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Constipation – The Loo Taboo

Why is it so hard to talk about our toilet habits? It seems to be generally accepted that it’s not polite, a hangover from the Victorian age. For centuries the output of the body has been seen as dirty, shameful, and even associated with the devil (for more on that, listen to my podcast here!). But in the modern age (and isn’t it about time we moved on?) faeces can tell us a huge amount about our health – and we ignore it at our peril.

What’s Normal?

Normal is such a tricky word! And, as in centuries past, it’s usually determined by getting an overview of lots of people and drawing generalisations. For example, the current wisdom on constipation is that it’s normal to open your bowels between 3 times a day and once every 3 days. Beyond this is deemed ‘Constipated’. It’s unclear whether this has been the result of deep analysis of the subjects’ gut health. In fact a recent study in the American Journal of Gastroenterology concluded that one in three people think their habits are normal despite them fitting the general criteria for constipation. But how will we truly ever know what’s normal unless we start talking about it?

My opinion is that ‘normal’ should really mean ‘healthy’. This allows for natural variation, but provides boundaries as well, so unhealthy conditions aren’t missed or ignored. If we eat three times a day, then going roughly once a day, give or take, seems about right. All sorts of joyless conditions can be caused or contributed to by slow transit of food through the gut, and 24 hours is generally seen as a healthy transit time.

Waste removal is no joke. Every moment of every day our cells produce waste, and it’s important these are eliminated regularly. The removal of hormonal waster is also crucial to overall health.

However, the gut and bowels are incredibly complex organs, and modern science is only beginning to get a grip on just how crucial it is to our lives and wellbeing. I’m no expert on the upper digestive tract so will leave the ‘normal’ digestion debate to them. However, as a pelvic health Physiotherapist, I see a range of issues with the other end – the bowels – that can have a severely debilitating effect on a person’s life – but can definitely be improved and often resolved, even many years after they first started.


What’s Not Normal?

This is much easier… though it may still surprise you. Once again, using the word ‘normal’ is not supposed to judge, shame or ridicule anyone – ‘not normal’ in my context is always stating ‘non-optimal health’ in terms of function of the body. And if it’s non-optimal, wouldn’t you be interested in knowing how to get back to full health? Because it is possible – and possibly easier than you’d think.

No Pain

Seems obvious, doesn’t it? Pain is generally seen as a sign from the body that it’s not happy, and we are hardwired to avoid pain at all costs. It’s ingrained in our deepest reflexes and our longest held habits. So why do people accept that soreness and painful passage is ‘normal for me’? It may be normal for an individual based on their sole experience, but in the context of a happy functioning bowel and a human species, this is the clearest message you can have that something is not 100%. In the case of pain, it’s a lot less than 100% and we need to pay attention.

Common, and commonly ignored, issues are:

Fissures: small tears in the lining of the anal canal. These have a habit of healing slowly due to the frequent use of the area, and re-tearing easily, just when you thought you’d got it under control. Typically they’re caused by trying to push something dry and hard through a narrow space… more on straining below.

Anismus: painful spasms of the anal sphincter during defaecation. Crucially, it’s defined as a failure of the normal relaxation of the pelvic floor muscles during this action. Yes, the pelvic floor is supposed to open and relax, not be working hard to push things along. Its precursor is Paradoxical Contraction – again a failure of the pelvic floor muscles to relax and allow the passage of a stool, indeed it’s a contraction – but often happens without pain and the person isn’t aware they’re contracting when they should be relaxing.

Proctalgia Fugax: essentially the same thing, though because the spasms can happen at any time, even overnight, it’s sometimes seen as a different condition, as it’s not directly related to doing a poo. From a Physio perspective, this is a sign of chronic, disorganised and unhappy behaviour of the pelvic floor muscles – and again the pain is a cry for help.

Haemorrhoids: funnily enough, these most common of afflictions are actually originally designed for a positive purpose. When happily doing their job you’d never notice them. These blood vessels sit inside the anal canal and because of their soft flexi-walls they act as cushions for any stools coming out, help to protect the lining of the canal and reduce the risk of fissures. Unfortunately that puts them on the front line, and when they get irritated or inflamed they can be an intense source of pain and misery themselves.

No Strain

This often surprises people – no, straining is NOT an essential part of opening your bowels. They are beautifully designed to move a stool throughout your tract un-monitored (do you have to push to get it from your stomach to your bowels? Not one bit), and only a gentle push should be necessary at the crucial moment to see it on its way.

Yet our modern lives are so busy that lots of us become impatient, or at risk of interruption, the moment our behinds hit the seat – and we try to hurry things along. Ironically, this urgency to get gone makes our fight or flight system perk up. Why are we hurrying? Is there a lion coming after us? Such ancient subconscious thoughts will actually create a heightened awareness, readiness and tension in all our muscles – including the pelvic floor, which right before that moment was trying to relax. Can you see how hurrying, or impatience, or pushing, can actually impede stool movement, and even start to cause you pain?

No Blood

This again seems obvious when considered in isolation; blood = damage. But if you have thought until now that straining and pain is kind of normal for you, then it seems less dramatic to see blood, indeed it seems almost inevitable. Fresh bright blood is usually the result of damage on the way out – fissures or haemorrhoids – but darker fluids or clots indicate there may be internal bleeding further up the tract – a priority to get checked ASAP. Either way, another sign of damage, inflammation and trauma. Why would that be acceptable for any part of your body?

No Smell

Well, OK, not totally odourless. And it will depend on what you ate yesterday. But generally, the majority of your stools should smell unremarkable, and need at most only a mild airing before the next visitor to the water closet, rather than security tape. A fair test is if you or your partner (used to your smells) are appalled by your own gaseous waste, there’s something that is asking for attention further up the gastro-intestinal tract.

What Now?

So how does it feel to know that all these criteria are for optimal health… and you might be among many others who fit none of them? It’s natural to feel unnerved if things aren’t going well, defensive even, and yes I agree there are multiple factors affecting bowel movements.

Luckily, without mentioning them to a soul (except for the blood thing – definitely get that checked), there are things you can easily do to help and heal your hard working back end. Take a look at my easy solutions in my next blog which will support you to make toilet time a relaxing and productive experience.

(Please note, yes, I would definitely recommend you going to see someone about all the above. But I understand that perhaps you’d like to try a few solutions for yourself before having that conversation… Read on!)