Bowel Health: Is There a Taboo within the Taboos?
This week we are thrilled to introduce Kate Walsh MSc, Physiotherapist and all round continence guru. With over 25 years clinical experience we felt she was the perfect person to help us really get to grips with bowel health.
Tell us what a normal day in your clinic looks like?
I am very lucky, I have great variety in my week working in at least 3 different clinics (both NHS and private) on Wirral and Liverpool. I have also started a monthly session in London so there is no such thing as a “normal day” in clinic. However, what they all have in common are the patients! No matter where they come from, they all present with the same symptoms and are all grateful to have arrived at a place where they can get help.
What are the common bowel problems you see?
Broadly speaking the bowel problems I see can be categorised into incontinence of varying degrees (the involuntary leakage of solid / liquid stool or gas) and defaecatory disorders (inability to actually open the bowels and complete to a satisfying conclusion).
You could also put constipation as a common problem, but this is a confusing and often misused term since it means different things to different people and as a result is not clearly defined in terms of symptoms.
Constipation is not just when you can’t open your bowels for days or weeks, it is also a term used to describe straining and other evacuation issues such as incomplete bowel movements, even when they might occur several times a day
How does the pelvic floor relate to bowel problems?
The pelvic floor is an incredibly important set of muscles with many different functions. Included in these, it has to support the pelvic organs, maintain continence (both bladder and bowel), allow controlled continence, sexual function and support reproduction and pregnancy. Because of its complexity it just takes one small change in these special skills to upset the apple cart and certain functions will become dysfunctions! These changes can occur for a variety of reasons, some we can control, some we cannot.
Relating to bowel function, in order to maintain continence and not feel any urgency with bowel movements or leakage , the focus is on the rings of muscle (anal sphincters) around the lower end of the back passage. The outermost sphincter muscle is part of the pelvic floor, looping around the lower end of the bowel, and can be strengthened with pelvic floor exercises to increase our control and reduce the likelihood of these problems occurring.
Once the stool has reached the lower end of the bowel and is ready to make its final passage out, the bowel contracts to push it down like toothpaste through a tube. In response to this, the pelvic floor must relax to allow the stool to pass without any effort. In some cases the pelvic floor struggles to relax and can indeed work to oppose this movement. This results in the person unable to pass the stool without a great deal of straining which is going to cause further damage and must be avoided.
Having said that for successful bowel movements the pelvic floor must relax to allow the stool to be passed, it must still also maintain its supportive role. A bit like when you pull a sweater over your head; it is helped by pulling the neck open so it is tighter and your head pops through, rather than leaving the neck opening floppy and struggling to find it. The pelvic floor can be thought of in the same way…”holding the passage open,” guiding the stool to the exit if you like!
What are your top 3 tips for a healthy bowel?
I will try and keep my response to this question brief…unlike the last!
Eat regularly throughout the day. Fasting, shift work and generally being too busy to eat play havoc with your bowel. Bowels like order and some form of routine.
Don’t ignore a “call to stool.” If you feel the sense you need to go, then go! Don’t wait until later or try and organise your bowel movements like you do your diary.
Drink plenty of fluid, preferably water. A simple tip that is often ignored but can work wonders in softening your stool and making it easier to go.
Is there a correct way to poo?
This is such an important question. Different people adopt different “ways” of going in terms of breathing, habits, rituals and posture which may work for them. There are principles you can apply to help someone poo more efficiently with less effort. I try to suggest ways of integrating these into their toilet routine whilst respecting that their habits may be deeply ingrained and hard to alter.
By “habits and routine” I mean which toilet you may want/not want to go to, how you sit, how you breathe, the time you take or don’t take, wiping etc. I once read that opening your bowels is not just a physiological function but a social skill and this is true! People have definite opinions on the social side of “having a poo” and these can be as hard to tackle as the physiological symptoms.
