Constipation and Obstructed Defaecation: The Bowel Side of the Same Floor

Constipation is a problem of what arrives at the rectum, obstructed defaecation is a problem of what happens when it gets there, and both matter to pelvic health physiotherapy because straining is a daily load test that no amount of contraction work can out-train. NICE NG210 covers bowel emptying disorders in the same guideline as urinary incontinence, prolapse and chronic pelvic pain, for women aged 12 and over¹, which is why bowel questions appear in an appointment you booked about your bladder.

That happened to me at every single appointment of my sixteen weeks, and I found it faintly irritating for about the first month. I had come about leaking when I ran; I was being asked how long I spent on the toilet. It took me until roughly the six week review to understand that the question was not politeness, it was load accounting. Read red flags and when to stop and get checked first, because several bowel symptoms need a doctor rather than a programme.

Two different problems that get one word

The word constipation covers at least two mechanisms, and treating them as one is how people end up doing the wrong thing for months.

Slow transit is about supply: the stool arrives infrequently, and the problem is upstream of the pelvic floor. Obstructed defaecation, sometimes called an evacuation disorder, is about the exit: the urge is there, the stool is there, and emptying does not happen properly. The typical description is straining without result, a sense of not having finished, several visits to complete one bowel movement, or needing to change position. A person can have both.

The distinction matters here because only the second one is largely a pelvic floor problem. Failure of the floor to relax and coordinate during emptying is one recognised mechanism, and descent of the back vaginal wall is another, which is why this article sits next to pelvic organ prolapse rather than in a separate bowel section. The International Continence Society maintains the standardised terminology used to describe these symptoms², and the International Urogynecological Association publishes plain-language leaflets on the same presentations³.

The number this site does not have

No prevalence figure for constipation, and no prevalence figure for obstructed defaecation, appears in the sourced evidence base behind this site. Neither does an effect size for physiotherapy in either.

That is a real gap and I would rather name it than borrow something. Figures for both circulate widely and vary enormously with the definition used, because “constipation” measured by frequency, by effort, by stool form or by a symptom questionnaire produces four different answers in the same population. When you meet a percentage, the three questions that make it interpretable are the ones this site applies to everything: what population, what definition, what comparison.

What can be stated without a number is the guideline position. Bowel emptying disorders are inside the scope of non-surgical management rather than outside it¹, which tells you that they are managed alongside bladder and prolapse problems rather than referred away from them.

Why straining is the thing that matters most

Because it happens every day, under effort, and it loads exactly the structures a programme is trying to support.

Think of the pelvic floor as one wall of a pressure system whose lid is the diaphragm and whose front is the abdominal wall. Straining raises pressure inside that container and directs it downwards, repeatedly, for as long as the attempt lasts. A supervised training programme might involve a few minutes of work a day. A person who strains hard for several minutes twice a day is applying a competing load of similar duration in the opposite direction.

That is the argument for treating the bowel first, or at least early, rather than as an afterthought once the muscle work has stalled. It is also why bowel habit and defaecation technique exists as its own article covering position, bracing and stool consistency, and why those things are discussed in an appointment about leaking. NICE puts supervised pelvic floor muscle training first in the pathway for stress and mixed urinary incontinence and for symptomatic prolapse⁴, and a programme run alongside daily heavy straining is not a fair test of that recommendation.

When the floor is the obstruction

This is the part most likely to change what somebody does next.

Emptying requires the pelvic floor to let go, and to let go in a coordinated way at the same time as pressure is generated above. If the muscle contracts instead of releasing, or simply never fully releases, the exit narrows at the moment it needs to open. The person then strains harder, which raises pressure against a closed door, which is both ineffective and loading.

Everything about that mechanism argues against a strengthening programme. Adding contraction work to a floor that will not release trains the excess, and it is why hypertonic pelvic floor and downtraining is linked from every strengthening page on this site. Urgency, frequency, incomplete bladder emptying and pain often travel with it, which is why the symptom picture can look like several different problems at once.

Why you cannot work this out yourself

Because people cannot reliably tell what their pelvic floor is doing, and the evidence on that is unusually clear.

In 47 women referred for urodynamic evaluation of urinary incontinence, only 23 of them, 49%, achieved an ideal contraction after brief standardised verbal instruction, and 12, or 25%, performed a technique that could potentially promote incontinence⁵. That was a referred, symptomatic clinic population in 1991, and it is not a statement about everyone: in 779 women attending community-based primary care practices, correct contraction on the first attempt ranged from 68.6% to 85.8% depending on symptoms, and of the 120 who got it wrong, 78% learned after brief instruction⁶. A meaningful minority get it wrong, most learn quickly when shown, and the error concentrates among people who already have symptoms.

Now apply that to release rather than contraction. If a substantial minority cannot reliably tell whether they are squeezing, nobody should be confident about self-diagnosing whether they are letting go. That is what an assessment is for, and what happens at a pelvic health physio assessment covers what it involves.

What a physiotherapy programme actually addresses here

Four things, none of which is a medicine.

• Position and mechanics of emptying. How you sit, what the knees and feet are doing, and what happens with the breath. This is the single most modifiable item and it is covered in bowel habit and defaecation technique.
• Release and coordination. Whether the floor can let go on demand, and whether it does so at the right moment relative to the effort above it.
• Habit and responsiveness. Whether the urge is answered when it arrives or deferred until convenient, and whether the pattern has become erratic.
• Consistency and the load it creates. A firmer stool requires more effort to pass, and effort is the variable this whole article is about. The medical side of consistency, including laxatives, is a conversation for a clinician or pharmacist and this site writes nothing about medication.

Where muscle training is part of the plan, it is prescribed against the assessment rather than assumed: pelvic floor exercise programmes explained covers how, and how to do a pelvic floor contraction correctly covers the movement itself without giving a dose.

Where this sits alongside prolapse and bowel leakage

Close to both, in both directions.

Descent of the back vaginal wall can itself produce obstructed emptying, and a person may find they need to reposition to finish. Meanwhile chronic straining is one of the loads that acts on the supporting structures over time. So a prolapse programme that ignores the bowel is working against a daily headwind, and the relationship runs both ways rather than one.

The evidence for training in prolapse is worth keeping in proportion while you do that. The POPPY trial randomised 447 women with newly diagnosed symptomatic stage I, II or III prolapse and found an adjusted difference of 1.52 points on a 0 to 28 symptom score at 12 months in favour of individualised training, with a 95% confidence interval of 0.46 to 2.59, and only 295 women, 66%, still in the trial at that point⁷. That is good evidence of direction and modest evidence of magnitude. The prevalence context is equally worth stating: prolapse defined by symptoms has a prevalence of about 3% to 6% and up to 50% when defined by vaginal examination⁸, and those are answers to two different questions.

For the leakage side of the same floor, see faecal incontinence and anal sphincter training, which covers why new bowel leakage after childbirth is urgent rather than routine.

What to bring to the appointment

A bowel diary, kept for the same three days as the bladder one if you are keeping both. Frequency, stool form, how long each attempt took, how much effort it required, whether it felt finished, and how many attempts were needed.

I resisted filling one in for a fortnight on the grounds that I knew what my bowels did. I did not. The written version differed from my recollection in two specific ways and both were relevant. It is the cheapest item you can produce and it does more to shorten an appointment than anything you can say. Questions to ask at your first appointment covers what else is worth having written down, and pelvic floor physiotherapy sets out the treatment as a whole.