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Do you leak stool with walking, running, or other physical activities? Do you have urgency of your stool and can’t make it to the toilet in time? Do you have to wear disposable underwear because you leak fecal matter?
As a pelvic health physical therapist, I see this quite a bit in my practice and everyone always asks the single question: “Why?!!!”
To know why this is happening, I’d like to provide a better understanding of the anatomy and function of the digestive system, especially the internal and external anal sphincters. I’d also like to discuss some causes of fecal incontinence, and how pelvic floor physical therapy can help.
The pathway of food in your digestive tract goes from your mouth, down your esophagus, into your stomach, and through your small and large intestines. Then it finally gets to your rectum and out your anus. The end of your digestive tract is probably the most essential part of keeping you from leaking.
Two muscles that surround the end of your digestive tract are the internal anal sphincter and external anal sphincter. The internal sphincter is where you get 70% of the control of your feces. The other 30% comes from your external sphincter and puborectalis muscle.
An important concept to understand about having a bowel movement is called the rectoanal inhibitory reflex (RAIR). There are receptors in your rectum that detect stool; and when stretched to a certain point, the reflex should inhibit your internal sphincter and tell it to relax. Once this happens, your external sphincter and your puborectalis muscle take over and contract. This allows you to feel the urge to have a BM. Once you make it to the toilet and relax your external sphincter and puborectalis muscle, the bowel then exits your anus.
Now that you understand some of the anatomy and function of how you empty your bowels, let’s talk about a few reasons why you might have troubles holding in your stool.
1. Constipation: Constipation stretches your rectum and causes weakness in your muscles. Have you ever pulled your hamstring or quad muscle? When this happens you have a period of time where you are weak and have to rebuild the muscles back. If you constantly have an over stretched rectum, it weakens the muscle –– and liquid stool from higher up in the digestive tract seeps around the hard stool and can leak out due to muscle and nerve damage.
2. Diarrhea: When you have chronic diarrhea your muscles are having to work harder to hold in your stool compared to a harder stool. When this happens your sphincter and pelvic floor muscles can fatigue and become weak, allowing stool to leak out. There can be multiple reasons for diarrhea: food intolerances, medications, bacterial infection, inflammatory intestinal diseases such as Crohn’s disease or ulcerative colitis, and many other reasons.
3. Hemorrhoids: Hemorrhoids are swollen veins (that may be internal or external) and could develop by straining during a bowel movement, vaginal birth, or some other episode. This makes it hard for the external sphincter to fully close which could cause some fecal incontinence.
4. Rectal Prolapse: This is when the rectum falls down into the anus. It causes the rectal sphincters to stretch, often resulting in nerve damage which causes muscle weakness and fecal incontinence.
5. Surgery: Any type of rectal surgery can cause damage to the sphincter and pelvic floor muscles, or nerve damage which can lead to fecal incontinence.
These are the main reasons fecal incontinence can occur. So I’m sure you’re now wondering how physical therapy can possibly help?
“Pelvic Health” is typically not a big part of a physical therapist’s education. It is a specialization requiring much further study, training and practice following graduation. Pelvic health physical therapists are specially trained to evaluate and treat bowel and bladder dysfunction, among many other things.
With constipation, diarrhea and hemorrhoids, a qualified physical therapist can review your diet to see if there are foods you are eating to cause these. We also have strategies to help you better manage your stress levels, both physical and mental, which often contribute to these conditions. We also do belly massages to help move your bowels. Furthermore, we assess your pelvic floor mechanics to make sure you know how to move your pelvic floor in the right direction to regulate your bowels. And, just like a “typical” PT, we teach you exercises to enhance your overall strength, flexibility, posture, and musculoskeletal health. Finally, we go through how you can use different tools to help with bowel movements. Check out this blog I wrote on how using the Squatty Potty can help with constipation?
If you are having weakness in your pelvic floor and your sphincters are not firing properly, we can train you on how to contract or relax your pelvic floor. This is similar to regaining control of any other muscle in your body.
If you are post-surgery, we can also work on any scar tissue formation that causes restriction in muscle development. Having bowel surgery (i.e., hemorrhoid, rectal prolapse, cancer, etc.) can cause you to develop scar tissue. This makes it harder for your muscles to work properly and causes an increase in fecal incontinence.
These are just a handful of ways a pelvic health physical therapist can help with your fecal incontinence, and just a few of the reasons why fecal incontinence occurs. If you are having blood in your stool and increased pain with your bowels, I would recommend first seeing a gastrointestinal doctor to clear you from anything PT cannot help with.
Disclaimer: The views expressed in this article are based on the opinion of the author, unless otherwise noted, and should not be taken as personal medical advice. The information provided is intended to help readers make their own informed health and wellness decisions.
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