The following questions are some of those I have been asked frequently throughout my years of practice. I include them here as general guidance only. If you are unsure about any of the issues discussed here as they relate to your specific situation, please consult with your family doctor.
If you are experiencing a problem with your bowel that is causing you discomfort, pain, inconvenience or worry, it is worth visiting your GP to see whether something can be done to alleviate this.
Almost the first thing any doctor will consider when a person presents with a bowel complaint is whether or not any serious bowel disease is likely to be present. The following symptoms and symptom patterns stand out as requiring more detailed investigation, to rule out pathologies such as cancer, polyps, infection and inflammation. If you have any of these, you should see your family doctor in order to rule out the possibility of serious bowel disease or, if disease is present, to have it treated promptly:
In essence, if your symptoms include rectal bleeding and abdominal or anal pain, and if they have persisted and even progressed over six weeks or more, you must bring them to your doctor’s attention. After a detailed assessment by your doctor, or where there is concern for any other reason, a colonoscopy (examination of the colon using a long, flexible telescope inserted through the anus) usually represents the most accurate means of detecting any serious bowel pathology. Your doctor will be well aware of the potential for serious pathology and will initiate appropriate investigation as required.
Constipation means different things to different people. In an effort to provide some sort of standard definition, doctors often refer to the patient’s stool frequency – how many bowel actions that individual has each day or each week – as the measure of normality. In general, a daily bowel action is regarded as normal, and having fewer than three bowels actions per week might be regarded as constipation.
However, recall the discussion in Chapter 1 about what constitutes ‘normal’. It is true that people who are not constipated often open their bowels daily or even more frequently, while people who are unequivocally constipated often open their bowels less frequently than daily. But some people who open their bowels only once per week do so with ease and leave the bathroom feeling comfortably empty. Conversely, there are others who achieve only partial rectal emptying despite attempting to empty their bowels several times each day.
In reality, what makes someone constipated is not so much how often they open their bowel but how easily and completely they do so. Constipation is best regarded as being difficulty with either initiating or completing rectal evacuation. Common symptoms include weak and infrequent urges to go to the bathroom, straining to do so, requiring laxatives to achieve a bowel action, abdominal bloating and a sense of incomplete rectal emptying. If you are genuinely bothered by the difficulty you are experiencing in either starting or finishing a bowel action (or both), then I think that you can rightly describe yourself as constipated.
Yes, of course it should. Just like my cholesterol level should, naturally, be normal (rather than alarmingly high without medication). And just like somebody else’s blood pressure should, naturally, not be raised to the point of needing medication.
The belief that our bowels should regulate themselves ‘naturally’ lies at the heart of the unfortunate and widespread reluctance to take the necessary medications that might speed up (or slow down) our malfunctioning intestines. Many people are completely convinced that the solution to their bowel problems must rest with diet and with diet alone (and, more often than not, with the ingestion of extra fibre).
This belief is misguided on three counts.
First, bowels malfunction just like any other part of the human body. They can be underactive or overactive or swing wildly between the two extremes. That they don’t always work perfectly in every person on the planet seems to me entirely unremarkable. That they sometimes need medication for satisfactory management seems absolutely consistent with what we all know about the human body and its all-too-frequent failings.
Second, diet alone cannot resolve the full range of our potential bowel problems any more than it can resolve the full range of our other health problems, such as high cholesterol, high blood pressure, diabetes and so on. Dietary manipulation forms an important element of the treatment of all sorts of health problems, including problems with bowel function, but it is rarely the whole answer. And in many cases increasing dietary fibre intake can aggravate rather than improve your bowel symptoms.
Third, the medications that so many of us do need to take to maintain comfortable control over our bowels are mostly extremely safe and entirely suitable for long-term use. Loperamide for those with loose stools and osmotic laxatives for those with constipation have minimal absorption into our bloodstream, meaning that they have very few side effects outside the intestines themselves. And they are not habit-forming, meaning that you can continue to take them for as long as they are working, confident that the current dose is likely to continue working without ill effect.
