I had the chance to spend some time with a lovely almost-six-year-old on vacation recently. She told her mom her three favorite things were "laughing, cuddling, and having a good poo." I have to say, I LOVE her list!
But, what happens when you're not having a good poo or few? Let's start the new year off right with a good chat about poop, shall we?
Constipation is a huge problem for a lot of folks, and has other consequences than a minor annoyance. Constipation essentially means that your waste products are sticking around on the inside longer than ideal...and in a permeable tube! I don't know about you, but I'd like to get that junk over and out! Also, the pressure and straining can lead to hemorrhoids or fissures and is a huge risk factor for pelvic organ prolapse (If you're not familiar, it's where 1-3 of your major pelvic structures are not staying in their supported position but are moving toward (and sometimes actually) falling outside your body. No bueno! Slightly more insidious is the effect that pressure has on other things such as the abdomen, breathing, lower back, hips, sciatica, etc.
Many folks who I would consider constipated don't even realize they are! Are you constipated? Let's define:
Diagnosis criteria for constipation according to the ROME classification of functional gastrointestinal disorders:
1. Includes TWO or more of the following:
3. Insufficient criteria for irritable bowel syndrome
Ideally, I'd like to see at least 1 easy-to-pass type 4 (or 3) each day.
But, what happens when you're not having a good poo or few? Let's start the new year off right with a good chat about poop, shall we?
Constipation is a huge problem for a lot of folks, and has other consequences than a minor annoyance. Constipation essentially means that your waste products are sticking around on the inside longer than ideal...and in a permeable tube! I don't know about you, but I'd like to get that junk over and out! Also, the pressure and straining can lead to hemorrhoids or fissures and is a huge risk factor for pelvic organ prolapse (If you're not familiar, it's where 1-3 of your major pelvic structures are not staying in their supported position but are moving toward (and sometimes actually) falling outside your body. No bueno! Slightly more insidious is the effect that pressure has on other things such as the abdomen, breathing, lower back, hips, sciatica, etc.
Many folks who I would consider constipated don't even realize they are! Are you constipated? Let's define:
Diagnosis criteria for constipation according to the ROME classification of functional gastrointestinal disorders:
1. Includes TWO or more of the following:
- Straining during at least 25% of defecations
- Lumpy or hard stools in at least 25% of defecations
- Sensation of incomplete evacuation for at least 25% of defecations
- Sensation of anorectal obstruction/blockage for at least 25% of defecations
- Manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic floor)
- Fewer than three defecations per week
3. Insufficient criteria for irritable bowel syndrome
Ideally, I'd like to see at least 1 easy-to-pass type 4 (or 3) each day.
Now, reasons why you might be experiencing constipation are quite complex....
One of the more commonly offered solutions by pelvic PTs and even now the CrossFit and Paleo communities is to elevate the feet while on the toilet. To do that, you need something to rest your feet on while you're on the toilet so that your pelvic muscles and organs are closer to a squatting position. Our species evolved pooping and birthing in a squat, and many cultures around the world still do it that way. Sitting on a toilet is truly not what our muscles were designed to do, especially these "handicap friendly" higher toilets! Squatty Potty's commercial explains this in an educational and strangely humorous way...check it out.
If you've never tried elevating your feet while on the toilet, I do recommend it as a trial. What you're aiming for, is to get your knees above your hips to mimic a squat position. This allows the muscles that normally tighten to keep you continent to relax and allow you to void. Maybe you just put your feet on a step stool, a box, even yoga blocks to try it out. Some folks prefer a special stool that fits neatly around the toilet and is just the right height such as Squatty Potty, PoopStoops or High Ends. High Ends (in the photo above) are actually my favorite of the bunch because they are nice and stable. They are made-to-order to exactly the height you need, which for a lot of folks is quite a bit higher than the highest Squatty Potty. The high end allows you to literally squat all the way, rather than just lifting your feet into a squat-like sitting position. If you are not used to doing full squats on a regular basis, you may need to work up to this height.
- poor gut health - that in and of itself is complex!
- endocrine (hormonal) influences
- food sensitivities
- dehydration
- stress
- side effects from medications
- insufficient movement/exercise
- imbalanced core pressure system
- dyssenergia - discoordination of muscles involved in defecation (pooping)
- non-relaxing pelvic floor
- poor mobility of abdominal/pelvic fascia from surgery or inflammation
- rectocele or posterior vaginal wall prolapse (chicken or the egg phenomena)
- and more...
One of the more commonly offered solutions by pelvic PTs and even now the CrossFit and Paleo communities is to elevate the feet while on the toilet. To do that, you need something to rest your feet on while you're on the toilet so that your pelvic muscles and organs are closer to a squatting position. Our species evolved pooping and birthing in a squat, and many cultures around the world still do it that way. Sitting on a toilet is truly not what our muscles were designed to do, especially these "handicap friendly" higher toilets! Squatty Potty's commercial explains this in an educational and strangely humorous way...check it out.
