Constipation & Pelvic Floor Dysfunction
In 2010, I spent two weeks at the Mayo Clinic in Minnesota to complete a biofeedback program for chronic constipation due to pelvic floor dysfunction.
For many years after my gastroparesis diagnosis, I struggled with worsening constipation was eventually diagnosed with colonic inertia. When it got to the point that I could no longer have a bowel movement without taking stimulant laxatives, I underwent some testing and was diagnosed with pelvic floor dysfunction.
What is pelvic floor dysfunction? That was my first question, too. Here's the official explanation:
Your pelvic floor muscles are a group of muscles that form the base of your pelvis. This "hammock" of muscles supports your internal organs including your bladder, uterus, and rectum. Sphincter muscles surround the openings to the bladder, the rectum, and, in women, the vagina. The sphincter muscles control the opening and closing of your urethra and anus.
Normally, the anal sphincter and pelvic floor muscles relax in coordination with the abdominal muscles, allowing you to pass stool. Sometimes, the anal sphincter muscles do not work or coordinate with the pelvic floor muscles. This can cause difficulty when trying to pass stool. This is known as pelvic floor dysfunction (PFD) or dysseynergia.
Though it often goes undiagnosed, PFD occurs in about 7% of the adult population. It's one of the main causes of chronic constipation that fails to respond to diet, lifestyle, or even laxative intervention. PFD can slow motility throughout the GI tract since once the rectum is full and cannot be evacuated, it sends signals to the brain to slow transit in the intestines.
While the cause of pelvic floor dysfunction isn't well understood, factors that may contribute include long-lasting or sudden constipation and childbirth. The nurse I spoke with at the Mayo Clinic also mentioned gallbladder surgery among possible precipitating events.
While I don't have any statistics, it seems that many gastroparesis patients may also suffer from pelvic floor dysfunction due to the constant physical stress GP puts on the muscles in the abdominal region (not to mention the emotional stress so many feel and the low-fiber diet many people follow).
The most effective way to correct pelvic floor dysfunction is through a bio-feedback program that retrains the muscles. Mayo Clinic offers an intensive, two-week outpatient program. It looks like this:
Week 1
Average of 3 sessions lasting 30 to 45 minutes every day.
Insertion of a rectal sensor that monitors muscle tension through electromyography (EMG). The EMG activity is visually displayed for the patient to indicate tension and relaxation of the pelvic floor.
Verbal explanation and cueing from the therapist on what pelvic floor relaxation feels like and how to relax these muscles. Simultaneous visual feedback strengthens learning by showing improvements in relaxation.
Learning to identify the internal sensations associated with day-to-day relaxation (baseline relaxation) and how to sustain that point.
Education on the negative effects of both pelvic floor and general tension. Relaxation training may be augmented with the help from occupational therapists who teach diaphragmatic breathing.
Week 2
Average of 2 sessions each day.
Insertion of a rectal balloon inflated with varying volumes of water to simulate a bowel movement. The patient learns to sustain relaxation with rectal volume present, to coordinate abdominal activation with dynamic pelvic floor relaxation, and to avoid habit co-contraction of the pelvic floor. The goal is unpressured release of the rectal balloon to simulate normal defecation.
Teaching long-term skills and exercises for home use to maintain pelvic floor relaxation.
Education regarding normal bowel function, identification of problematic toileting habits, and behavioral modification.
The program has an 75-80% success rate, with up to 40% of participants noticing improvements by the end of the two-week retraining period. While there's no way to predict which patients will be most successful, I was told that a positive, relaxed attitude guarantees the best chance of success.
My Results (updated 2022)
I did not notice significant long-term results from the biofeedback program, though over the years I have heard from others who did. I do not regret doing the program and actually wish that I had been more consistent with my at-home practice afterward, as that might have improved my results. I still struggle with pelvic floor issues, especially since having my daughter in 2012.
Fortunately, despite those issues, my constipation has improved significantly over the last several years. I don’t know for sure what to credit with the improvement but I began to notice a change when I stopped relying so much on meal replacements like Orgain and MacroBars and moved to a dairy-free diet.