POO and the Squatty Potty

Most of us have seen the squatty potty ad with the unicorn by now and if you haven’t, take a look  entertaining right? Of course it is! That’s one of the best ads out there, but is it legit?

The simple answer, yes! But what is this puborectalis muscle they are talking about and why haven’t we heard of it before this unicorn’s perfectly formed rainbow poop?

Pelvic outlet obstruction (POO), is a form of constipation that occurs due to a paradoxical contraction of the pelvic floor muscles during defecation. Simply put, rather than relaxing to allow the anus to stay open so stool can escape, the pelvic floor contracts causing a restriction in the canal leading to inability to fully expel the stool. The puborectalis muscle plays a large role in this as it slings around the rectum causing an angle between the rectum and the anus, known as the anorectal junction. If this angle decreases by the puborectalis muscle shortening and contracting, it will become harder for stool to pass. However, if the anorectal angle is increased by puborectalis relaxation, the stool will easily pass through. This is the idea behind the squatty potty. By elevating the knees above the hips (squatting) the angle is increased and  voilà. But is it really this easy? For some it may be but others may need pelvic floor physical therapy.

Image result for puborectalis squatting

Contraction of the pelvic floor during defecation is known as pelvic floor dyssynergia or a paradoxical contraction, meaning, the pelvic floor does the opposite of what it was supposed to. Biofeedback and pelvic floor down training can be  very useful for patients with a paradoxical contraction. A pelvic floor therapist may use either external sensors or an internal probe to monitor pressures in the anal canal during simulated bearing down from the patient. The patient receives visual feedback from the computer screen which displays real time EMG activity. If the pelvic floor contracts, the EMG will increase, this would be the paradoxical contraction. The patient is then given external verbal and positional cues from the physical therapist in order to achieve proper pelvic floor relaxation while bearing down. Through trial and error the visual feedback should eventually display a decrease in EMG activity i.e. pelvic floor relaxation.


The diagram shows normal defecation (control, left) with coordinated relaxation of the pelvic floor muscles. However, in patients with dyssynergic defecation (patient, right), we see a failure to relax, or inappropriate contraction of the pelvic floor (1).

Biofeedback is showing promising results for patients with outlet obstruction. In fact, randomized controlled trials have evaluated the efficacy  and concluded that biofeedback is consistently superior to laxatives, standard therapy, sham therapy, placebo, and diazepam. Success rates have been reported in the range of 70 to 80 percent (2).

In addition to pelvic floor relaxation, there must also be an increase in rectal pressure which is achieved through what pelvic floor therapists call the “abdominal pressing out maneuver”. Ideally, increased intra-abdominal pressure comes from the abdomen rather than valsalva (breath holding) to cause an increase in rectal pressure that is simultaneous with pelvic floor relaxation which can be seen with the top row of both the control and patient graphs.  Valsalva can lead to further contraction of the pelvic floor or even passing out on the toilet which I have had reported in the clinic, so no, it is not far fetched.

The first step to the abdominal maneuver is to make your belly soft and just let it all hang! We tend to suck our stomachs in all day long, but when you’re trying to poop, simply don’t, it can cause the pelvic floor to contract even further. Next, make the belly big (like you are pretending to be pregnant) and then make it hard (fill it with air) with your exhale breath. At the same time try to relax your anus and pay attention, if it contracts and cuts your stool off, try to relax again. All the while using the squatty potty to further relax the pelvic floor.untitled

I have had excellent results with biofeedback neuromuscular retraining while simultaneously using the squatty potty. Several patients of mine have gone from suffering with constipation for years to having bowel movements daily. I have seen the results time and time again and I’ll end this post with a section of a referring physician’s report on a patient of mine that I treated for outlet constipation.

GENERAL:  Well-appearing, pleasant woman, not acutely distressed.

GI:  With the help of wonderful pelvic floor physical therapy,
Colace 20 mg daily and the Squatty Potty, the patient has had
soft, almost daily bowel movements and feels her constipation is
the best it has been. 


1. Motility testing: When does it help?. Anthony J Lembo, MD

2. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. AUChiarioni G, Whitehead WE, Pezza V, Morelli A, Bassotti G SOGastroenterology. 2006;130(3):657.




The Short Pelvic Floor


A non relaxing or shortened pelvic floor is not as widely recognized as the weak pelvic floor. Many women, especially those in the child bearing years, are aware of pelvic floor weakness and kegel exercises. However, women as well as clinicians are typically not as well-informed on the shortened pelvic floor and the conditions that may present. Consequently, these conditions are often left unreported, undiagnosed and untreated. Unlike the weak pelvic floor where muscles are stretched leading to a loss in the support system, muscles of the short pelvic floor tighten and are held in a non-relaxing state. This can cause many symptoms such as pain, urinary frequency, constipation or even erectile dysfunction.

