“Everybody Poops” (Taro Gomi) If only it was this simple!

I treat many patients with chronic constipation. Usually, they are referred to physical therapy with the diagnosis of “pelvic floor dysfunction”.  The first thing most patients ask is “What does physical therapy have to do with not being able to poop?”  I probably should come up with a concise, one sentence response, but I have yet to figure out how to do that.   So this is my usual response:

Bowel issues (problems with pooping) can usually be broken down to 2 basic categories.  That is transit problems, when things don’t move smoothly through the length of the digestive system,  or evacuation problems, when things make it to the end of the digestive system, but there is a problem getting them out.  Luckily, physical therapy can (to some extent) help with both of these problems.

First it is important to understand the basics of how the digestive system works.  In 3rd grade, my daughter put together a presentation highlighting the basics that she title Taco Meets Mouth,  that went something like this.  First, food enters the stomach, where acid kills off some harmful bacteria, and the food gets churned up into a watery mush.  A little opening at the bottom of the stomach (pyloric sphincter) controls how much of this mush enters the small intestine at a time.  This mush gets combined with enzymes from the pancreas and bile from the gallbladder (or liver).  These enzymes along with helpful bacteria in the small intestine, break down the food its basic parts.  The walls of the small intestine are designed to be able to absorb the basic parts that the body needs, such as carbohydrates, proteins, fats, vitamins and minerals.



Usually about 6-8 hours later, this food “mush” has completed its journey through the small intestine, and the body has absorbed most of the nutrients that it needs.  At the end of the small intestine is another valve like structure (iliocecal valve) that controls the flow of this waste mush into the large intestine (aka colon).  In the large intestine, a couple of remaining vitamins are removed along with a lot of water.   At the start of the of the start of the large intestine, this waste is quite watery,  and by the end it should be rather solid.  The time that it spends in the large intestine can make a big difference on how soft or hard this waste (poop) is.  When it gets to the end of the large intestine (aka colon),  it triggers the urge to poop (usually 24-72 hours after entering the mouth) .  This is where my daughter’s presentation ended….but not for me.


Under ideal circumstances this urge to poop, should be followed by squatting or sitting in a relaxed position, to allow the colon to do its final job and squeeze out this poop.  But, it may not be convenient, nor socially acceptable to just squat and poop where ever you are when the urge strikes.  Around the age of 2 years old, the nervous system develops a reflex called the rectoanal inhibitory reflex.  This reflex allows us to delay that urge, when it is not convenient, by contracting the pelvic floor muscles.  If we are successful in using this reflex, the end of the colon should relax and the urge should subside or go away.  Great for social situations, not so great for emptying waste from the body.



Problems can arise anywhere along the path from mouth to, as my daughter called it,  “the end of the line”.  Spasm in those small valves can cause difficulty for food to move from the stomach to the small intestine or the small intestine to the large intestine.  Tightness in the tissue that surround the intestines (visceral fascia) can cause slowing of the movement through the intestines, especially in the large intestine, where the waste becomes solid.  Over activity of the pelvic floor muscles can trigger that rectoanal inhibitory reflex and cause the colon to relax and not be able to effectively push the poop out.   Or, as I often say, it “slams the door shut”.



Finally,  the part that we sometimes forget, is that the digestive tract is controlled primarily by the autonomic nervous system.  This part of the nervous system is not under voluntary control.  There are two basic sides to the autonomic nervous system, the fight/flight , and the rest/digest part.  In a very simplified model when the fight/flight part goes up,  energy decreases from the digestive and immune systems and instead goes to the arms, legs, heart and brain.  This is a great response if you find yourself face to face with a bear or tiger.  Problem is everyday stress can also trigger this response, and too much time spent in the fight or flight response can really harm the body’s ability to rest and digest.



So to get back to the question “what does physical therapy have to do with not being able to poop?”  Physical therapists, trained in treating bowel issues, can use exercise or manual therapy to decrease tightness in the visceral fascia around the intestines.  They also have special training in using exercise, manual therapy and biofeedback to help patients be able to decrease over activity of the pelvic floor muscles.  Finally, there are many different types of exercises and breathing techniques that can help to quiet down or control that fight/flight response.

Keep following, for future posts on simple tips and exercises that you can try at home to help manage bowel symptoms and chronic constipation,

Love and Peace,



What’s Going on “Down There”?

Every time I evaluate a new patient  (before I do a physical exam) I take the time to review the anatomy in the pelvis.  It doesn’t matter if I am talking to an 11 year old and her mother or a nurse or doctor, the response is always the same “wow, I didn’t know that all that was “down there”.  Even in my undergraduate  physical therapy training, we barely touched on the anatomy and function of what is inside the pelvis.

I usually start from the inside out.  Starting with the bony structure,  the pelvic is made up with the sacrum in the middle and a pelvic bone on each side (actually each pelvic bone is 3 bones that have fuse together-but that is only important to anatomy geeks, like me).


This ring is held together by ligaments that attach the bones together like tight rubber bands.  Some people have really tight ligaments and some people have really loose and stretchy ligaments.  If they are too loose and stretchy, it may lead to instability, and possibly greater risk of injury to this area.


Sitting inside this pelvis are very important organs.  From front to back, the organs are the bladder, uterus and the rectum.  Each of these organs are also suspended by ligaments that attach them to the inside of the bony structure of the pelvis.


These ligaments can also be very tight or very loose.  It is also possible that these ligaments can become damaged, during surgery, childbirth or chronic straining (think constipation or frequent coughing)

Luckily, we have some additional support from below these important organs.  The pelvic floor muscles (aka levator ani) support the organs from the bottom of the pelvis.  These muscle create a hammock or sling from the pubic bone in the front to the tail bone in the back.  I think they look  more like a bowl that supports the organs from front to back and from side to side


The pelvic floor muscles need to be able to contract, to close off the urethra (bladder opening) and the anus  (rectum or bowel opening).  They also need to be able to relax to allow the bladder or bowel to empty, or to allow for childbirth or intercourse.    The muscles that support the bladder are the same muscles that support the bowel and create the side walls of the vaginal canal.  This is why bladder, bowel and sexual issues are so closely related.

Issues can arise when these muscles either don’t contract properly or don’t relax properly.  Many of the patients that I see that think they have weak muscles, actually have tight muscles that don’t relax properly.

One more layer down from the pelvic floor is the superficial perineal muscles.  These muscles help to keep the rectum closed at rest, and keep the labia (lips around the vaginal and urethra opening) closed, protecting this area from bacteria and irritation.  These muscles can also be affected by childbirth or chronic straining.

Female Genitalia, Dissected View

Sudden hormone changes, such as menopause, birth control, or after child-birth can also affect the flexibility and elasticity of these muscles.  It is quite common to see patients who start having difficulty (pain) with sexual activity at these times due to changes in the muscles.

The last thing we review, which is probably the most familiar (but not familiar enough) to most women, is the external genitalia.  This includes the labia majora, labia minora, clitoris, urethral opening, and vaginal opening (aka introitus).


I recommend that all women should become familiar with the appearance of this area.  There is such a wide variety of what is normal,  shape, texture, and color can vary quite a bit.  It is very hard to tell if there has been a change, if you don’t know what it looked like before.  Most of us would notice a new mole on our face or a lump in our breast, but if something feels different “down there”, could you tell if it looked different too?

Understanding your pelvic anatomy is the first step in understanding and treating  any  bowel, bladder or sexual issues that you may be dealing with.

Peace and Love,