What is normal?
Bowel habits vary from person to person. In terms of bowel emptying, normal frequency varies from 2-3x's/day to once every 2-3 days. The bowel motion should be easy to pass. There should be no need to strain.
The Bristol Stool Chart - or as we affectionately call it - the poo chart - describes the different types of stool and categorises them Type 1 to 7. Type 3 and 4 are the ideal stool types. These are easy to store, and easy to pass.
Types 1 and 2 cause constipation as they are harder and dryer and type 5-7 are loose bowel motions - diarrhoea and are more likely to cause faecal incontinence.
The Digestive System
When we eat, food enters our stomach. From here it passes first into the small intestine (duodenum, jejunum and ilium) where most of the digestion and absorption of food occurs before passing into the large intestine (colon). This consists of 4 sections - the ascending colon on the right hand side of the body (from right hip to ribs), the transverse colon (that passes across the top by our stomach), the descending colon (from left lower ribs to hip) and the sigmoid colon across the bottom. As the remains of the food matter pass through the colon, water is absorbed and the stools are formed. The formed stools are then stored in the rectum until we are ready to expel them from the body through the anal canal.
Food is moved along the intestines by peristalsis - rhythmic contractions of the smooth muscle that lines the walls of the intestines. The intensity and rhythm of the peristalsis is not always constant. At night-time, it is very gentle and localised so that the food is churned but not moved forwards (this is why we don’t need to empty our bowels at night). However, during the day there is more variety.
With regards to the colon, there are times in the day when there is, what is technically know as, High Amplitude Propagated Contractions (HAPC). In essence this is a wave of contractions from the ascending colon all the way round to the sigmoid colon. Think of it like you squeezing toothpaste out of the tube from back to front. The pressure of the stools reaching and stretching the walls of the rectum trigger the emptying reflex which relaxes the anal sphincter and allows you to empty your bowels. If you choose to.
Fortunately we also have voluntary control over our anal sphincter so that we can override this automatic response if there is no toilet in sight. BUT, using this mass movement and reflex action is the most efficient way to empty our bowels, so if you are struggling with constipation, this is the time when you should be finding a toilet. Luckily for us, there are very set times when these mass movements occur – 60 minutes after waking in the morning and 10-50 minutes and 75-90 minutes after eating.
Emptying your bowel
Our standard 'western' toilet is, in effect, like a chair. We sit, more or less, with our hips and knees at 90 degrees. Research shows that this maintains the 'kink' in our bowel. This 'kink' is formally known as the anorectal angle - ie the change in direction between the storage compartment of the rectum and the anus/anal canal (approximately 3-4cm tube surrounded by the external and internal sphincter muscles).
You can see this angle in the picture on the left hand side of the adjacent drawing.
Research also shows that if we come into a deep squat position, as is used for 'eastern' squat toilets, this kink flattens out. (Picture on the right hand side of the drawing)
It make sense then that this is a more efficient way to empty the bowels but how do we do that with our standard toilets?
The answer is the toilet stool.
These come in many different forms but are basically all the same thing - a 'U' shaped stool that allows you to sit on a 'normal' toilet but bring your feet and knees up towards a squat position to 'unkink' the anorectal angle. They are 'U' shaped so that when they are not in use they push back to wrap around the stem of the toilet in a more discrete way than a standard stool. They are also higher than a standard step or toddler stool.
The version that we stock at the clinic, that is available for purchase, is the Australian made Toilet Stool. A simple, and really effective tool for helping you to empty your bowel without straining.
Healthy Bowel Habits
For some people, emptying their bowel is no effort at all. We all know someone who 'goes like clockwork'. They get the urge, go to the toilet, empty their bowel, then get on with their day.
Unfortunately, for others it is not so simple. There are many possible reasons for this that are beyond the scope of this blog. However, sometimes, by using the above information to form an efficient bowel emptying strategy, it is enough to enable you to empty your bowel regularly. At the very least it will optimise your bowel mechanics.
To do this you will need to form a strict morning routine that takes advantage of the naturally occurring mass movements in the colon:
Wake up 60-90 minutes before you need to leave the house
Immediately have a drink of warm or cold water/lemon water/tea/coffee and eat your breakfast
“Listen” to your body to be aware of feeling the urge to empty your bowel
When you feel the urge, go to the toilet immediately
Sit with your feet on a stool to bring your knees higher than your hips and relax
Relax your abdominals
Relax your pelvic floor muscles
Slow down your breathing and drop your shoulders
Gently allow your bowel to empty
Avoid heavy straining
If unsuccessful, wait for the next mass movement and urge to come and try again
Never sit for longer than 5 minutes trying to empty your bowels
As ever, if you have any concerns or questions about the above information, or if you would like to purchase a toilet stool, please don't hesitate to contact us by phone: 8964 5579 or 0435 150136 or by email at: hello@beachespelvic.physio