The function of the pelvic floor is to support the pelvic organs, maintain continence, aide in sexual function and stabilize adjacent joints. All, one, or a combination of these functions can be affected if the muscles are too tight. Constipation for example, can occur if the pelvic floor muscles are held so tight that stool is unable to pass through, this is know as pelvic outlet obstruction. Overtime, constant straining and pushing to pass a bowel movement can weaken the pelvic floor and put extra stress on the bladder, leading to an overactive bladder or incontinence. The muscles may also start to become involuntarily contracted and small knots or trigger points can form within the muscle. A majority of women with a shortened pelvic floor will complain of pain during intercourse, clinically known as dyspareunia. Dyspareunia can occur when the muscles of the pelvic floor are unable to stretch enough to allow for comfortable penetration, hypersensitive trigger points are being irritated and/or a psychological component, such as a history sexual abuse, is causing the pain.

It often takes a lot of time and frustrations for women with pelvic floor dysfunction to receive proper treatment. It’s easier to recognize incontinence or prolapse, it’s not so easy to diagnose pelvic pain to be of a musculoskeletal origin, let alone something that physical therapy can help. By the time a patient comes to physical therapy, they have likely already seen a gynecologist, urologist, urogynecologist, gastroenterologist, etc. and yet still have no diagnosis. Their pain may be directly in the pelvis or it can refer to other locations such as the abdomen, hip or low back, making the diagnosis even more difficult. The pain described may seem vague, random or non-characteristic of diagnoses practitioners are familiar and may deter physicians from a pelvic floor diagnoses. However, women need to advocate for themselves and know that pelvic pain is not normal.You should feel comfortable talking about this with your health care provider, it is not something you have to just live with.

Physical Therapy Down-Training

Remember, kegels are not for everyone, in this case they provide the adverse effect. Down-training promotes relaxation and muscle lengthening done in several ways ie: stretching, meditation, manual techniques to reduce trigger points and promote tissue mobility or EMG assisted biofeedback.  

EMG biofeedback uses a sensor which can be placed either internally or externally depending on the patients pain tolerance and comfort level. The sensor records the pelvic floor EMGmuscles activity and displays the information on a computer screen, similar to that of an EKG of the heart. Treatment begins by first obtaining the resting tone or baseline, which is the muscle activity when neither a contraction or relaxation is performed. Tightened, hypertonic muscles will have an elevated resting tone where as a normal resting tone would be less than 2 microvolts. Once the resting tone is obtained, a relaxation goal that is achievable for that specific patient is set. The patient may be instructed on several relaxation techniques such as, a pelvic drop (the opposite of a kegel), deep breathing, meditation, body scan relaxation etc. During the down-training, the display provides visual as well as auditory feedback to both the patient and therapist, showing whether the muscles are actually being relaxed or not. Once the patient can see the evidence on the screen that they are able to control their muscles, the reconnection between their brain and body starts. Stress, pain and anxiety are all mental factors that can influence our body and heighten our nervous system that results in tightening of muscles. The reconnection to control the relaxation of muscles with the brain is pivotal for successful treatment. Our mind and body are never separate from one another, but are instead connected in every way.

General stress reduction, whether through yoga, meditation or reducing life stressors are all important treatment pieces. Yoga poses such as, garlands, down dog, pigeon and happy baby, to name a few, provide an excellent stretch for the pelvic floor. Yoga has also been shown to reduce overall stress and increase one’s awareness of their body. Again, regaining the connection between the mind and body. 

Manual techniques for trigger point release and internal stretching are also used to promote tissue mobility and release muscular tension. Vaginal dilators, which come in a gradual increase of sizes, provide a stretch to the pelvic floor muscles and can be very useful for treating dyspareunia. Proper progression through the different sizes is important so that the muscles can be properly desensitized and stretched at incremental levels. Patients can use dilators in the comfort of their own home which is a great way to increase the patients involvement in their care.  

All of these methods for treatment, among others, may be used to treat a shortened pelvic floor. Treating chronic pain is never easy and many areas need to be considered. In regards to the pelvic floor, gastrointestinal, reproductive, mechanical, gynecological and psychological factors may be contributing to the pain, making treatment difficult, but not impossible. This is an area of physical therapy that needs more awareness. No longer should it be undiagnosed and left untreated, the pelvic floor is an area we all need to discuss. And don’t forget, men have a pelvic floor too!



