What is Constipation?

Constipation is a bowel condition that is estimated to affect approximately 20% of people. Typical symptoms include less than three bowel movements a week, where the consistency of the stool is dry and hard making it difficult to pass. The sensation of incomplete emptying can be a common complaint for those with constipation.

What causes constipation?

Constipation occurs when our waste moves through our digestive tract too slowly or the stool cannot be eliminated effectively from the rectum. When this happens stool becomes more solid, dryer and even harder to pass. 

The pelvic floor and constipation. 

Today let's talk about the pelvic floor and the important role it plays in helping you to eliminate a stool. For many this happens naturally and there is no need to think about it. But if you have dyssynergy of your PFMs (puborectalis - PR)  they become uncoordinated making it difficult to have a bowel movement.  

Why is coordination of the Pelvic Floor Muscles so important for a bowel movement?

It is increasingly recognized that pelvic floor dysfunction can cause difficulty with bowel movement and constipation. 

The puborectalis (PR) muscle originates from the pubic bone and wraps around the bowel, by doing so it creates a kink in the bowl. This kink works as part of our continence system. When the timing is right and you're getting ready to expel a bowel movement the PR muscles should relax in a coordinated manner, this straightens the back passage and with a strong propulsion through the rectum should allow for easy expulsion of the stool. 

Up to 50% of those who are chronically constipated have dyssergy of their PR. This means that either the PR is unable to relax or it reflexly contracts rather than relaxes with a bowel movement. This results in constipation. 

How do I treat constipation?

Our Osteopaths will work alongside your current health care providers to produce an individualized treatment plan, they use a variety of techniques to help your pelvic floor muscles relax and with biofeedback techniques teach you how to effectively bear down. 

Osteopaths work with your breath and facial system to help relieve any tension within the abdominal region restricting movement of your bowel. Then, through education, work with you to create a healthy bowel routine, defecation training, ensure good toilet habits using correct posture/stool and breathing strategies while having a bowel movement.

Tips to Improve Constipation at Home

1. Stop and chew your food. No rushing. 

2. Drink adequate water

3. Eat a variety of fibrous foods.

4. Exercise regularly

5. Abdominal massage

6. Spend time outside each day

7. Use a stool when sitting down for a bowel movement.

8. Relax the rectum when sitting on the toilet, allow your perineum to bulge. 

9. Keep your mouth and jaw relaxed.

10. Use low toned sounds - oooooo cha.

11. Never delay a bowel movement.

12. Relaxed breathing 

13. Don’t strain - use correct breathing strategies. 

14. Avoid negative self talk when toileting. 

What is Bladder Pain Syndrome/interstitial cystitis ?

What is Bladder Pain Syndrome/Interstitial Cystitis ?

A little bit of anatomy first, the bladder is a muscular organ that receives filtered urine from the kidneys. As the bladder fills the bladder wall is stretched. This stretch automatically sends information to your brain, making your brain aware of how full the bladder is and when it will be an appropriate time to wee. When the time is right you will feel the urge to void and, with that sensation, look for a toilet. 

Bladder pain syndrome (BPS/IC) typically involves bladder hypersensitivity with symptoms of bladder urgency, frequency and pelvic pain in the absence of any infection. In extreme cases it is common to visit the toilet in excess of 40 times a day. 

BPS is a complex pain condition involving the bladder, pelvic floor and nervous system. 

BPS is more common in women than in men and it is estimated that 1.2 million Australians are living with this condition. BPS is often associated with negative cognitive, behavioural, sexual or emotional consequences and can be linked to a reduced quality of life (Engeler et al, 2020).

What are BPB/IC symptoms?

Symptoms vary between individuals, but can include,

• Suprapubic pain (pain above the pubic bone)

• Bladder pain and pressure with filling, that is not relieved with a void

• Burning sensation with a void

• Increased urgency and frequency of void

• Vulva pain - vulvodynia 

• Phantom UTIs

• Generalised back hip and pelvic pain

• Dyspareunia - general term for painful intercourse 

What causes BPS/IC?