If you've never tried elevating your feet while on the toilet, I do recommend it as a trial. What you're aiming for, is to get your knees above your hips to mimic a squat position. This allows the muscles that normally tighten to keep you continent to relax and allow you to void. Maybe you just put your feet on a step stool, a box, even yoga blocks to try it out. Some folks prefer a special stool that fits neatly around the toilet and is just the right height such as Squatty Potty, PoopStoops or High Ends. High Ends (in the photo above) are actually my favorite of the bunch because they are nice and stable. They are made-to-order to exactly the height you need, which for a lot of folks is quite a bit higher than the highest Squatty Potty. The high end allows you to literally squat all the way, rather than just lifting your feet into a squat-like sitting position. If you are not used to doing full squats on a regular basis, you may need to work up to this height.
I've had some folks come to see me after having been to other pelvic PTs that say they tried squatting stools or platforms and it didn't work for them. The main caveat to elevating the feet while on the toilet is what's going on with the hips. There are 2 main concerns.
1. Your ankles don't bend enough
A full squat requires sufficient ankle dorsiflexion, or the ability to bring the top of your foot to your shin. Depending on the degree of stiffness in your ankles, you may have a hard time with partial squats (like chair pose), getting the heels down in a down dog in yoga class, or coming into a full squatting position (like Malasana, or the photo above on the High End). If these are difficult for you, it's not a lost cause! Sometimes just practicing squatting for practical purposes throughout the day everyday can help over time. I also, of course, recommend working with an orthopedic manual physical therapist - they can help mobilize your ankles and teach you some strategies to practice at home. Yup, squatting to poop is THAT important!
2. If your hips don't flex enough
Maybe you no longer have the kind of range of motion in your hips that would allow you to get in a squat-like position even if you were supported on the toilet. Possibly this is due to a hip replacement, an injury, or simply from a lifetime of sitting in chairs and not squatting. This may make elevating your feet impossible. Or you may get your feet into position, but your body has to compensate most often by tilting your pelvis way back and curling your back into a c-shape. For some folks this might be painful or uncomfortable. Even with no discomfort, this is not helpful for better pooping because gravity is no longer on your side and your muscles are not being put into a more efficient position. In many cases, it's possible to improve the range of motion in your hips (best with the help of a PT) and you can work toward getting into a better squat-like position.
3. If your hips glide posteriorly/inferiorly when you flex them to this degree
This is one I don't hear many folks talking about. We talked a little more in-depth about posterior glide in this post. This posterior glide can overstretch the deep hip stabilizers, create increased tension in the pelvic floor, and anger the nerves in the pelvic region. Even though you're not trying to put your foot behind your head on the toilet, depending on the extent of hypermobility in the hips, this posterior glide may come quite easily. For some folks it happens as soon as the knees go above the hips at all, especially when the proximal femur (the part of the thigh closest to the pelvis) is unsupported as happens on a toilet seat. If constipation is a problem, and there are other signs of pelvic floor "tightness" or "hypertonicity", elevating the knees may not be the right answer. For this person, I would investigate other causes of constipation (as in the list above) and work with a PT who understands the relationship between hip accessory hypermobility and the pelvic floor. This is a rare breed for sure!
Happy pooping! Let me know what questions you have!
1. Your ankles don't bend enough
A full squat requires sufficient ankle dorsiflexion, or the ability to bring the top of your foot to your shin. Depending on the degree of stiffness in your ankles, you may have a hard time with partial squats (like chair pose), getting the heels down in a down dog in yoga class, or coming into a full squatting position (like Malasana, or the photo above on the High End). If these are difficult for you, it's not a lost cause! Sometimes just practicing squatting for practical purposes throughout the day everyday can help over time. I also, of course, recommend working with an orthopedic manual physical therapist - they can help mobilize your ankles and teach you some strategies to practice at home. Yup, squatting to poop is THAT important!
2. If your hips don't flex enough
Maybe you no longer have the kind of range of motion in your hips that would allow you to get in a squat-like position even if you were supported on the toilet. Possibly this is due to a hip replacement, an injury, or simply from a lifetime of sitting in chairs and not squatting. This may make elevating your feet impossible. Or you may get your feet into position, but your body has to compensate most often by tilting your pelvis way back and curling your back into a c-shape. For some folks this might be painful or uncomfortable. Even with no discomfort, this is not helpful for better pooping because gravity is no longer on your side and your muscles are not being put into a more efficient position. In many cases, it's possible to improve the range of motion in your hips (best with the help of a PT) and you can work toward getting into a better squat-like position.
3. If your hips glide posteriorly/inferiorly when you flex them to this degree
This is one I don't hear many folks talking about. We talked a little more in-depth about posterior glide in this post. This posterior glide can overstretch the deep hip stabilizers, create increased tension in the pelvic floor, and anger the nerves in the pelvic region. Even though you're not trying to put your foot behind your head on the toilet, depending on the extent of hypermobility in the hips, this posterior glide may come quite easily. For some folks it happens as soon as the knees go above the hips at all, especially when the proximal femur (the part of the thigh closest to the pelvis) is unsupported as happens on a toilet seat. If constipation is a problem, and there are other signs of pelvic floor "tightness" or "hypertonicity", elevating the knees may not be the right answer. For this person, I would investigate other causes of constipation (as in the list above) and work with a PT who understands the relationship between hip accessory hypermobility and the pelvic floor. This is a rare breed for sure!
Happy pooping! Let me know what questions you have!
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