Pelvic Physiotherapy for Bowel Conditions
It has been known for several years that strengthening the muscles of the deep pelvis -the pelvic floor – makes a significant impact for those with bladder leakage. What is increasingly used in clinical practice is retraining of the pelvic floor muscles (PFM) to improve bowel function.
Inflammatory Bowel Diseases show injury to the lining of the gut, and markers of inflammation in tissue samples. Two of the most common and best known are Crohn’s disease and Ulcerative Colitis. Crohn’s disease can appear anywhere along the digestive tract, but especially in the upper portion. It is typically found in patches. Ulcerative Colitis affects the colon (also called large intestine or large bowel), beginning with the rectum and can progress upward. These inflammatory diseases can also have liver, eye and joint changes.
Irritable Bowel Syndrome has no changes to the gut lining, and no inflammatory markers. It is thought that hormone changes impacted by the gut-brain axis may influence gut sensitivity. Stress and diet can influence symptoms and flare ups considerably, and so managing them well is key. Relaxation, meditation and diet changes are useful for many patients.
Inflammatory bowel diseases (IBD) and irritable bowel syndrome (IBS) have in common diarrhea and/or constipation, cramping and abdominal pain. The pelvic floor muscles and the abdominal wall can tighten with stress and pain. We meet many patients with considerable stress whose PFM have been tightened for a long time. Their abdominal and pelvic muscles are often full of sensitive spots, sometimes called trigger points, that can refer pain to other areas, especially the hips and low back. Pelvic physiotherapists release the muscles internally to help get relief and teach patients exercises to maintain relief. The abdominal wall can tense in the same way, with cramps and pain that go along with bowel disorders. Motor control areas in the brain have become accustomed to the constant contraction, and often need to practice ‘letting go’. Undoing years of one behaviour or pattern takes considerable effort and is sometimes more than one strategy.
Breathing mechanisms can impact the experience of pain, and being able to use your whole ribcage, abdominal wall and PFM for breathing. Working core muscles makes a difference in freedom of movement for many, especially if they have struggled with abdominal pain for many years.
Pain also appears to be a factor in muscle tone in the pelvic floor. Dyssynergic defecation is the term for contraction of the pelvic floor muscles (especially the puborectalis muscle) at the wrong time. Relaxation of the muscles is needed to evacuate the bowels, but instead the pelvic floor muscles will contract, making it difficult to evacuate the bowels. Pelvic health physiotherapists teach the co-ordination of the muscles and optimal posture so that evacuation is more efficient and less painful and difficult.
Biofeedback involves insertion of an electrode probe into the anus. The probes are about the size of an index finger with a slightly enlarged tip. The wires from the electrode are connected to the biofeedback unit and then the electrical impulses are shown on a screen as images. It can be useful to allow the patient to correlate the action of a flower opening and closing or an airplane rising and falling as the muscles are contracted and relaxed. It is usually practiced in the office, but home biofeedback units are available for purchase if a patient would like to practice independently at home.
Another form of biofeedback involves inserting a small (medical) balloon into the rectum and inflating it to a set pressure to retrain the sensation in the rectum. Rectal sensation is key to the functioning of the anal sphincters and the sense that one needs to empty the bowels.
Changing posture on the toilet to get the hips fully flexed helps relax the muscles of the pelvic floor. The rectum is a flexible tube which is bent and flattened a little by the pelvic floor muscles. There is a band that loops down and lifts the rectum up, like the tie that holds back a curtain. The tighter the muscle is, the less one is able to push stool out. It is tightest in a standing position, when the hips are straight. A small footstool under the feet takes the hips past the usual 90 degree angle we have sitting on the toilet, and relaxes the muscles. This allows for much easier evacuation for many people. In full hip flexion or squat position, the rectum has no bend in it and the straightened bowel has minimal resistance against the pushing to evacuate. Relaxing the pelvic floor muscles deliberately with gentle breathing, and even mindfulness, can be an additional help.
Gentle massage of the abdominal wall can help to trigger the bowel’s own reflexes to help with the rhythmic contractions of the bowel muscles. This helps propel stool. One of the main roles of the bowel is to absorb water from what we eat. That absorption continues for the entire time the stool is in the large intestine, and means that stool becomes hard and more difficult to pass the longer it stays in the bowel. Conversely, too much peristalsis (irritated lining is one cause) means that relatively little water is absorbed and the stool is loose and watery.
The anal sphincter itself can be injured with childbirth, or occasionally from other surgeries. The area is also prone to fissures and pain. Helping to release the sphincters manually and to release the muscles in the area via the rectum can be a huge relief for those with sphincter pain, fissures, and tailbone pain (coccydynia). Many of the same techniques for breathing, relaxation, and retraining can be useful with these issues as well.
Many of the people who come to seek care have waited years. They include both men and women. They are often deeply embarrassed and have tried many things on their own, often avoiding social situations because of their symptoms. Physiotherapy can offer an adjunct to your physician’s care and work with the rest of your team members to help you manage your symptoms better and reduce the discomfort of flares.