There is much debate on this topic, and no consensus; some believe it is caused by Hunner’s lesions, a dysfunction in the lining of the bladder. However only 10% of those with BPS have these lesions. 

What we do know is that 87% of those with the condition have overactive, tight pelvic floor muscles (Peters et al, 2007). We also know that these muscles, when tight, can cause referral patterns that mimic the sensation of urgency and/or bladder pain. When these muscles are released it gives the bladder an opportunity to function optimally. 

We also know that after having experienced 3 UTIs the bladder can be up-regulated, making it easily irritated.  

How do we treat Bladder Pain Syndrome?

According to the American Urology Association, pelvic floor therapy is the first line of treatment for BPS/IC. 

Kathryn, our pelvic health trained osteopath has completed extensive training in the field of BPS/IC where she has studied under and been mentored by some of the world's leading experts in pelvic health and BPS/IC. She has an incredible understanding of the anatomy and facial connections impacting both the bladder and the pelvic floor muscles. 

Kathryn believes in adapting a multi dimensional approach to treatment, including internal and external myofascial release to the pelvic floor muscles and the fascia supporting the urethra and bladder. Education and home exercises on breathing, yoga hip and spine movement practices and meditation along with self care and self compassion.  

Kate's Tips for Pooping in the Postpartum Period

Now let me tell you something I found out the hard way… NO ONE tells you that having a vaginal birth can feel like the baby is coming out of your bum. Anyone with me??

Postnatally, there are lots of conversations about looking after your vagina; regarding tissue tearing, episiotomy and surgical repairs. Today however, we are doing a 180 and talking about the rectum, and, you guessed it... poop. It certainly makes sense that this area might be tender, and if you have had the privilege of seeing a vaginal birth in person or via photos or video, you can see how the rectum has been pulled and stretched away from its usual position. As unpleasant as this may sound, we do actually need for this to occur, as it helps make room for the little (or in my case - not so little) one, to exit. 

Personally, I had more pain rectally after giving birth than I did vaginally. I actually had no redness, swelling or stitches associated with my magic vagina, but did I have rectal pain? HELL YES! And let me tell you, I was more than a little scared to go poop. However, I knew that prolonging the act was definitely not going to help in the long term. 

So today I'm giving you my top tips for pooping directly after you give birth. 

• This is a biggy.. please don’t delay the poop! It might seem scary, but the longer you wait and the more you suppress the urge to eliminate waste, the more backed up you will get. As the stool backs up, it ends up being stored in the descending colon, and in doing so water is removed from your poop making it harder and harder. This will make it more painful and even harder to pass. If you feel the urge, please be brave and poop. 

• When it's time to go, remember to use the squatty potty. The posture the squatty potty encourages helps to relax the pelvic floor muscle (puborectalis), which straightens your back passage and allows poop to exit with ease. Adding a low tone sound like mooooo, zoooooo or rooooooo can aid in this process by encouraging your abdominal muscles and diaphragm to contract, increasing the pressure around the rectum and stimulating the parasympathetic nervous system.

• Still nervous about doing a poop? Take a small pillow with you, placing it on your lower belly (this is even more important if you’ve had a cesarean section) and adding some pressure. The act of pooping requires tension (intra abdominal pressure IAP) to be created by our diaphragm and abdominal muscles , the pressure from the pillow can help regulate the IAP normally created by our stomach muscles. Plus it takes pressure off your fresh scar. 

• A great way of stimulating the parasympathetic and dampening the sympathetic nervous system is with relaxed diaphragmatic breathing. If you are not sure how to do this, check out this video. When we stimulate our parasympathetic nervous system, it gets our digestive system moving and stimulates our rectum to contract while inhibiting our internal anal sphincter, i.e. the back passage opens. The parasympathetic nervous system is all about rest and digest. This type of breathing will also massage the bowel with the rhythmic motion of your breath. Plus, as a bonus, diaphragmatic breathing will also start building an awareness of your breath and pelvic floor muscles. Did you know that when contracting your pelvic floor muscles you increase blood flow to the area which also aids in healing and recovery?

