.

If you have reached your limit and have done these steps with no relief you may have a pelvic floor dysfunction. This dysfunction should often be found with two of the tests listed above: Balloon expulsion test and Anorectal manometry test. However, even some of the well known Boston hospitals have failed to perform these correctly leading to false negatives. Continuing to lead you down the blackhole of what is now healthcare.

If you are at this stage or any of these stages taking a look at pelvic floor dysfunction may be a better path for you. What is pelvic floor dysfunction? It is when your pelvic floor muscles, that envelop both the front and back of your pelvis, hinder your ability to urinate or have a bowel movement normally. In some cases it can cause incontinence where you have leakage during inopportune times such as with running, coughing, laughing, etc. In others it can prevent you from having normal bowel movements leading to chronic constipation. The tightness in certain muscles of the pelvic floor can cause you to actually limit the opening of the anus leading to straining. Straining leads to further weakness of the surrounding muscles which can limit your ability to perform normal bowel movements. Patients with tightness in their pelvic floor can not feel that they are clenching or tightening this area because it has become a normal occurrence. When told to relax they feel they are relaxed. This is similar to other people holding their stress in their lower back or neck leading to pain in those areas, pelvic floor stress leads to pain and constipation. Knowing when to seek help is important and knowing that the path you are on is not helping is equally important. There are exercises including biofeedback to help your body recognize when your muscles are not functioning properly. Finding the right PT to help properly diagnose this is key. Pelvic floor is only taught for a couple days during PT school. So finding someone who has more experience in this area is crucial for a proper evaluation and treatment. All PTs vary in their treatment approaches. So if you’ve tried one and their approach did not work, do not hesitate to leave and find someone else. It is the same with all healthcare practitioners. If one specialist isn’t helping you, you get a second opinion somewhere else. This approach is the same for PT.  Make an appointment with Dr. Kim today to review your medical history and work to form an appropriate diagnosis and treatment plan for your limitations today.