So key principles are :-
Don’t rush, take your time and try to relax
Sit on the loo fully (don’t hover)
Lean forwards from your hips
Rest your feet on a stool or some spare loo roll so they are raised slightly
Rest your arms on your thighs
Breathe into your belly so it bulges out
Gently bear down without straining
If after a few minutes this does not result in success, leave the loo and try again later
NEVER FORCE ONE OUT even if you have passed a small amount and feel the job is not done but no sign of being able to pass more
Try later it doesn’t matter
Can pregnancy change this?
Pregnancy can change everything! In terms of bowel function, some women find they get constipated during pregnancy, often due to hormonal changes or taking iron supplements. Even more reason to keep the diet healthy and plenty of fluid and keep bowel habits as good as possible avoiding the temptation to strain. Haemorrhoids (piles) are common in pregnancy, basically varicose veins of the back passage, and would be aggravated by straining.
Most of the time after the baby is born the bowels settle back down, unless the new mum is too preoccupied to eat and take care of herself, which is often an issue, this can prolong the problems.
Obviously, if the delivery results in a significant tear affecting the back passage (3rd and 4th degree) then this will affect bowel function. This is one of the reasons that new mums must seek help to make sure they are strengthening their pelvic floor using the correct exercises post natally.
As we tackle taboo areas seems we have stumbled into taboo within taboo, why do you think this is?
It has always fascinated me how people are wary about mentioning anything to do with pelvic health problems. I have women talking to me in the supermarket, perhaps having been a patient, and when they mention the word “prolapse or leakage” their voice drops to a whisper! It both bemuses and amuses me!
Where bowels are concerned the situation is 100% worse. Anything associated with bottoms, poo or wind is simply not something people want to discuss, until their problems are so bad they have no option but to seek help. As a profession, it is not well advertised how Physiotherapists can deal with these issues in a skilled and sensitive way, so people feel isolated and have no way of understanding that help is at hand.
People view bowel problems as more private and personal than bladder and somehow something to feel ashamed of. A bit like when you were at school and no one got nits until they realise everyone gets them and they actually thrive in clean hair! Being poorly informed can have very damaging consequences.
If you could change one thing about the way we view pelvic health in the U.K. what would it be?
Education and communication is the key. Physiotherapists getting out there and promoting our services, raising awareness both amongst the medical profession and the public that we need to recognise these problems exist and create pathways so people can access the right help more easily.
What is the one thing you wish all your patients knew?
That they are not alone!
What is next for you?
More of the same! Whilst I would describe myself as a “coal face clinician”, I am really enjoying developing in teaching roles at undergrad level, as a tutor for the POGP and other courses.
I love educating clinicians and I learn a lot from that process. I also see it as vital in raising the profile of our speciality, training up more specialist clinicians to try and reduce the shortfall we are currently experiencing. This will go some way towards improving public access to the services we provide.
Somehow you manage to juggle everything you do with raising 3 kids. What is your secret?
I have been very lucky and able to work throughout the time my kids were small and needed me more, although I question that they ever need you “less” as they grow up, just in a different way. There have been times I have had to put my professional life on the back burner, which I did willingly. There have also been times I could bring it forward and devote more time to it.
The last 7 years have been a significant time in my evolution as a specialist, since I completed the prostgrad continence course at Bradford and got more involved in education, it really motivated me at a time in my career I could easily have decided to relax a bit I went in the opposite direction! I am now combining teaching with clinical work and loving the fact that I am continuing to learn more than ever.
As a Mum, my family comes 1st always, but I also think they gain from seeing me in a fulfilling role away from the home and they seem to respect that. I am always saying how we mums put ourselves at the bottom of the pile and it can inadvertently create problems in our lives. I suppose my “secret” is that as I have grown older I have come accept there needs to be a balance…even if this means occasionally putting yourself 1st for a change.
Kate Walsh works at Continence Physiotherapy, Wirral, Merseyside and runs clinics in London continencephysio.com