• As I’m sure you know, things can be a little tender downstairs after a vaginal birth. If you can handle the pain after giving birth, try to avoid medication containing codeine, as it will clog you up even more. There are other alternatives such as panadol for pain relief, and the use of ice to numb the area. Using ice as a cold compress also aids in your recovery by adding compression to your first aid steps. 

• If you are having trouble with passing stool and need help with softening the waste, magnesium oxide can be a great way to achieve this. However, before taking magnesium please consult with your maternity health team. 

• Your first meal after giving birth should be nutrient rich and easy to digest. Why hello Bone broth, this yummy nourishing substance can be a great way to keep you hydrated during the labour, plus it will help to give you loads of energy (trust me when I say you will need it) during the birth, and again once you have your new bubba in your arms. This liquid gold is rich in collagen (did I mention collagen can help repair any tissue damage during the labour), gelatin and lots of minerals which are thought to have many medicinal properties, one of which is strengthening the gut lining and improving our immune system. YAY! This is exactly why people offer to cook chicken soup when we are sick. When I say cook I don't mean reheat from a can. I mean the type of soup our nannas cooked when we were young. Not sure on how to cook a bone broth? Check out Chloe’s blog. You can consume the bone broth on it’s own or use it as a base for your yummy soup.

• Look after your gut MICROBIOME - these are the bugs that live in our gut - with the greatest concentration being in our large bowel, they are very much involved with the health and function of the bowel, and the quality and ease of our poop! Pregnancy and birth interventions can cause lots of disruptions to our microbiome, so it’s important to support and rebalance the microbiome postnatally (in fact it’s super important to optimise it the whole way through pregnancy learn more about that here.

• We need both PRE & PRObiotics to restore & maintain our microbiome - this can get confusing - let me explain; PREbiotics feed the good bugs and PRObiotics are the good bugs. PREbiotics are found food in plant foods (a rich and diverse plant-based diet creates a rich and diverse gut microbiome) and PRObiotics are found in fermented foods and drinks (yoghurt, kefir, kombucha, sauerkraut etc) or supplements can be used. 

Supplemental PRObiotics are amazing to use postnatally for gut health. They help with motility, reducing inflammation, repairing tissue, regulating stool composition (keeping them soft!) etc. BUT (and this is a big but!) not all probiotics are created equal, you need to consider specific strains, mechanism of action (what they do in the body) and also quality of manufacture. We recommend Qiara - it has lots of great research, many of the beneficial mechanisms of action and it’s a quality Australian made product, it’s actually a breastmilk strain (meaning it was originally isolated from healthy human breast milk). As well as having many proven benefits for gut health and the gut microbiome - it also helps breast milk microbiome, breastfeeding outcomes and infant gut, microbiome & immune development. As far as PRObiotics go - it’s one of the best. I wish every mum and baby could have it. 

• When choosing food from a menu in a hospital, or if you have a friend or family member who has organised a food roster (these can be the best!), just remember to be fussy and ask for nutrient rich, organic whole foods that rot and make up the colours of the rainbow. Having a 1kg tray of lasagne delivered to your door, as yummy as it sounds, may not be the best for your digestive system. Chicken soup with a side order of sauerkraut can be an awesome request.

• Most importantly, when eating, take your time to chew, chew, chew your food. Chewing breaks our food down and promotes the production of gastric enzymes. Gastric enzymes are responsible for breaking our food down to an appropriate size for the small intestine to start removing nutrients. The act of chewing, filling our stomach and dumping into the small intestine stimulates a nerve pathway that causes our colon, and it’s natural peristaltic motion, to start. This peristalsis gently propels our stool through the large intestine. Way to go chewing, filling and dumping (pun intended)!

• Water, water, water! Always have a water bottle on hand and take it everywhere. Being hydrated is absolutely essential if you plan to breastfeed. It is vital to be hydrated for the production of your milk. Did you also know that dehydration can be a major cause of constipation? Since you are taking your bottle everywhere, when you have had a poop or a wee, rather than wiping the area with dry toilet paper, try using a soft damp cloth, especially if you have stitches, hemorrhoids or fissures.