As a general rule, men have faster colonic transit than women, along with reliably frequent bowel actions accompanied by reliably strong urges to evacuate their bowels. (Recall from Chapter 2 that boys and men are generally ‘good bowel athletes’.) Men also tend to respond briskly to any food or medication that speeds up colonic transit. Conversely, women are prone to having slow and sluggish bowels, and to being especially sensitive to any medications that slow bowels down (see Chapter 4).
Many men have an annoying tendency to parade their bowel athleticism in front of their inherently less (bowel-)athletic female partners. Simplistically, he concludes that if eating extra fruit and vegetables makes him go more often and more easily, then surely eating extra fruit and vegetables will do the same for her. But it’s just not that simple.
For women with slow colonic transit, the laxative action of fruits, vegetables and fibre more generally is particularly weak. Even a massive increase in dietary fibre intake often fails to move a determinedly sluggish colon. Yet, even in this sluggish colon, bacteria reside appropriately in their billions and act on all this undigested dietary fibre to form unwanted excess gas (flatus).
Abdominal bloating, not infrequently painful, is thus a characteristic complaint among patients with slow transit constipation. And this bloating is largely due to the distension of their colon by flatus, which their sluggish colon produces quite normally but cannot adequately propel and expel. By increasing their dietary fibre intake, women with slow colonic transit routinely experience an undesirable increase in bloating far in excess of any desirable speeding up of colonic transit.
So you can tell your husband that he is welcome to increase his fruit intake whenever he feels the need. You can also tell him that what works for him may not, alas, work for you. The fact that you don’t find eating more fruit helpful to your constipation – or that it actually makes your tendency to abdominal bloating worse – is quite consistent with your being a woman.
The belief that our bowels should work every day is deeply embedded in our society. But, as discussed in Chapter 1, what matters much more than having a bowel action every day is that our bowel actions are, as much as possible, prompt and effortless, brief and complete. How often we open our bowels is simply nowhere nearly as important as how easily and completely we do so. To this end, the weekly (not daily – see Chapter 5) use of an effective dose of laxatives can assist.
Many people – mostly women (see Chapter 2) – do not need to open their bowels every day. They can safely and very comfortably wait until they experience a spontaneous – and appropriately forceful (see Chapter 3) – urge to open their bowels before doing so. If such an urge takes several days to develop, that is absolutely fine. If no such urge arrives after a whole week, it is totally safe and appropriate to clean out thoroughly by taking another decisive dose of laxatives.
While a bowel habit characterised by laxative-induced cleansing once a week (with few or even no spontaneous bowel actions in between) is an undeniably foreign concept, it is nevertheless absolutely safe and sustainable. In fact, it is far better to clean out thoroughly just once per week with a substantial dose of laxatives than it is to effect incomplete evacuation day after day as a result of the daily use of smaller doses.
In a perfect world, every one of us would be able to regularly and reliably generate an ‘irresistible’ urge – provided we have waited long enough for that urge to arrive – that would predictably and satisfactorily empty our bowels. The truth, however, is that many people (mostly women) have inherently sluggish colonic transit and only rarely, if ever, experience a forceful urge to empty their bowels.
Many of these people have, therefore, learnt to recognise what represents the ‘best’ urge they are likely to experience, and respond to that sensation by heading to the bathroom. They have also learnt that they are likely to have to strain to initiate evacuation, and that they might not feel completely empty when they leave the bathroom. They know from experience that it is far better to respond to the ‘best’ urge than it is to wait in hope for something stronger – which, deep down, they know is never going to arrive. If they miss this opportunity, they have come to know, they are likely to become genuinely impacted and uncomfortable, and will likely need to take laxatives to correct the situation. This need to respond to a modest urge – precisely because an irresistible urge is unlikely ever to appear – is the characteristic pattern of slow colonic transit. It represents a clear signal that steps should be taken to speed up (and, hopefully, restore speedier, spontaneous) colonic transit. In this circumstance, the regular or intermittent use of an osmotic laxative (see Chapter 5) is definitely the way to go.
One of the most difficult challenges I face in looking after people with evacuation disorders is trying to explain the notion of a false or misleading urge to empty their bowels. People in this situation find it genuinely confusing when I ask them to explain what it is that makes them choose to attempt to evacuate their bowels at any given point in time. Why else would anyone try to empty their bowel if not in the belief that they needed to do so then and there?
