What's a 'normal' bowel habit?
I always ask my patients “How are your bowels?".
The reply is often “Fine" or “Normal”, which leads me to ask “What is normal for you?”
This baffles many who assume "Normal" is normal.
The reality is, where bowel function is concerned, there is a broad spectrum of “normal” and what is normal for one person may not be for another. I suppose a more accurate way to describe a person’s bowel habit is what is “usual” for them.
There is a common misconception that if you do not need to open your bowels daily, this is described as, constipation. However, constipation is a symptom, not a disease in itself, and represents not just infrequent passing of stool (less than 3 times per week), but also difficulty doing so.
You may find yourself opening your bowels daily at the same time, but experience pain doing so, or struggle to finish and completely empty your bowels. This can leave you with a sense of incomplete emptying, and many people find it hard to get on with the day leaving the "job undone", having to return to the loo many times in an attempt to finish off. They then strain to empty the bowel fully. This can lead to weakening of the pelvic floor muscles and further problems.
Imagine the embarrassment felt when having to explain being late for work because you couldn’t leave the house without feeling you have completed a bowel movement.
So many people describe this pattern of behaviour to me and the problems it can cause in their daily lives, and yet so few seek help as they are too embarrassed.
People have little awareness of “normal bowel function “ or the full spectrum of bowel habit within that accepted norm because no-one feels comfortable discussing their bowels. This creates problems in itself as people put up with symptoms, often unaware either that they are not normal or that any specialist help is available. It also makes it difficult to identify when bowel function deviates from the usual pattern and the significance of this when seeking help.
As a specialist physiotherapist working in pelvic health, I see many patients with bowel dysfunction. They may present with faecal urgency and incontinence as well as constipation and obstructed defaecation, pain and bloating, often all of the above!
My role is to identify what "normal" is for that person and crucially why they have deviated from this and how I may help restore them back to their “normal”.
Many of the clues lie in the answers to detailed questions ranging from diet, lifestyle and mental health to the actual physical way they open their bowels including methods used to initiate/complete a bowel movement which can be hugely varied and imaginative!
An ano-rectal examination will also provide valuable anatomical clues to complete the clinical picture.
Bowel function can be thought of as being the body’s waste disposal system and, as such, is fundamental to mental and physical well-being. Bowel dysfunction can arise through problems encountered at various stages throughout the system.
The bowel is made up of the small and large intestine/colon finishing as the rectum at the lower end which acts as a reservoir storing the stool until it reaches a critical volume. Small changes at any stage along the gut can trigger significant disruption further down the line. Broadly speaking these changes can affect two aspects of the system, the transit or movement of waste as it travels through or the actual evacuation process where the waste arrives at the end of the system and exits as a stool.
There can be many causes which may trigger disruption in bowel function, and all must be explored. Constipation can be secondary to a pathology or disease, and this must be ruled out or confirmed by investigations such as colonoscopy. However, the vast number of patients I see with bowel dysfunction are those who have no identifiable cause regarding pathology. While this is comforting, the remaining poor bowel function can have a devastating impact on their quality of life.
Many of my patients fall into the category where they have bowel dysfunction due to disruption of the anatomy around the ano-rectal junction at the lower end of the bowel and sphincter mechanism, compromising the “exit”. This can be due to childbirth, rectal prolapse, rectocele, haemorrhoids or chronic straining and often develops insidiously without any identifiable trigger.
Many people are surprised to find themselves being referred to a “pelvic floor physiotherapist" - what have bowel problems got to do with the pelvic floor and how can physiotherapy help?
The association of bowel problems with the pelvic floor will be addressed in a different blog, the role of the specialist physiotherapist is that of functional rehabilitation.
We offer a holistic package of care identifying the problems and teaching people strategies to manage them so that they feel confident enough to continue to manage unsupervised. This may be through exercise, diet, defaecatory techniques, relaxation and re-training of breathing, electrical stimulation and biofeedback, lifestyle advice and practical devices to aid management such as irrigation systems. These will be discussed in greater detail in future articles.
People of all ages suffer bowel problems, male and female. There is an urgent need to break the taboo in bowel habits so that people are more aware of what is "normal" and what may be perceived as a problem.
Ultimately we need to spread the word that help is available to relieve the pressure and isolation created by these problems and crucially show people where to find it. They may then restore their equilibrium and regain their “normal”.
If you need to seek advice for an issue, schedule a free consultation call with Kate Walsh here.