• Whether you have, small graze or a minor perineal tear, an epsiotomy or a larger tear involving the external anal sphincter; it’s likely your perineal area ( the space between your vagina and anus) will be tender and need some ice and compression for 24-48hrs. Keep the area dry and clean. When drying after a shower, remember to dab the area dry. 

• Sleep. When you can, get some sleep. Hahaha… I know that this idea is good in theory but quite hard to achieve in practice. However, it is super important that you look after yourself and get sleep when you can. Try to limit screen time - especially at the 2 am feed... as tempting as it is to pick up your phone, DON’T! The blue light can affect your melatonin levels, therefore making it much harder to go back to sleep. 

• Move. This may seem like a hard task, but starting with small walks like checking the mail can be a great way to stimulate your GUT to get moving. 

At Eastern Osteopathy we believe that having good quality poop and optimising your gastrointestinal tract (GIT) health should be part of all new mamas postnatal health plans. Doing so will not just have a positive impact on your git, it will have a positive impact on your immune system, your mental health, the function of your pelvic floor and then there are the health benefits to your new baby. 

What is overactive bladder and why is my pelvic floor important?

Note: This article is designed to be educational and informative and should not be used to make decisions about any health-related issues. An appropriate health professional should always be consulted when seeking to diagnose, treat and make decisions about your health. 

When the bladder fills with urine, the bladder wall (detrusor muscle) remains relaxed; simultaneously the pelvic floor muscles (PFMs) contract, this allows your bladder to fill with urine without leakage. When the bladder is full, a signal is sent to the brain where a decision is made about whether it is an appropriate time to urinate. 

When we are on the toilet, the bladder wall (detrusor muscle) starts to contract and at the same time the PFM will automatically relax to allow for the flow of urination. This system is great when both the bladder and PFMs are working correctly. However, with Overactive Bladder (OAB) the relationship is often dysfunctional. Typically with an overactive bladder, the detrusor muscle contracts inappropriately (ie not when the bladder is full) causing the person to feel a sudden, and sometimes overwhelming urge to urinate. 

What are the symptoms of overactive bladder?

Overactive bladder syndrome consisting of urinary urgency, is usually accompanied by frequency and nocturia, with or without leakage, in absence of urinary tract infection (UTI) or other obvious pathology. (1)

URGENCY - The sudden strong urge to urinate. Urgency is often triggered by events such as putting the key in the lock, running water or seeing a bathroom.  

FREQUENCY - It is normal to pass urine 4 - 8 times in a 24 hour period, including once or perhaps twice at night (depending on your age). If your detrusor muscle is contracting when your bladder isn’t full, you may need to urinate more frequently, usually to pass small amounts of urine.  

URGE INCONTINENCE - Making it to the toilet on time can be difficult for some people as their bladder gives them very little or no warning, resulting in urine leaking. This can range from a few drops to a full bladder. 

NOCTURIA - If your detrusor muscle is contracting more frequently, you may find that you are waking at night to pass urine more than what is considered normal. It is normal to wake to void  up to twice at night (depending on your age)

Lifestyle modifications 

Lifestyle modifications, including a variety of behavioral changes can reduce OAB symptoms.

1. Regulating your fluid intake; Too much fluid can overfill the bladder and too little can concentrate the urine, which irritates the bladder. (2)

2. Limit bladder irritants;  Limit Alcohol, caffeine-based drinks, artificial sweeteners, spicy foods and carbonated drinks which can irritate the bladder, further exacerbating symptoms of overactive bladder. (3) (4) Alcohol also has a diuretic effect, which can cause more frequent urination.

3. Avoid Constipation; constipation can trigger or worsen symptoms of overactive bladder. Straining to open your bowels can weaken the pelvic floor. (2)

4. Keep your weight in the healthy range; evidence suggests that losing weight can decrease the severity and frequency of symptoms. (5)

5. Avoid smoking; ceasing smoking can reduce urinary frequency. (6)

Bladder training 

Step 1. Increasing bladder fill volume. (7)

The aim is to increase your urine volume by visiting the toilet less often. How do I do this? 

When you first feel the need to go to the toilet, try to ignore it. If the ‘need” is a strong urge, use the strategies below to defer the urge. Put off going to the toilet until the next time you feel the urge. Initially this may only be a few minutes. As you improve, you should be able to defer for 30 minutes or longer. 