But very many people do enter the bathroom with an inadequate urge to empty their bowels, notwithstanding their strong conviction (and ardent hope) that that is what they need to do. In truth, for many people, the feeling of needing to evacuate their bowels is not accompanied by any confidence that successful evacuation will ensue. Rather, despite the compelling sense of needing to go, they more often than not arrive in the bathroom correctly anticipating difficulty, discomfort and frustration.
When I am talking with such a patient, I ask whether they have ever either experienced some form of gastroenteritis or undergone a colonoscopy (each of which brings on overwhelming diarrhoea with urgent and watery stools). Nearly every patient I see has experienced one or the other of these at some point in their life. When I ask them to recall that urgent call to evacuate their bowel and to compare it to the feeling that more usually prompts them to attempt evacuation, the distinction is readily apparent.
An absolutely routine question to my patients is: ‘When you go to the bathroom to open your bowel, is it in response to an irresistible urge to go at that instant?’ Under this sort of direct enquiry, most people concede that they are able to tell the difference between the real thing and a false alarm.
A related question, also totally routine in my practice, is ‘When you sit on the toilet, does your bowel action commence immediately, or do you have to wait or strain to get things started?’ Failure to promptly and spontaneously initiate a bowel action is cogent evidence that your decision to sit on the toilet at that moment was flawed, that the urge to empty your bowel was inadequate or misleading. If you regularly fail to commence rectal evacuation within just 30 seconds of sitting on the toilet, you are almost certainly choosing to attempt evacuation in the absence of a sufficiently strong urge to go.
In general, the quicker the colonic transit, the softer the stool is likely to be, and the more urgent will be the need to empty your bowel. Consequently, initiation of rectal evacuation in this situation is likely to be easy.
However, if colonic transit is too quick, stools can become excessively liquid and pressingly urgent to pass, even to the point of provoking urge incontinence of faeces. Moreover, although soft and fast-moving stools do make the initiation of defecation easy, they can also make it extremely difficult to achieve complete rectal evacuation, since even unusually powerful intestinal contraction waves tend to fade and disappear before the stool has been completely passed. So, despite being associated with a promisingly strong urge to go to the bathroom, soft faeces can all too easily be left behind after defecation, leaving with it an acute and uncomfortable awareness that the rectum has not been emptied.
The truth is that the ideal stool consistency for satisfactory and complete rectal evacuation is firm and well formed (see Chapter 4). Provided that it is accompanied by a strong and true urge to initiate rectal evacuation, a firm and well-formed stool is unequivocally optimal for the completion of rectal evacuation.
Speedy colonic transit undoubtedly favours easy initiation of defecation, while firm and well-formed stool consistency undoubtedly enables complete rectal emptying. The trick is to balance the pursuit of the ideal stool consistency with consciously deferring rectal evacuation until the urge to do so is strong.
This is a real ‘First World’ conundrum! Nevertheless, it is a genuine one, since many people do use moist wipes rather than toilet paper, and many of those who do genuinely believe that it is the healthier alternative.
Before answering this question, it is worth noting that the perianal skin (the skin around the anus) in human beings likes to be clean and dry. You might well ask yourself, if human perianal skin is so concerned about being clean and dry, why did it position itself in an area so prone to moisture and soiling? This human design enigma notwithstanding, the undeniable truth is that perianal skin that is moist and/or soiled is prone to become broken, chafed or overtly macerated, which can result in stinging, itching, burning pain and even bleeding.
So leaving the bathroom after a bowel action with our perianal skin clean and dry is absolutely what we want. But when our stools are soft and sticky, we often find it difficult to wipe up completely. Repeated wiping is time-consuming, frustrating and, not infrequently, a little painful. In these situations, a moist wipe makes the process of cleaning up quicker and more comfortable.
But moist wipes are, well, moist! By their very definition they generally do not leave the skin dry. (Their use should therefore really be followed by gentle drying with soft toilet paper.) Further, many moist wipes also contain soaps and scents that might irritate the skin of sensitive individuals. For these reasons – residual moisture and chemical sensitivity – moist wipes are not always as suitable and straightforward a solution as they might first seem.
