Avoiding straining on the toilet - this is one of the most common topics of conversation that you'll find occurring in a Pelvic Health Physio appointment.
Two of the most common reasons that women come to see us is for management of prolapse, and management of stress urinary incontinence. Both of these management plans include a variety of strategies that, in general, aim to optimise the support of the pelvic organs from below, and prevent unnecessary, repetitive strain on the organs from above.
And one of the main reasons for repetitive strain in a woman's life? Straining to push out a poo on the toilet.
Below are the Top 5 Tips that Women's Health Physiotherapists have for women - because we all deserve the experience of a good satisfying poo on a regular basis, with no pain and minimal straining!
1. Aim for a seated squat position
Sit with your knees higher than hips. This may involve putting your feet on a foot stool, putting two spare toilet rolls under your feet, or simply raise up on your tip toes.
Then lean forward and put your elbows on your knees. This position where the pelvis is tilted forward aims to increase what's called the 'anorectal angle'. This refers to the angle that is formed between the rectum and the anal canal, by the pulling back action of the resting tone of part of the pelvic floor muscles.
This angle is crucial for the proper functioning of the digestive and excretory systems, because it helps to maintain bowel continence. The angle acts as a natural barrier, preventing involuntary passage of stool or gas. When a person is not having a bowel movement, this angle is bent, which helps keep the anal canal closed.
However, during a bowel movement, the anorectal angle should straighten out, allowing the stool to pass through the anal canal and out of the body. Sitting in this forward lean position with the knees higher than the hips, in most women, will help them to poo more easily, and prevent having to strain to 'push the poo around a corner'.
It's important to note - for some women this position won't be the best for defecation, and one size doesn't necessarily fit all. In particular, if a woman has a 'posterior vaginal wall prolapse', which means a pocketing of the rectum into the vagina, then leaning forward might make the poo pocket into the prolapse and increase the feeling of needing to strain.
In this case, and for some other women, it can actually be more helpful to lean back, or to move from a forward to back position a few times, or side to side a few times, to get to stool to move down without strain.
2. Ensure that your pelvic floor muscles are completely relaxed
Proper coordination of the muscles around the anorectal angle, in particular a part of the pelvic floor called the puborectalis muscle, is essential for the control and timing of bowel movements.
As mentioned above, it's essential to have good resting tone in this muscle to keep the anorectal angle functioning during daily life, but when you sit on the toilet to defecate, it's essential that this muscle knows how to relax. Some women's muscles (including the puborectalis and the anal sphincter muscles) accidentally contract and squeeze when they're trying to poo - this can definitely cause a feeling of needing to strain, even without the stools being hard, and is something that a Pelvic Health Physiotherapist can help to retrain.
As a first step, simply bring focus to that area, potentially take a couple of deep breaths, and become aware if you are relaxing the muscles around the anus as you should or if you're accidentally tensing them.
3. Wait for a proper urge, and make it efficient
Usually, a poo should just 'happen'! You should have a nice, strong urge to poo when you decide to go to the toilet, rather than simply going and sitting there to 'try'.
You should be in, done and dusted within a couple of minutes. Sitting on an open toilet bowl is no time to check social media, especially for those with prolapse or a tendency to get haemorrhoids.
If nothing is happening after a couple of minutes, don't sit there any longer. Get up, go and move around more, have something to eat or a hot drink, and wait for another urge to come later in the day.
If you must stay in the toilet for another five minutes of family-free time after you've finished, by all means do! But finish up first, stand up, close the lid and sit back down on top of the toilet lid, without having all of that pressure down into the pelvis while you scroll!
4. Learn to use your breath to help your poo
As mentioned before, when your body is properly ready to poo and the stool is a normal consistency, it should just 'happen' when you sit down.
However, if you're having trouble, you can try using your breath or verbal sounds to help yourself to defecate without unnecessary strain.
Try breathing out and widen your tummy to poo, and consciously avoid blocking off your throat and holding your breath.
You may find that making sounds such as 'Moo' 'Hiss' 'Shh', or pretending
that your fist is a wide straw and blowing through it, can help.
5. Optimise food and drink to aim for a Type 3 or 4 stool
This is the Bristol Stool Chart, which is often used by health practitioners to get a measure of how close to 'optimal' your stools are.
Type 3-4 on the Bristol Stool Chart is the most ideal - this is the stool consistency that is most likely to be passed without straining, without being overly loose and increasing the risk of faecal urgency, or needing to excessively wipe.
Everybody's bowel will be different with regards to which foods harden or soften stools, but in general - always have breakfast, because the bowel loves this as a way to kick start getting moving in the morning, aim for adequate fluid intake (1.5-2.5L) with most of it being water, and consider including more soluble fibre in your diet (this includes 'wet' fruits like berries, kiwi fruit and grated apple, and some grains such as oats, psyllium and chia)
Need extra help?
Please speak to your GP for other options if not achieving Type 3-4 stool with diet measures alone - there are often other factors at play, and some women will need advice on laxative use and/or a dietitian referral.
Book a Women's Health Physiotherapy appointment to help diagnose if you have any physical issues that could be adding to straining to defecate - things like pelvic floor overactivity or dyssynergia, or a posterior vaginal wall prolapse.