Let’s Talk About Constipation
Constipation is one of the most common gastrointestinal issues, but it’s also one of the most misunderstood. It isn’t always about how often you open your bowels. Many people go daily and still meet the criteria for constipation. For others, a missed day isn’t a concern — it’s how they feel when they do go that matters.
To help explain what’s happening, I often use the analogy of a tube of toothpaste. Bowel movements involve two phases: transit (moving stool through the colon) and evacuation (expelling it from the rectum). Both need to function properly — otherwise, you’re likely to experience constipation.
Understanding Transit and Evacuation
1. Transit refers to how well stool moves through the colon. When this is slow, stool becomes dry and hard as more water is reabsorbed. A slow or inefficient transit time can be due to anatomical variations (such as a long colon), connective tissue conditions like Ehlers-Danlos Syndrome, certain medications, low fluid or fibre intake, or reduced physical activity. Sometimes we don’t know why people have slower transit than others.
2. Evacuation refers to the process of stool exiting the body through the rectum and anus. This is controlled by a complex coordination of pelvic floor muscles, abdominal pressure, and neural feedback. Even with normal stool consistency, evacuation can be difficult if the muscles aren’t working in harmony.
Examples That Highlight the Difference
– Someone may have regular bowel movements with normal stool consistency, but they strain excessively and never feel fully empty. In this case, the stool is making it to the rectum — but evacuation is compromised – the toothpaste tube has a blocked nozzle.
– Another person might experience infrequent bowel movements, with hard, pellet-like stool and significant bloating. Here, the issue is likely related to slow transit through the colon – ineffective squeezing of toothpaste to the top of the tube.
The management of constipation should always start with identifying which part of the system is struggling — transit, evacuation, or both.
Common Misconceptions
Let’s address a few frequently held beliefs:
– “I go every day, so I can’t be constipated.”
You can still have incomplete evacuation or require excessive effort. Frequency alone doesn’t rule constipation out.
– “I alternate between diarrhoea and constipation, so it’s just IBS.”
Not always. Loose stools can actually be overflow from severe constipation. If the lower bowel is impacted, softer stool may bypass it.
– “It’s normal for me to go once or twice a week.”
The colon can adapt, but this doesn’t mean it’s functioning well. Infrequent emptying often leads to hard stool, discomfort, and straining and then compromises the gut’s ability to perform peristalsis.
What Slows Transit? (moving the toothpaste to the top of the tube)
Several factors affect how efficiently stool moves through the bowel:
– Dehydration – Without adequate water intake, the colon draws moisture from the stool, making it harder and more difficult to pass.
– Low fibre intake – Fibre adds bulk and supports motility. Soluble fibre helps soften the stool; insoluble fibre adds roughage. However, not all types of fibre suit everyone, and too much insoluble fibre can make symptoms worse in some cases.
– Medications – Opioids, tricyclic antidepressants, iron supplements, and calcium channel blockers are common causes of constipation.
– A redundant sigmoid colon – This anatomical variation increases the length and curve of the colon, prolonging transit time and making the final descent more challenging.
– Neurological or muscular, or connective tissue conditions – These can slow motility or reduce the ability of the bowel to contract effectively.
When Evacuation Is the Problem (aka ‘the blocked toothpaste nozzle’)
Evacuation issues can occur even when stool is well-formed. Key contributors include:
– Pelvic floor dysfunction – Difficulty relaxing the pelvic floor muscles during defecation is common. Instead of releasing, the muscles may contract, effectively blocking stool from exiting.
– Poor coordination – The normal pattern of abdominal pressure increasing while the anal sphincter relaxes may be disrupted. This can be due to chronic straining, habit, or trauma.
– Rectal hyposensitivity – Some people lose the normal urge to open their bowels. This may be due to prolonged stool retention, neurological conditions, or nerve desensitisation from childbirth, surgery or medical conditions.
– Structural changes – A rectocele (a bulge in the rectal wall) or internal intussusception (when the rectum telescopes downward) can physically interfere with the passage of stool.
