Bowel Habit and Defaecation Technique in a Pelvic Floor Programme

Bowel habit is part of a pelvic floor programme because the bladder, the bowel and prolapse all sit on one muscular floor, and straining loads that floor daily while a training programme only unloads it for a few minutes. NICE NG210 covers urinary incontinence, bladder emptying disorders, faecal incontinence, bowel emptying disorders, pelvic organ prolapse, sexual dysfunction and chronic pelvic pain in women aged 12 and over, all in one guideline, because they are not separate systems¹.

I teach, which means there are roughly two windows in a school day when going to the toilet is realistic. I had spent years treating my bowel as something to be dealt with quickly between a lesson and a corridor duty, and the first thing my physiotherapist changed was not an exercise. It was that. I remember being faintly insulted that we were discussing it at all when I had come about leaking on a run. It turned out to be the change I noticed first. Before any of this, read red flags and when to stop and get checked, because one bowel symptom on that list needs a clinician rather than a programme.

Why the bowel question comes before the exercises are progressed

Because of the arithmetic of load. The guideline minimum programme is at least 8 contractions performed 3 times per day, a recommendation that carries a [2006] tag because it was brought forward unchanged from the earlier guidance and not re-reviewed in the 2019 update². That is a few minutes of loading in the helpful direction. A long straining episode every morning is loading in the unhelpful one, and it does not stop for the sixteen weeks you are training.

For prolapse in particular the margin being protected is small. In the POPPY trial, 447 women with newly diagnosed symptomatic prolapse were randomised, and individualised pelvic floor muscle training produced a mean improvement of 3.77 points on the 0 to 28 Pelvic Organ Prolapse Symptom Score against 2.09 in controls, an adjusted difference of 1.52 with a 95% confidence interval of 0.46 to 2.59³. A modest, real effect is exactly the sort of effect that daily straining can cancel. NICE records that in UK primary care 8.4% of women reported a vaginal bulge or lump, that prolapse is present on examination in up to 50% of women, that 1 in 10 women will need at least 1 surgical procedure, and that the re-operation rate is as high as 19%². More on all of that in pelvic organ prolapse and prolapse symptoms versus prolapse stage.

What defaecation technique consists of

Four things, described here rather than prescribed. Position, with the feet supported so the knees sit above the hips and the body leaning slightly forward. Relaxation, meaning the pelvic floor lets go and opens rather than clamping, which is the opposite of what a person who has spent months practising contractions may instinctively do. Bracing outward through the abdominal wall rather than holding the breath and bearing down. And time, in the sense of not sitting and straining for long stretches waiting for something to happen.

This is taught and checked in a clinic, and that is not a formality. NG210 recommendation 1.3.15 states that programmes should be supervised by a physiotherapist or other healthcare professional with the appropriate expertise in pelvic floor muscle training¹, and the same argument applies with more force to a movement you cannot see yourself perform. The general evidence for supervision points the same way: supervised and more intensive training is more effective than unsupervised training, and pelvic floor muscle training needs proper instruction and close follow-up to be effective⁴. Patient level explanations of the anatomy involved are published by the International Urogynecological Association⁵, and the muscle side of the same conversation is in how to do a pelvic floor contraction correctly.

Stool consistency, and the numbers this page does not have

Stool consistency is usually the variable doing the damage, because everything else is downstream of it. If what is arriving is hard, no position and no bracing technique rescues the situation, and the straining continues whatever else changes. Clinicians commonly work from a stool consistency chart, comparing what you report against a set of standard descriptions, and set the target from there.

Here is what this page will not do. There is no constipation prevalence figure in this site’s fact file, no named stool form scale, and no trial of toilet position, so you will find no percentage, no scale name and no effect size for any of them here. Other sites will hand you all three. This one names the absence instead, on the same principle that keeps invented waiting times off pelvic health physiotherapy waiting times. What actually changes stool consistency, including anything you might take for it, is a conversation for a clinician or a pharmacist, and this site carries no medication content.

The one duration this site can quote in this territory is narrow and specific: NG210 recommendation 1.6.15 says to consider a programme of supervised pelvic floor muscle training for at least 4 months for women with faecal incontinence and coexisting pelvic organ prolapse¹.

Bowel leakage is a different conversation, and a more urgent one

New faecal incontinence is not a habit problem and it is not treated by improving your position on the toilet. New loss of bowel control or of control of wind after a vaginal birth should prompt a review for an obstetric anal sphincter injury. The Royal College of Obstetricians and Gynaecologists puts the overall UK incidence at 2.9% of vaginal births, with a reported range of 0 to 8%, at 6.1% in women having a first vaginal birth against 1.7% in women who have given birth vaginally before, and records that the reported rate in England tripled from 1.8% to 5.9% between 2000 and 2012⁶.

The contrast is what makes this easy to miss. Pooled data put any urinary incontinence at about 33%, with a 95% confidence interval of 32 to 36, in the first 3 months after birth⁷. Bladder leakage after a birth is common; bowel leakage is not, and the two are frequently reported in the same apologetic sentence and treated as the same order of problem. They are not. The follow-up is covered in perineal tears and OASI recovery and the symptom itself in faecal incontinence and anal sphincter training.

What the evidence does and does not support

It supports treating the bowel side as part of the programme. It does not support claiming that muscle training fixes bowel leakage around childbirth. In the Cochrane review of pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women, the faecal incontinence results were consistently null and low certainty across every comparison, and this site therefore makes no claim of benefit there⁸.

That is a deliberately unhelpful sentence for anybody who wants a reason to be optimistic, and it is the accurate one. The same review contains the strongest prevention finding in the field on the urinary side, so it is not a pessimistic source: it is a source that separates its outcomes properly. What it found on the urinary side is in postnatal pelvic floor recovery and antenatal pelvic floor training.

Where this sits in the order of a programme

Early, and then permanently in the background. NG210 requires at least 1 review to assess progress during a supervised programme and 1 at the end¹, and bowel habit is one of the things a good review revisits, because it is the part most likely to have quietly reverted while you concentrated on the exercises.

The reason it sits before progression rather than after it is straightforward: a programme measured over 3 to 4 months cannot be assessed fairly if a daily source of load is still running underneath it. How that programme is prescribed and progressed is in pelvic floor exercise programmes explained, how long it runs is in how long does pelvic floor physiotherapy take, and the bowel condition that most often derails it is in constipation and obstructed defaecation.

When to stop and ask somebody

If the floor will not relax, more technique is not the answer. An overactive or hypertonic pelvic floor fails to switch off rather than failing to switch on, and obstructed emptying is one of the ways that shows up, so the treatment runs in the opposite direction to strengthening: hypertonic pelvic floor and downtraining.

And if the symptom is new bowel leakage rather than difficulty emptying, this stops being a physiotherapy question first. Roughly 6 in 100 first vaginal births and fewer than 2 in 100 births to women who have given birth vaginally before involve an anal sphincter injury⁶, which is uncommon, treatable and routinely missed when it is reported as ordinary postnatal weakness. For the treatment as a whole, pelvic floor physiotherapy is the place to start, and for what the first appointment covers, what happens at a pelvic health physio assessment.