Constipation: isn't it just hard to pass poos?

Author             Jóh-Ann Gouws BPhysT (UP) (NZRP)

Designation     Registered physiotherapist with a special interest in pelvic function

Constipation affects a large percentage of the population. Constipation is the most common gastro-intestinal complaint people present with and it is of particular concern because it is a risk factor for developing colo-rectal cancer.

The ROME IV criteria classify constipation as experiencing 2 or more of the following in the last 3 months and a symptom onset that started at least 6 months before being diagnosed

1. Straining to poo more than 25% of the time

2. Hard or lumpy stools more than 25% of the time

3. Feeling like you did not evacuate completely more than 25% of the time

4. Feeling like you are obstructed at the anal opening more than 25% of the time

5. Using your finger(digitation) or an object to assist you to poo more than 25% of the time

6. Less than 3 spontaneous bowel movement a week

This classification works well with adults who can sense and tell you what they feel and who can monitor how many times they feel that way. It is a different story in children, who often lose the ability to feel in their rectum when they are constipated because their rectum stretches to a point where their sensation is lost. In children constipation may present as infrequent, large, lumpy stools but they may also present with very frequent loose/watery stools.

Here are 12 signs of constipation in kids as described by Dr Steve Hodges, an American urologist who specializes in kids with constipation related problem. You can access his website here https://www.bedwettingandaccidents.com/ .

1. Hard, lumpy poos: when the poo stays in the rectum longer, it dries out more and can dry so much that it becomes like rabbit droppings.

2. Huge poos! If it’s not coming out, then it is piling up! The rectum stretches and it can come out one day as a very large poo.

3. Not pooing often enough: kids ideally should be having a good bowel movement without straining daily. BUT some kids poo daily and are still constipated.

4. Very loose stools or skid marks: Some of the new poo that is still liquid, seeps past the harder poo and leaks out.

5. Pee leaks: the rectum stretches so much that it squishes on the bladder, since it shares space in the pelvis. The pressure exerted on the bladder is too much and it compensates by allowing some urine to pass. This can be during the day or at night. 

6. Going to pee frequently: as stated above, the bladder has extra pressure from the stretched rectum. This causes a feeling of bladder fullness and having to go urinate more often.

7. Poo leaks: if the rectum and anus stretches beyond capacity, then poo just moves out.

8. Pooing more than 2x a day: if the rectum is stretched, it loses tone (almost like a balloon that has been blown up for a while – it doesn’t return to the way it was when you first blew it up). When its stretched out, it doesn’t empty all the way because it can’t exert enough pressure to push all the poo out, you then need to go more often as a little stays left behind.

9. Belly pain: when your rectum is stretched out for a time, you lose the sensation of having to poo that you normally feel in the anus. Your body still knows that you need a signal when there is poo in the rectum and it often creates it by giving you belly pain. A colon that is very backed up can also be painful. When a child complains of belly pain – you need to rule out constipation first!

10. Recurrent urinary tract infections: when the anus is stretched from having poo stay there instead of just passing through, bacteria can creep out and forward on the body towards the urethra. This can cause a urinary tract infection. This occurs more commonly in girls than boys because their urethra is closer to the anus.

11. Itchy anus: because the poo stays longer and clogs up the kids the anus gets more pressure and more exposure to bacteria than it is used to. It is also often more difficult for these kids to wipe, irritating it even further. Poo leaks can also irritate the skin causing itchiness.

12. Trouble with toilet training: Ideally kids should start to potty train between 2 and 3 years. We expect them to be continent during the day by age 4 and at night by age 5.

We also know that constipation in kids lead to bedwetting, pee leaks and poo leaks (often referred to accidents). This creates a whole lot of emotional complications and if that is not enough, constipation can also lead to fissures (seen in 80% of constipated kids) and haemorrhoids. Kids who are constipated are also more at risk of developing pelvic pain. This tells us that we should be treating the cause of constipation effectively as soon as we can, to avoid the whole snowball effect it has on our kids’ future health.

Managing constipation should not only include medication but lifestyle factors as well. A very important part of dealing with constipation is teaching the muscles surrounding the anus to LET GO. These muscle act like a door, if it opens, the poo can pass. If it is shut, the poo stays inside. The pelvic floor muscles can be voluntarily let go to open the passage for poo to pass.

Physiotherapists trained in pelvic floor dysfunction can teach you how to let these muscle go, so you can poo better. They are a vital team member when managing kids who have pee leaks, poo leaks and bedwetting problems.