Constipation and Bowel Urgency - When You’ve Tried the Basics and Need to ‘Reboot’ your Bowels

Laurie Bickerton, PT, FCAMPT, AFCI
Registered Physiotherapist – Pelvic Health and Orthopedic Manual Therapist

Bowels are more complex than we give them credit for, and when they aren’t working well, they will make life really uncomfortable. I have seen so many people limit their social lives, and even work, based on not being able to predict their bowel habits.

If you struggle with your bowels, it’s likely you have already tried increasing your fibre intake (fruits and vegetables or fibre supplements), drinking more water, exercising, taking laxatives, abdominal massage, etc. If emptying your bowels on most days is still not easy or comfortable, there is another treatment option: it can be useful to try using tiny balloons to retrain the sensation. Pelvic physiotherapists trained in bowel techniques are able to help people relearn their body’s signals and respond appropriately.  

Bowel Function

The colon (or bowel) begins from the small intestine on the lower right side of the abdomen, goes up to just under the ribs, across under the diaphragm, and down the left side of the abdomen. The colon functions to absorb water and electrolytes from the food and fluid that has been consumed. Smooth muscle in the wall of the colon moves stool along. The wall of the last part of the colon (rectum) is particularly full of sensors (mechanosensory cells) that register stretch. As stool moves into that last part of the bowel, the sensors register the stretch, send the message to the spinal cord, and you get a sense of fullness. The internal sphincter is normally held tightly closed. It is controlled by our autonomic nervous system (that runs our internal organs without our conscious thought). The body relaxes that sphincter for us in preparation to eliminate stool. The external sphincter is the outermost ring of muscle that children generally learn to control as toddlers. Once the internal sphincter relaxes, there is more pressure on the external sphincter. We learn to control that external sphincter so that we can choose to go to the toilet and eliminate it when it is convenient.

One Way That We Train Ourselves to Be Constipated

Normally, shortly after an urge comes, you go and empty your bowels. If you need to hold it, you need to tighten the external sphincter to manage that. The urge gets stronger when the bowel pushes a little more into the rectum. Most people will go and find the bathroom at this point. The reverse can happen too : imagine ignoring the signals from your gut sensors. You are aware that there is something in the last part of the colon, but you are busy and ignore the urge. The signal comes on again, a bit more intensely, to tell you to empty your bowels. Perhaps you ignore the message again. Perhaps you have a habit of ignoring it, even for most of the day. You’ve been delaying and ignoring signals from the bowel as a habit for years. This is common with those busy folks who are in meetings all day, or otherwise not able to get to the bathroom.

The signal is ignored, the stool sits there, even more water is absorbed (and becomes a harder and harder stool), and things get a bit backed up. Eventually, you empty, but it is much tougher when stool is harder and drier. If this is a regular habit, the colon and its messages are suppressed. Dyssynergic defecation is a special case. See my blog on that here: Dyssynergic Defecation. After doing this as a habit, you lose the sense when you need to empty. I will note that this is more common with people in some careers since they have fewer opportunities to get to the bathroom in a timely manner. We see this in mail carriers, teachers, surgeons, and executives in particular. Sometimes there is a work culture of ignoring breaks, or little opportunity.

What If The Bowel Sends Messages Too Often?

The opposite of the process with constipation can happen too, and then, of course, you feel the need to go too often. Loose bowels can have many causes, and working with a primary care practitioner or naturopath can be really helpful as a first step. Working with fibre can also be useful, although it seems counter-intuitive. If you have tried the basics, it may be that you are “over-aware” of bowel sensations. The more you empty, the more the sensors in the rectum are used to having stool in small amounts, and having it move out quickly. Being “over-aware” of anything in the rectum means people have the urge to go to the toilet and try to eliminate frequently. Often there is not enough there to eliminate, and they strain to get rid of the sensation that there is stool ready. It just feels like you’re not done. In this case, it can be worth trying the balloon to desensitize the rectal walls partially. The goal is to bring that sensation back to a more normal level.

