What Your Pelvic Floor Has to Do With Constipation

For some people, constipation is not a slow bowel or a fiber problem. The pelvic floor muscles tighten when they should relax, so stool meets a closed exit. This is called dyssynergic defecation, or pelvic floor dyssynergia, and a GI doctor can test for it.

What it feels like

You push hard, even when the stool is soft. It can feel like pushing against a closed door. You may change position, press on the perineum or vagina to help, or go back two or three times because you never feel finished. Fiber and laxatives soften things, but the struggle at the exit stays.

If your stool is soft and regular and you still strain, my straining without constipation page goes into that pattern.

How a normal bowel movement works

A bowel movement takes teamwork. The American Society of Colon and Rectal Surgeons puts it simply: certain muscles need to contract while others relax at the same time for stool to pass easily. The abdominal muscles push gently. At the same moment, the pelvic floor, especially the puborectalis and the anal sphincter, relaxes and opens.

The American College of Gastroenterology notes that problems with the muscles and nerves of the pelvic floor can cause constipation by making it hard to relax or coordinate the muscles needed for a bowel movement.

When the muscles do the opposite

In dyssynergia, that teamwork is reversed or incomplete. As you push, the pelvic floor tightens or fails to relax, and stool meets resistance. It is a coordination problem, and coordination can be retrained.

When nothing comes, the natural move is to push harder, but holding your breath and bearing down hard tend to increase the resistance at the exit. Over time, straining raises pelvic floor tone further and can lead to rectal pain, hemorrhoids and pelvic aching.

How a GI doctor tests for it

These tests are ordered by your gastroenterologist and are not done in my clinic.

• Anorectal manometry. A thin tube is placed in the anal canal and rectum to measure muscle pressures at rest and during different maneuvers. It can show the pelvic floor contracting instead of relaxing when you try to empty.
• Balloon expulsion test. You are asked to push out a small water-filled balloon. Trouble passing it points to a pelvic floor outlet problem.
• Defecography. An x-ray, or sometimes a dynamic MRI, that shows how the rectum and pelvic floor move as you empty.

Your GI doctor also looks at the rest of the picture, such as diet, medications, thyroid and colon health, and whether you are due for a colonoscopy.

Where muscle work fits

The standard treatment for dyssynergia is biofeedback, retraining usually guided by a pelvic floor physical therapist. Its aim is to correct the timing between the abdominal, rectal, puborectalis and anal sphincter muscles. The colorectal surgeons' society notes that randomized trials in adults with dyssynergia have found biofeedback better than control treatments. A typical biofeedback course is four to six sessions.

Retraining is harder when muscles are tight at rest or hurt as they stretch. That is where I work, alongside your biofeedback therapist or GI doctor, not in place of them. The first visit runs 60 to 75 minutes, and the pelvic floor is examined from the outside only, with no internal exam. Dry needling is used to release the puborectalis and surrounding pelvic floor muscles, through the skin of the buttock, perineum or inner thigh, never through the vagina or rectum. Alongside dry needling, I use neuro-functional acupuncture, built on neuroscience and evidence-based practice. Unlike regular electroacupuncture, the needles and gentle electrical stimulation are mapped to the specific nerves involved, such as the sacral nerves. It works in three ways. It neurorehabilitates, helping irritated tissues and nerve receptors recover. It neuromodulates, shifting the body's own pain-relieving chemistry. It neuroregulates, rebalancing the nerve signals and circuits that help regulate bowel function. The pelvic floor dyssynergia page explains the full plan. Results vary from person to person.

If you are not sure what is causing your pain, try the My Symptoms tool.