The real ‘trick’ to getting the perianal skin clean and dry has nothing to do with the material with which we choose to wipe the area. A firm and well-formed stool that is accompanied by a genuinely strong urge to evacuate will almost always pass completely, leaving nothing behind within the rectum and no residue on the skin. Almost every person I have ever spoken to about the workings of their bowels can recall the passage of precisely such a well-formed, solid stool (even if it was a long time ago), and can remember fondly the accompanying sense of complete rectal emptying, snug anal closure and perianal cleanliness.
So the best way to keep your perianal skin clean and dry is to keep your stool consistency firm and well-formed. Moist wipes are almost always only necessary where stool consistency is too soft.
This is a common grievance. Very few people are completely at ease sharing the workings of their bowels with anyone at all – even close family, let alone total strangers. The sounds and smells, especially, of our bowels at work are matters of utmost privacy to all but a tiny percentage of the human population. And public toilets – a little like the public ablution blocks of Ancient Rome – are remarkably public places. It is not at all surprising, then, that many people find it awkward and embarrassing to open their bowels in this environment, and that they will therefore avoid this situation as much as they possibly can.
Given this deep and widespread reluctance to embark upon a bowel action in a public toilet, the likelihood is high that you will only go in public when the urge is truly irresistible. In other words, having done your level best to defer defecation until you get to a private facility (preferably in your own home), it is generally only when you have little choice that you will go in public. At least then you can be assured that the strength of the urge is likely to provide excellent impetus to favour prompt and effortless initiation and complete evacuation.
Deferring defecation until you can be at ease and free of embarrassment is completely acceptable. We have anal sphincters to close off the anus, and our rectum has the physiological capacity for ‘receptive relaxation’ (see Chapter 2) precisely for the purpose of ‘holding on’ when it is inconvenient or even dangerous to stop and open our bowels.
As long as, having delayed that trip to the bathroom until a more private opportunity presents itself, you await the arrival of another forceful urge to empty your bowel, you should be fine. As discussed in Chapter 3, sitting on the toilet waiting for a bowel action to start just because you had the urge a few hours earlier is a form of speculative defecation, and is a recipe for straining and frustration. If you do choose to hold on and not go when the urge is strong, just make sure you await the arrival of the next strong urge before attempting to open your bowel.
The short answer is: why not? An appropriately experienced dietician will review your current diet and adjust it according to your specific requirements.
There is much public awareness nowadays about dietary sensitivity to things such as gluten (a protein found in wheat, barley, rye, oats, spelt and other grains), lactose (found primarily in dairy products) and FODMAPs (sugars contained in a vast range of fruits, vegetables and grains). Accordingly, there are any number of ‘exclusion diets’ that can be applied in an effort to control troublesome gastrointestinal symptoms.
A comprehensive discussion of these dietary sensitivities is beyond the scope of this book. Certainly, in my opinion, these diets should only be conducted under the supervision of a qualified dietician. I will also make these two brief points:
Having our hips flexed – sitting on the toilet with our knees slightly higher than our hips – serves to relax the pelvic floor muscles and help open the anorectal outlet (see Chapter 3, and especially Figure 3). This is why the vast majority of toilets are lower than the standard sitting chair. For people who find that they need to strain to initiate or complete rectal evacuation, additionally flexing their hips assists this process further.
But the essential problem is rarely, if ever, the posture. Rather, it is the absence of a sufficiently strong urge. I have looked after scores of people who experience overwhelming urgency and outright urge incontinence of faeces while, bolt upright, they are running to find a bathroom. They certainly didn’t need to have their hips flexed to get their bowels working. Conversely, I have treated scores more patients who have been bedevilled by a sense of obstructed defecation regardless of the posture they adopt, because they have attempted defecation in the absence of an appropriate urge. No degree of squatting ever helped them.
I have nothing against the little stools and footrests that people do use, and I appreciate that they make a big difference for some people. But the urge to go – or the lack thereof – is nearly always the critical issue, and not the posture adopted on the toilet. If you are able to get to the bathroom with an urge that is strong and true, you will be able to initiate defecation promptly and effortlessly without the need for any kind of furniture to modify your posture.