Symptoms That Suggest Constipation
You may be constipated if you experience:
– A sensation of incomplete emptying
– The need to strain regularly or excessively or spend a long time on the toilet
– Infrequent bowel movements (fewer than three per week)
– Hard, dry, or pellet-like stool
– A feeling of blockage or needing to manually assist the process
– Alternating diarrhoea and constipation
– Bloating, fullness, or discomfort that improves after defecation
Red Flags to Discuss With a GP
While constipation is common, it can also mask more serious issues. Please make a GP appointment if you experience:
– Unexplained weight loss
– Rectal bleeding
– A persistent change in bowel habits lasting more than 6 weeks
– Anaemia
– Persistent bloating or loss of appetite
– A family history of bowel cancer or inflammatory bowel disease
– Symptoms that don’t improve with lifestyle changes or routine treatments
Why Constipation Matters
Chronic constipation can affect more than just your bowels:
– It places strain on the pelvic floor, contributing to pelvic organ prolapse, especially in women.
– Prolonged stool retention can compress the bladder, worsening urinary urgency or incontinence.
– It increases the risk of anal fissures and haemorrhoids from repeated straining and hard stool.
– It can lead to perineal descent, where pelvic support tissues are stretched and weakened.
– Lastly, chronically constipated people don’t always realise they are constipated but without exception, when this improves, they feel so much better
Practical Strategies to Improve Transit
Hydration – Aim for enough fluid to keep your urine a mid-pale yellow
Diet – Consider adding linseeds/flaxseeds to your diet. They act as natural stool softeners and make your stool softer and more slippery. Buy them whole and either consume them whole or blend in a smoothie or grind up yourself. Some people need up to 20g per day (I know, it seems like a lot!). Start off with a teaspoon and work up gradually as needed.
Mealtimes – Try to stick to regular mealtimes. Intermittent fasting is not always a constipated person’s friend
Training – Consider retraining your bowel. Bowels (like dogs) are pretty trainable. I will often advocate glycerine suppositories in this training period. In the morning, fairly soon after getting up, have a hot drink and/or breakfast (stimulates peristalsis) and then insert a glycerine suppository. They don’t contain medication. They merely help gently stimulate the bowel and allow you to ‘go’ and they work pretty quickly too. If you do this every day for a few weeks, your bowels should work more efficiently and hopefully soon you will find you no longer need to use them because your body will be in the routine of going at that time of day.
Management – Try to be pro-active about managing your bowels if you know that hi-days and holidays are a tricky time for you. Use your linseeds, drink your water and take your glycerine suppositories away with you. If you can keep yourself in a fairly good routine, you will stop it building into a bigger problem.
Movement – Regular physical activity supports gut motility. Even walking is helpful.
Practical Strategies to Help Evacuation
Use a footstool – Elevating the feet while seated on the toilet (knees higher than hips) straightens the recto-anal angle, making evacuation easier.
Breathe – Take 3–5 deep abdominal breaths before attempting to go. Breathe into your sides and back to gently increase pressure without straining.
Avoid holding your breath – Use a relaxed, open-mouth breath or a gentle “shhhh” sound as you bear down to prevent excessive pressure on the pelvic floor.
Don’t ignore the urge – Delaying a bowel movement repeatedly can dampen the body’s natural signals.
Gently widen around your waist – use this pressure to help you open your bowels. Make sure you are staying soft and relaxed around your back passage
How Pelvic Health Physiotherapy Can Help
If you’ve tried lifestyle changes and are still experiencing symptoms, an assessment with a pelvic health physiotherapist can identify whether pelvic floor dysfunction, poor coordination, or evacuation difficulties are contributing to your constipation.
At Pelvix, we assess pelvic floor muscle function and coordination We use biofeedback, muscle retraining, and education to help retrain the evacuation process. We also advise on toileting positions, gut-friendly habits, and simple techniques to support bowel movements — all tailored to you. And if at any stage we thought your symptoms needed further investigation or management then we will arrange onward referral as necessary.
Final Thoughts
Constipation is often manageable — but understanding the underlying cause is key. Whether it’s a transit issue, an evacuation problem, or a combination of both, targeted treatment can make a significant difference.
If you’re unsure what’s causing your symptoms or where to start, a pelvic health physiotherapist can guide you through the process and help you regain control and comfort.