Chronic constipation: Could pelvic floor rehabilitation be the solution?

Perineal Rehabilitation as a Treatment for Chronic Constipation

When we think of pelvic floor rehabilitation, we naturally think of pelvic floor strengthening exercises—also known as Kegel exercises, and the treatment of urinary incontinence. However, we often overlook another major pelvic disorder for which pelvic floor rehabilitation can be extremely helpful: chronic constipation.

This problem affects more than 15% of the population, with women being more commonly affected. Many live with this condition in silence, sometimes for years. When they consult a healthcare professional, they are usually offered laxatives, supplements, or significant dietary changes. Despite this, they are rarely referred for pelvic floor rehabilitation, even though it can be a key solution.

This blog aims to educate you on the various possible causes of constipation and show you how consulting a physical therapist specializing in pelvic floor rehabilitation could be the missing piece of the puzzle to finally improve your situation.

What is chronic constipation?

Most people think that constipation is characterized by the absence of daily bowel movements. In reality, the definition is more complex. Yes, constipation can mean fewer than three bowel movements per week, but it can also manifest as:

• The need to strain to pass stool
• Hard or fragmented stools
• A feeling of incomplete evacuation
• A sensation of blockage in the rectum

So, even if you have a bowel movement every day, you may still be constipated if any of these symptoms are present. Constipation is therefore a more complex condition than is often believed.

Anatomy : Understanding the Colon, Rectum, and Anal Sphincter

To understand why constipation occurs, it is helpful to briefly review how the final part of the digestive system works.

The colon is a long tube that rises from the lower abdomen, runs horizontally, and then descends, forming an inverted U. Its main function is to absorb water from the stool. Stool enters the colon highly hydrated, and water is gradually reabsorbed as it moves through the colon.

At the end of this journey, the stool reaches the rectum. Ideally, it should have a soft, “sausage-like” consistency. The rectum serves as a temporary reservoir until you can go to the bathroom. To prevent leakage, the anal sphincter, a circular muscle, keeps the rectum closed.

Two main categories of causes

Constipation can be linked to two types of problems:

• A slowing of intestinal transit in the colon
• Mechanical dysfunction in the rectum or anus

These two categories can coexist, but it is important to distinguish between them to better understand what is happening.

1) Slowed bowel movement

When stool moves slowly through the colon, the colon has more time to absorb water. As a result, the stool becomes harder, drier, and more difficult to pass.

This slowing down can be caused by:

• Certain medications
• Medical conditions
• Lifestyle habits

Three habits in particular affect bowel movements:

1. Not drinking enough water

If you’re dehydrated, your stool is already dry when it reaches the colon. The colon then absorbs as much moisture as it can, making the stool even harder. It’s generally recommended to drink about two liters of water a day.

2. A lack of fiber

Fiber increases stool volume and makes stools softer. It also helps them move through the colon. The recommended intake is about 25 g per day for women and 38 g for men.

3. Insufficient physical activity

Physical activity acts as an “internal massage,” stimulating bowel movements. Walking for at least 30 minutes a day can already make a difference.

Changing these three habits can help relieve constipation. But sometimes, even with adequate hydration, a high-fiber diet, and regular physical activity, constipation persists. In such cases, another cause should be considered: mechanical dysfunction of the rectum and anus.

2) Mechanical dysfunction of the rectum and anus

These dysfunctions are very common in chronic constipation, but often go unrecognized.

• Loss of rectal sensitivity

When constipation persists for a long time, the rectum becomes accustomed to holding large amounts of stool. As a result, it becomes less sensitive. Imagine a ball inside a small balloon versus a very inflated balloon: in the stretched balloon, you can feel it much less.

Result: a larger amount of stool is needed to trigger the urge to have a bowel movement.

• Weakening of the rectum

A constantly stretched rectum also loses its ability to contract. However, these contractions are essential for expelling stool.

When these two phenomena combine, the rectum becomes both less sensitive and less effective, which perpetuates constipation.

• Anal sphincter dysfunction and dyssynergy

The anal sphincter must relax completely to allow for bowel movements.

Two problems can occur:

Difficulty relaxing the sphincter,
Dyssynergy: when the rectum pushes, the sphincter contracts instead of relaxing.

These dysfunctions make bowel movements difficult and require straining, which can make the situation worse. Perineal rehabilitation is particularly effective in treating these mechanical dysfunctions.

If the problem originates in the rectum:

The goal is to improve its sensitivity and strength. The primary tool is rectal balloon training, which mimics the presence of stool. It allows the rectum to learn to detect volume sooner and regain its ability to contract.

If the problem stems from the anal sphincter:

We focus on:

• Relaxation
• Coordination
• Muscle control

The goal is for the sphincter to relax at the right moment, in sync with the contractions of the rectum.

Conclusion: An Often Overlooked Solution

Chronic constipation is a common problem that significantly impacts quality of life. Standard advice, such as drinking more water, eating more fiber, and getting more exercise, is helpful, but it isn’t always enough.

If you’re still constipated despite these measures, the cause may be mechanical. In that case, consulting a physical therapist specializing in pelvic floor rehabilitation could really make a difference.