A look at the different types of constipation and how to approach them based on root cause. Biofeedback therapy is a promising and successful approach to clearing up symptoms of chronic constipation caused by pelvic floor dysfunction and lack of proper rectal muscle coordination.
Treating Constipation with Biofeedback Therapy
Constipation is a common complaint that interferes with quality of life and is difficult to get good help for. To address constipation, most doctors or gastroenterologists will rule out more serious problems like colon cancer or Crohn’s disease with an internal scope, or they will prescribe a laxative.
But what if that doesn’t bring relief? I recently interviewed Dr. Satish Rao on my podcast and he shared some helpful tips on constipation. Dr. Rao is one of the nation’s leading researchers in biofeedback therapy. Biofeedback therapy helps 80 percent of people with constipation caused by pelvic floor dysfunction, also called dyssyenergia.
First, let’s define constipation.
Bowel habits vary from person to person. According to Dr. Rao, it’s normal to go anywhere from three times a day to three times a week. The frequency of bowel movements alone doesn’t determine constipation, but rather the ease and quality of those movements. Hard to pass stools, excessive straining, or incomplete evacuation are much better indicators of constipation. As are sudden and prolonged changes in bowel habits or needing to use manual manipulation or massage to produce a bowel movement. The need to remove stool through enemas or colonics can also be a sign of constipation. Incomplete evacuation is a deceptive symptom because the inability to empty the bowels in one try can lead to frequent defecation throughout the day. In this case, going multiple times a day is still considered constipation.
Biofeedback therapy can help with specific types of constipation.
It doesn’t help with acute constipation, caused by normal changes in routine such as travel, stress, or diet. Simple treatments like relaxing, establishing a routine, or increasing fiber from prunes or a mix of soluble and insoluble fiber powder can bring relief. This type of constipation usually resolves quickly by itself. Biofeedback also doesn’t work well for secondary constipation, which is caused by an underlying issue. Examples are opioid use, diabetes, thyroid disease, pregnancy, or neurological conditions like strokes or multiple sclerosis. These underlying causes must be addressed to clear up constipation. Biofeedback therapy is typically used for chronic constipation caused by a primary dysfunction of the colon, or related nerves or muscles of the pelvic floor.
But within the category of chronic constipation there are three subtype groups. Biofeedback therapy is only used for one of them.
- The first group includes people diagnosed with irritable bowel syndrome (IBS), who have abdominal discomfort or pain associated with altered bowel movements or difficult to pass stool.
- The second group suffers from slow transit constipation with an underlying muscle or nerve problem that compromises the colon’s ability to push and move stool. Methane gas production in the colon, interstitial cell damage, or higher progesterone receptors in the colon are a few things that can make the colon slower and more sluggish.
- The third group has dyssyenergic constipation. When defecating, instead of being relaxed, anal muscles are squeezed or not properly coordinated to push. This condition affects about 1/3 of people who suffer with chronic constipation. There can be significant overlap between sluggish transit time and dyssyergic bowels. Two thirds of patients that have pelvic floor dysfunction and dyssyenergia also have slow transit time. In some cases, when pelvic floor dysfunction is treated, slow transit will also get better.
It’s best to tailor the treatment to each constipation subtype.
The IBS type may need prokinetics or other medications to resolve the issue. Resalor is a prescribed medication that works well as a prokinetic or laxative, depending on dosage. Slow transit constipation may require balancing hormones, healing the gut lining, or taking a prokinetic.
Pelvic floor dysfunction or dyssyenergia is best treated with biofeedback therapy, which is performed at a motility center by trained specialists like Dr. Rao. Biofeedback therapy aims to retrain the body to increase intra-abdominal and rectal push force while at the same time relaxing anal muscles. These muscles are deep inside, and hard to feel. To help patients better connect to these muscles, a pressure probe device is put next to them and patients are asked to squeeze, bear down, or push down to feel what muscles change in response. A visual display also connects patients to what’s happening inside their body.
To correct behavior, patients are taught diaphragmatic breathing, posture modifications, and how to improve muscle coordination without excessive force. At the same time, patients get real time feedback from a probe, nurse, or doctor to correct behavior. Also, using a posture-correcting device at home, such as Squatty Potty, may help align the body for easier bowel movements. Each session takes 45 minutes and requires 4 to 6 sessions for correction. Patients must practice at home in between sessions to achieve and maintain results.
There are 3 ways to test for dyssyenergia constipation.
Digital rectal evaluation is 75-85 % effective, but many people get nervous and tense when a finger is inserted inside the rectum. Other methods include anorectal manometry or inserting a water balloon inside the rectum to see how long it takes to expel the water.
If you’ve seen a GI specialist to rule out something more serious, don’t be afraid to advocate for yourself if you suspect you have dyssenergic constipation. Ask your doctor to refer you to a motility center or search online to find a local motility center near you.
What do you think? I would like to hear your thoughts or experience with this.
Dr. Ruscio is your leading functional and integrative doctor specializing in gut related disorders such as SIBO, leaky gut, Celiac, IBS and in thyroid disorders such as hypothyroid and hyperthyroid. For more information on how to become a patient, please contact our office. Serving the San Francisco bay area and distance patients via phone and Skype.