What is Mindfulness?


Being mindful has lost its stature in our society. We are all guilty of walking with headphones in, talking/texting on the phone or having a wondering mind and we fail to recognize our surroundings. Being mindful is having full awareness of the present moment, not allowing anything to distract you from that moment. Thich Nhat Hanh, a Buddhist monk who has significantly influenced me, once said, “Mindfulness is the energy of being aware and awake to the present moment. It is the same as happiness.” Mindfulness brings your body and mind together. It is the act of living in the moment and not worrying about events in the future or regretting events in the past. The only moment that matters is the current moment.

Being in the present moment does not require you to sit in an incense filled room, cross-legged and uncomfortably trying to erase your mind, it is as easy as feeling your feet hit the ground when you walk, or being present and aware as you drive or even wash dishes. The act of meditation is to quiet your mind, it doesn’t require you to sit for hours. One can meditate while they walk by simply feeling their feet hit the ground, focusing strictly on the act of walking rather than, how long it is to your destination, what the work day will bring or what your will be doing over the weekend. Being aware that you are walking and simply focusing on the movement of your legs and the pressure on your feet will awaken you to so many of your current surroundings. Maybe you start to notice the beauty in the architecture of your city, the dew on the grass or the smell of the coffee shops.

Mindfulness plays a role therapeutically as well, and I consider it while treating all of my patients. For strengthening, in order to feel a muscle contract, especially a muscle you cannot see, you have to be mindful of your body. The brain and body are not separate, they work as one. If your brain is not focusing on the action your muscles are trying to produce, the contraction will not be as strong. Relaxing muscles works in a similar manner and mindfulness now plays an even stronger role. If a mind is constantly wondering, anxious and anticipating future events, muscles will respond by tensing. Remember, the mind and body are not separate, to relax tightened muscles, the brain needs to relax first. Deep breathing for relaxation and encouraging focus of the mind on relaxing the muscles while eliminating any anxious thoughts is one technique I will use. There are many different ways to become more mindful and there is no correct way, finding what works best for each individual is important. It can be hard to teach someone how to relax but once they get it, they essentially become their own therapist.

Mindfulness is wonderful thing, it can help so many realize that events of the past are unchangeable, and the future is unpredictable. If we cannot change the past and cannot predict the future, all of our energy should be spent on the current moment.

Stay present and enjoy the current moment, because there is only one.


Healthy Bladder Habits


Go every 3 – 4 hours, 5-7 times per day

A bladder takes 3 hours to fully fill and can hold 20 oz of fluid. Increased frequency can be due to poor habits, medications or consuming bladder irritants, such as coffee, alcohol, carbonated drinks, spicy foods or citrus fruits to name a few.

Tip: If you feel an urge to go and it has been < 2 hrs since your last bathroom visit, perform a kegel and see if you can maintain without going to the bathroom right away.

Do not go “just in case” JICing

Remember when your mom used to say “You better go to the bathroom now because we won’t be stopping for hours.” Well, she was all wrong. You should only go to the bathroom when you need to, not “just in case” which causes poor bladder habits.

Go for 8 Mississippi’s

Each time you void, the bladder should empty at least halfway. If you’re only counting 4 Mississippi’s, you did not wait for your bladder to fully fill to go.

Sit on the toilet and NO straining

In order to void, the pelvic floor muscles need to relax and the bladder contracts, therefore there should be no need to push. Sitting on the toilet places the PFM in the proper position to relax.

Avoid dehydration

As a good rule of thumb, you should be drinking ½ body weight in ounces of fluid/day and 2/3 should be WATER. Dehydration can lead to increased concentration of urine which our body wants to remove, thus leading to increased urge and frequency.

Tip on Breast Feeding: Drink 2 cups (8oz) of water after each feeding to stay hydrated.

Avoid Constipation

Constipation causes chronic straining and increased pressure on the pelvic floor. Overtime, this increased pressure can lead to PFM weakening, in turn exacerbating urinary incontinence.

Colon englishTip: A stomach massage for constipation, it’s called the I.L.U. To perform, (I) start at your lower left rib, massage down towards your left hip bone. (L) Then massage from the right side of your rib cage to the left and then down to the left hip to make a L shape. (U) Start at your right hip, massage up to the right rib and over to the left rib and down to the left hip. This massage outlines the course of your ascending, transcending and descending colon.


Finding the Pelvic Floor and Understanding Kegels

What is the pelvic floor?