During the night if you wake with the urge to go, get up and go immediately. 

Step 2. Deferral strategies: 

These strategies aim to dampen or suppress the overwhelming urge associated with OAB. We recommend you experiment with the below strategies and find the one that works best for you. Continue with your most effective strategy until the initial urge has passed. Then you can make a decision, if you need to go to the toilet or perhaps you can now wait. 

1. Pelvic floor muscle contractions: Stop, relax, breath and engage your pelvic floor. 

This is one of the most effective methods, as a pelvic floor contraction can turn your detrusor muscle off. Try taking a relaxed breath in and slowly engaging your pelvic floor for 10 seconds or 5-6 rapids contractions until the urge has subsided. (2)

2. Use perineal or clitoral pressure, (hand pressure over the crotch), while sitting on the edge of a chair or table. 

3. Roll up a bath towel and keep it on a chair. Sit on this roll when you have a strong urge to urinate. Tighten and hold your Pelvic floor muscles until the urge passes. You may even choose to place the chair in a place where triggers happen, i.e. at the front door. 

4. Squeeze the skin under your nose, Toe curling, Walk on toes - These can be a great way to distract you from the urge to urinate.

It is important to celebrate every time you reduce the urge to go to the toilet! Even if you last one minute before you need to head to the toilet. This is a positive step towards changing the relationship you have with your bladder.

 Step 3: Decrease your sensitivity to triggers.

Firstly identify your triggers, the most common are running water, arriving home and putting your key in the lock, or entering the bathroom. 

To help decrease the sensitivity of your triggers, try approaching the trigger with an empty bladder. Then, slowly approach the trigger with increasing periods of time after voiding. For example, if your trigger is ‘the running shower’, try going to the toilet prior to turning the shower on,  then slowly start to increase the time period before turning the shower on.

How can osteopathy help with overactive bladder and urgency?

As osteopaths we look at the person as a whole, we will assess overall alignment, movement patterns, breathing, pelvic floor function and deep core engagement. We will endeavour to work out why your symptoms arose in the first place and create a specific treatment plan that will include an osteopathic treatment.

As a part of our treatment plan we  may give advice on a specific bladder training program, urgency deferment strategies, lifestyle modifications, pelvic floor muscle rehabilitation (strengthening or relaxation), and mindfulness. 

With the use of real time ultrasound, your osteopath can check to see if you are correctly/fully emptying your bladder. 

Some patients with an overactive bladder also have tight pelvic floor muscles. A tight pelvic floor can increase the sensations of urinary urgency. You may be asking your pelvic floor to work extra hard to prevent leakage, which can cause your pelvic floor to become overactive and tight. When in this state, the pelvic floor is no longer able to positively influence the bladder (i.e. turn the detrusor muscle off), which can make the symptoms of OBA worse.  

If this is the case for you, your osteopath will help you to address this before any strength training. 

Referneces

1. ICS terminology report, 2010

2. Evaluation and management of overactive bladder: strategies for optimizing care. Marcella G Willis-Gray, Alexis A Dieter, and Elizabeth J Geller

3. Dietary caffeine intake and the risk for detrusor instability: a case-control study.Arya LA1, Myers DL, Jackson ND.

4. Caffeine and urinary incontinence in US women.Gleason JL1, Richter HE, Redden DT, Goode PS, Burgio KL, Markland AD.

5. The prevalence and risk factors of overactive bladder symptoms and its relation to pelvic organ prolapse symptoms in a general female population. de Boer TA1, Slieker-ten Hove MC, Burger CW, Vierhout ME.

6. EFFECT OF SMOKING CESSATION ON OVERACTIVE BLADDER SYMPTOMS IN ADULTS: A PILOT STUDY. Wyman J1 , Allen A2 , Hertsgaard L2 , Overson E2 , Allen S2 , Hatsukami D2 1. School of Nursing, University of Minnesota, 2. School of Medicine, University of Minnesota 

7. Bladder training for urinary incontinence in adults. Wallace SA1, Roe B, Williams K, Palmer M.