Treating constipation with biofeedback for the pelvic floor

Constipation is often clinically defined as having three or fewer bowel movements a week. Sometimes this is about expectations; people generally feel like they're not "healthy" if they don't have a bowel movement every day. But three bowel movements a week can be normal for some people, especially if that has been their pattern for a long time.

There are many other factors that affect how people perceive bowel movements. According to the Rome IV criteria of constipation often used in research, frequency alone doesn't explain all complaints of constipation. Patients complaining of two or more of the following also qualify for a diagnosis of constipation:

• feelings of incompletely evacuating (not getting everything out)
• straining
• lumpy or hard consistency of the stool
• sensation of blockage
• using a finger to dislodge the stool.

When constipation is a problem, there are two main reasons for it: slow movement of the colon and pelvic floor dysfunction. Treatment for slowed movement of the colon is usually laxatives and drugs to move your colon. But getting your pelvic floor evaluated is worthwhile, because a diagnosis of pelvic floor dysfunction typically involves nondrug treatment.

Pelvic floor dysfunction

The pelvic floor is a muscular bowl that encompasses the rectum, bladder, and (for women) the uterus. There is a complex interaction among these different organs. In the act of defecating, or having a bowel movement, the anal sphincter (the group of muscles at the end of the rectum) has to relax, and the abdominal muscles need to contract.

A common analogy I give is that it's like getting toothpaste out of a tube. When you want the toothpaste to come out, you loosen the cap and press on the tube. However, if you leave the cap on or even tighten it, pressing is not going to get the toothpaste out. In the same way, some people who have constipation fail to relax, or actually tighten, their anal sphincter, while using their abdominal muscles to contract the colon when they are trying to defecate. This leads to feelings of incompletely evacuating; hard, small stools; or even feeling like you have to use your finger to get the stool out.

These uncoordinated pelvic floor dynamics are usually diagnosed with a test called anorectal manometry, which uses a thin tube to measure pressures, sensations, and reflexes in the rectum and anal sphincter.

Biofeedback-based physical therapy to treat pelvic floor dysfunction

The good news is that treatment typically does not involve medications. Instead, treatment involves physical therapy in the form of biofeedback. Currently, the best way to undergo physical therapy is in a private setting, with the help of a trained physical therapist who coaches you on the dynamics of defecating. During these sessions, the physical therapist inserts a probe into your anal sphincter and places sticky pads on your abdomen, to detect the movement of your anal sphincter and abdominal wall as you simulate defecation.

By doing this, you receive feedback (either visual or verbal) on what you are doing with your abdominal wall muscles and anal sphincter during a bowel movement. The physical therapist will lead you through breathing exercises, as well as muscle strengthening and relaxation exercises, in order to help you retrain the movement and coordination of your pelvic floor.

There are currently no devices available for at-home training, but such devices are undergoing research and development.

The physical therapist will also discuss dietary recommendations including increased water and fiber consumption, positioning techniques (like using a Squatty Potty), or massaging your abdomen to stimulate the gut.

The usual time commitment is about four to eight sessions, one session a week. Like physical therapy for your shoulder or your back, learning what you have done in physical therapy takes time and also practice at home. Some people understand and incorporate these techniques right away, and others take more time and practice.

Retraining your body to change the way you have a bowel movement takes time. But it could potentially help with all of the symptoms of constipation.