The pelvic floor is a group of internal muscles at the base of your pelvis that lie between the sits bones and run from the pubic bone to the coccyx (tailbone). These muscles act like a sling to support your pelvic organs (bladder, uterus, rectum), assist in urinary and fecal continence, aid sexual function and provide a stable base for adjacent joints. Similar to other muscles in our bodies, these muscles can be weakened or damaged (from childbirth, pelvic surgery or aging) leading to bladder dysfunction, bowel disorders or sexual dysfunction. Pelvic floor exercises can help alleviate disorders such as incontinence or pelvic organ prolapse.

Pelvic Floor

Exercising your pelvic floor muscles – What is a kegel?

Most of us have heard of kegels before and many of us know we should be doing them, but how many of us are doing them correctly? The first step to performing a kegel is to have a sense of what a pelvic floor contraction feels like. Start by thinking about its function; these muscles lift to hold organs andsqueeze to maintain continence, now attempt to lift and squeeze your pelvic floor, imagine you are stopping the flow of urine or holding back gas. Try to lift and squeeze without holding your breath, squeezing your glutes or activating your inner thigh muscles. Some women find these exercises are easiest while lying down, others feel that sitting is easier. Try both and find what’s best for you. Eventually progressing your strengthening to standing against gravity will be the most beneficial for your pelvic floor health.

Why should I exercise my pelvic floor?

Pelvic floor dysfunction can lead to a variety of disorders, including but not limited to, urinary/fecal incontinence, constipation, pain with sexual activity (dyspareunia), chronic pelvic pain, prenatal or postpartum pain or pelvic organ prolapse. 1 in 3 women alone experience urinary incontinence, affecting 25% of young women and 44% to 55% of middle-aged women and postmenopausal women. Additionally, 1 in 7 women ages 18 to 50 experience some type of chronic pelvic pain, of these, 61% have no diagnosis. Pelvic floor physical therapy will help the pelvic floor muscles function optimally in order to reduce pelvic pain, urinary leakage and increase sexual function. Help is available; women do not need to suffer in silence. If you are experiencing any of these symptoms, ask your medical provider about pelvic floor physical therapy.

Pelvic Organ Prolapse

What is it?

The pelvic organs are supported by the PFM, vagina and endopelvic fascia which is a sheet of connective tissue that covers the internal organs. A loss in the support system can result in the descent of one or more of the pelvic organs. Although POP is more common among older women, it can occur in women of any age. Common causes include: vaginal childbirth, aging, obesity, estrogen deficiency (menopause/hysterectomy), connective tissue injury (endopelvic fascia), injury to levator ani muscle (PFM) and chronic straining such as with constipation.


Common symptoms include; a feeling of fullness in the pelvic region, low back pain, urinary/fecal incontinence, inability to fully empty to bowel or bladder and pain with intercourse. Women may state that their symptoms are worse towards the end of the day and better in the morning or while lying down. This is due to gravity’s downward force on the organs and increased demand placed on the PFM.


Prolapse Patient HandoutDiagnosing and staging the degree of prolapse is done via observation of organ descent as the patient performs the Valsalva maneuver (bearing down). The amount of descent is observed and graded 0 – 4 based on organ location in relation to the hymen. Further testing may also be used, such as urodynamic tests or MR Defecography (MRI of the pelvic floor, rectum and sphincter). Classification of the type of prolapse is based on which organ has descended.


Management of POP should include pelvic floor strengthening exercises, pessary inserts, as well as behavioral modification to teach patients how to avoid worsening their prolapse. Prolapse Patient Handout2In particular, patients should avoid activities that increase intra-abdominal pressure, such as heavy lifting and constipation. Pessaries, the mainstay of conservative treatment, are supportive devices that are inserted into the vagina, similar to a contraceptive diaphragm, which acts as a sling to elevate and support the prolapsed organ. Proper training and strengthening of the PFM will encourage stability and support. Enforcing PFM contraction and abdominal stability during lifting, bending, standing etc. can help increased PFM tone and strength to provide increased support for the prolapsed organ.

Will I Need Surgery?

There are many surgical options to correct POP however it is only indicated for symptomatic cases that have failed conservative treatment.

You can now find this handout on the Pelvic Guru site as part of the Pelvic Health Handout Project!


What is Women’s Health Physical Therapy?

I consider myself fortunate to have a profession that is diversified with settings that range from acute care in the ICU, outpatient facilities treating general orthopedic disorders, to more specialized fields such as vestibular rehab and women’s health. A physical therapist typically finds the field they have the most skills and or interest in and practices within that subset. Fortunately, I have found my niche, women’s health, or more specifically, pelvic floor dysfunction.

