When I work with patients that experience IBS-C, 3 potential key pieces of their digestive health care puzzle come to mind:
- Adjust & individualize diet: either trial a low FODMAP diet (particularly modifying fructans and GOS), potentially reduce dairy, and ensure adequate fiber per tolerance for starters.
- Rule out methane + small intestinal bacterial overgrowth.
- Assess for pelvic floor issues such as dyssynergic defecation.
Today’s post will start with a patient’s story and end with a Q & A with physical therapist, Jenna Leader, PT, DPT, from Boston based Beth Israel Deaconess Medical Center Pelvic Floor Program who shares her insights about pelvic floor dysfunction and treatments.
A patient’s story:
“The diagnosis was IBS-C and SIBO (IBS with constipation and Small Intestine Bacterial Overgrowth). Fortunately, I had just started working with Kate Scarlata, so she coached me on the proper protocol for eliminating SIBO and how to follow the Low FODMAP diet. More importantly, she gave me encouragement, validation and assurance that I would feel better and live a more normal, healthy life.
Within weeks of following the Low FODMAP diet, the majority of my symptoms were gone: gas, bloating, pain, and alternating phases of constipation and diarrhea. And, my bowel movements became somewhat routine. Yet one symptom remained: my daily bowel movement(s) took FOREVER, and increasingly my colon never felt completely empty. My diet was great — I drank plenty of water and ate lots of fiber — and I otherwise felt great, so I was perplexed.
In a follow-up visit with my GI, she suggested an anal manometry test which confirmed I had a motility issue. I was adamant about not relying on medication to resolve my GI issues — at least not before exhausting all alternatives. So, my GI referred me to a pelvic floor physical therapist who, she explained, would coach me through a ‘proper bathrooming technique.’ My first thought was that despite all the testing I had been through, this could be an extremely embarrassing PT appointment. My second thought was, “Isn’t ‘bathrooming’ something innate that didn’t need to be learned?”
Well, I soon found out otherwise. I learned a series of light massages and stomach movements and a proper seating position to help me overcome my motility issue. With the right pelvic floor physical therapist — mine was extremely kind, caring, patient and knowledgeable — and almost immediate results and a feeling of relief, the embarrassment became secondary and vanished quickly.
Unfortunately, I now understand that I have a chronic motility issue. With a commitment to eating a healthy diet (and knowing which FODMAPs I can tolerate and how much), drinking lots of water and taking the time necessary to perform a ‘proper bathrooming technique’ daily, I remain healthy and without the need for laxatives or other constipation medicines”
To understand a bit more about what pelvic floor physical therapy entails, I asked Jenna Leader, PT, DPT, at Boston-based BIDMC Pelvic Floor Program a few questions:
Kate: Can you tell me a little about pelvic floor dysfunction?
Jenna: The pelvic floor is a group of internal muscles at the base of your pelvis that lie between the sits bones and run from the pubic bone to the coccyx (tailbone). These muscles act like a sling to support your pelvic organs, assist in urinary and fecal continence, aid sexual function and provide a stable base for adjacent joints. All, one, or a combination of these functions can be affected if the muscles become tight, weak, uncoordinated or damaged (from childbirth, pelvic surgery or aging). Pelvic floor dysfunction (PFD) is an umbrella term that encompasses these issues. Thus, those suffering with PFD can present with a variety of symptoms varying from, urinary/fecal incontinence due to muscle weakness to constipation or pelvic pain due to muscle tightness.
Kate: Who’s impacted? What conditions predispose someone to pelvic floor issues?
Jenna: Many people are affected by PFD that is unbeknownst to them. Consequently, these conditions are often left unreported, undiagnosed and untreated. PFD can impact men, women and children. Although there are many factors that can predispose these issues, common factors I see in the clinic include: damage to the muscles from childbirth, aging, pelvic surgeries, anxiety, depression or a history of physical, sexual or mental trauma.
Kate: How would an individual know they have pelvic floor dysfunction? Are there certain tests?
Jenna: I feel the most important step to identify pelvic floor dysfunction is to increase awareness on what normal function is. Any alteration in bowel, bladder or sexual function could be due to PFD. Constipation and significant straining to have a bowel movement is not normal, painful intercourse is not normal and leaking after childbirth or with aging is also not normal. These are all signs of PFD.
There are tests to identify PFD such as an anorectal manometry to rule in pelvic outlet constipation, MR defecogram to identify pelvic organ prolapse or urodynamic studies to identify urinary dysfunction. Although these tests can diagnose PFD, I am a strong advocate for diagnosis through subjective and symptoms. I feel that with increased knowledge, patients can be identified quicker and in return get the help they need. People should feel comfortable discussing bladder, bowel or sexual issues they are experiencing with their provider and providers should have the knowledge to know when referral to pelvic floor PT is appropriate.
Kate: If a patient presents with dyssynergic defecation and is sent to see you for physical therapy, can you enlighten us as to what they should expect in the first appointment?
Jenna: During defecation, the pelvic floor muscles should relax and lengthen in order to allow stool to pass. With dyssynergia, these muscles will instead contract paradoxically causing closure of the anal canal, thus not allowing stool to pass. People suffering from outlet obstruction will typically report symptoms such as: a sensation of stool in their rectum, excessive straining or a sensation of incomplete emptying. They may also have failed treatments of laxatives and stool softeners because the issue is not one of digestive motility but instead due to pelvic outlet obstruction.
The first time a patient meets with their physical therapist, they will be asked several questions regarding their bowel movements and dietary habits. The therapist will then go over how the pelvic floor muscles play a role in constipation and discuss any relevant findings from their testing, mainly the anorectal manometry, that are conclusive for pelvic floor dyssynergia. After the subjective, a digital rectal exam is done to assess pelvic floor muscle function. Lastly, biofeedback may be used as an assessment tool as well as form of treatment to detect a paradoxical contraction of the pelvic floor and to re-train proper relaxation.
Kate: How many visits should most patients with dyssynergic defecation expect to have with the PT?
Jenna: Typically, patients are seen for 5-10 visits for down training of the pelvic floor and muscle re-education. One thing I will always integrate into my treatments, especially for pelvic pain or constipation, is helping patients understand that the mind and body are not separate. Learning this alone can be the key to success for anyone. Achieving proper relaxation can often times be the most difficult part for patients but I have had a lot of success using apps such as calm or headspace. When our body becomes stressed or anxious, muscles tighten in response. When re-training muscles to relax and lengthen, we have to also calm our minds.
Kate: Are there any new and novel adjective therapies in this area? Botox?
Jenna: If a patient is having limited results from PT, there are other options such as Botox injections, trigger point injections or valium suppositories that may be used to help relax the pelvic floor muscles. Direct injection of Botox into the puborectalis muscle has been used for outlet constipation but research is limited on the efficacy. I personally have had good success with valium suppositories for patients with pelvic pain and dyspareunia(painful intercourse). Trigger point injections are another option that may be used to help release hypertonic muscles.
Pelvic Floor Provider Directory:
Additional Pelvic Floor Info from Pelvic Guru.
Toilet Meditation: https://www.youtube.com/watch?v=w9zsTUvNn-8
To learn more about Jenna, follow her blog here.