The ‘Reset Button’ Is Possible!

There is a method of retraining the sensation on the inside of the wall of the bowel. Balloons are used to fill the space and cause graded pressure to the sensors in the wall of the rectum in particular. Practice with an experienced pelvic physiotherapist helps to relearn the body’s signals.

An assessment always begins with a discussion of health history, and details of the symptoms that are bothering you most. The pelvic physiotherapist will then give you a moment of privacy to undress. Usually the exam begins with the abdomen and external genitals. After that, gently, the pelvic physiotherapist will examine the muscles of the base of the pelvis (the pelvic ‘floor’) by inserting a gloved finger into the rectum. She (very occasionally he), will ask you to squeeze and to relax the muscles and assess their strength, speed, endurance, and ability to relax. Co-ordination with the abdominal wall (muscles important for generating the pressure to push) is important. If it is appropriate, she will talk to you about using a balloon catheter for a second or subsequent visit.

How Balloon Catheters Are Used

Balloon catheters are tiny medical-grade balloons that are typically the size of a golf ball when inflated. They are used by covering them with a condom (usually) and then inserting them into the rectum through the sphincter when deflated. Deflated, they are smaller than a ballpoint pen, on a small tube. The pelvic physiotherapist attaches a large syringe full of air or water and slowly fills the balloon. The physiotherapist will ask when the person first feels a sensation of something in the bowel, and then with more filling, when there is a strong urge to empty. From this, the pelvic physiotherapist can evaluate what is happening and give feedback that the bowel is over or under sensitive. See the image above.

Treatment With Balloon Catheters

As treatment progresses, the pelvic physiotherapist will work with the patient to track the number of times the person is going to the bathroom in a day, and the amount of urge they are aware of. In the clinic sessions, the pelvic physiotherapist tracks the amount of inflation of the balloon that triggers a feeling of fullness. When patients are struggling with constipation, we seek to have awareness sooner, to really pay attention to the sensation before the balloon is fully inflated. For patients with urgency, we practise waiting with that sense of urgency, usually with the balloon only slightly inflated so that it is relatively small. This causes very little stretch of the wall of the rectum. We want a small sensation to be perceived with a small object in the rectum, and a greater sensation with a larger, full rectum. Gradually, the bowel decreases the input to the nervous system with the minimally inflated balloon. Then the person feels less urgency, which is appropriate with only a small amount in the rectum.

It continues to amaze me how neuroplasticity allows us to adapt our bodies. In a few weeks to a few months of training and deliberate home exercises for a few minutes each day, you can reset an over- or under-sensitive gut.

Balloons can be a real help in learning to listen to your body's signals. Don't be surprised if your pelvic physiotherapist also recommends doing other types of listening such as breathing meditations, stretching, or Mindfulness. It can be more helpful that most people would guess in reprogramming the body. These types of home activities reach deep into our nervous system to calm the ‘fight or flight’ many of us have learned to live with. We have elevated adrenaline and stress hormones in our bodies, and it impacts our digestive system more than we realize. Pain and abdominal discomfort also contribute to tension in the pelvic floor muscles.

Experience Counts

As you look for a pelvic physiotherapist, ask about experience, and particularly whether they have experience with rectal balloons. At Proactive Pelvic Health Centre, there are at least four of us who work with these types of bowel issues and are proficient with balloon catheters. Many pelvic health physiotherapists do not have balloon catheters and have never used them, so communication before the assessment is important.

References:

Knowles CH. Human studies of anorectal sensory function. Ir J Med Sci. 2018 Nov;187(4):1143-1147. doi: 10.1007/s11845-018-1847-5. Epub 2018 Jun 20. PMID: 29926337; PMCID: PMC6209020.

Ritchie J. Pain from distension of the pelvic colon by inflating a balloon in the irritable colon syndrome. Gut. 1973 Feb;14(2):125-32. doi: 10.1136/gut.14.2.125. PMID: 4696535; PMCID: PMC1412559.