Women’s health physical therapy is distinctive and specialized. The diagnoses are personal and significantly impact a woman’s quality of life. Many of the women I see are embarrassed, distraught and hopeless; most have been suffering for years never knowing that there was treatment out there for them. This area of physical therapy is not the same as your typical orthopedic setting. Returning to a sport or being able to run again is not the goal for these women. The women I see cannot leave their house due to incontinence. They avoid relationships because they cannot have pain free intercourse, they contemplate surgery to “fix” their incontinence or prolapse day in and day out. These are the women I get to help.  

Who Has Pelvic Floor Dysfunction and How Do You Treat It?

The pelvic floor consists of musclesanatomy_pelvic_floor, connective tissue, nerves and blood supply, same as any other region of the body. The only difference being how one accesses these muscles to accurately evaluate and treat them. Because the pelvic floor is located internally, in order to provide superlative care for patients with pelvic dysfunction it is pertinent to perform an internal assessment. This may seem off putting or alarming to some, but think about in it this sense, a physical therapist wouldn’t treat a strained hamstring without formally assessing the muscle beforehand.

Broadly speaking, there are two presentations of patients, those with a shortened and tight pelvic floor or those with pelvic floor weakness. A weakened pelvic floor can lead to issues with incontinence (urinary and or fecal) and pelvic organ prolapse. A short and tight pelvic floor can cause pain during intercourse (dyspareunia), hip or low back pain, general pelvic pain and sacroiliac dysfunction. In this post, I will focus on the weak pelvic floor but stay tuned, a post on the shortened pelvic floor is soon to come. 

The Weak Pelvic Floor

Incontinence: Weakness can lead to urinary leakage with a cough or sneeze, known as stress incontinence. Others may have leakage once they reach the door, known as “key in door syndrome” or urge incontinence. It is important to note that incontinence is not a normal part of aging and at no point in a woman’s life, no matter how many children she has had it is considered “normal”. Remember that the pelvic floor’s function is to squeeze the urethra to hold urine in. Once the muscles are weakened, this mechanism can malfunction causing increased urinary frequency, urgency and leakage.

Stress incontinence occurs when there is an increase in intra-abdominal pressure which causes increased stress on the pelvic floor muscles (PFM), resulting in leakage. Women often complain that they leak when they laugh, run, jump, cough or sneeze. Sound familiar moms? Stress incontinence is common not only with postpartum women, but also among gymnasts (yes this happens to young women too!) and cross fit trainers (don’t get me started). Seems not so fun, right? But the good news is, you most likely do not need surgery or medication, you need kegels!

Remember the “gotta go gotta go gotta go right now” commercial? Well, it pretty much sums up urge incontinence and overactive bladder. Women with urge incontinence and urinary frequency or overactive bladder (OAB) often state that they feel a sudden and intense urge to go. Typically there are triggers that precipitate the urge such as running water or coming home and putting the key in the door. Leakage occurs due to the bladder contracting at an inappropriate time. In addition to pelvic floor strengthening, women with urinary incontinence also benefit from retraining bladder habits and behavioral modification, which I delve into further here.

Prolapse: Another common diagnoses seen as a result of pelvic floor weakness is pelvic organ prolapse. A prolapse occurs when a pelvic organ (ie: bladder, rectum or uterus) drops and pushes against the walls of the vagina. This can be very devastating and typically occurs after a long labor, menopause, hysterectomy and even chronic constipation. Women will typically complain of pelvic pressure, pain in their low back, inability to fully empty their bladder or pass a bowel movement. Pelvic floor strengthening plays a vital role in regaining the support system in order to reduce current symptoms and prevent further progression. Pessaries, which are internal devices that are placed into the vagina to support the prolapsed organ may also be used in addition to strengthening as conservative treatment. In severe cases, surgery may be required.

How Physical Therapy Can Help

My goal with this post is to bring increased awareness to these issues, not to frighten women into doing their kegels. A doctor can instruct their patient to go home and perform kegels but studies have shown that verbal or written instruction is not adequate for patient instruction. Bump et al’s study found that of 47 women tested after being given a brief description on PFM contraction, 40% had an ineffective effort. Furthermore, 25% utilized a technique that could actually promote incontinence.

Physical therapy that specializes in pelvic rehabilitation can help manage pelvic muscle dysfunction. A physical therapist can instruct proper strategies for muscle activation and immediately assess for effective technique. Understanding proper contraction and relaxation of the PFM can improve outcomes and significantly impact a patient’s quality of life.