Anita Rao
One of the fun facts I loved throwing out as a kid was that my dad invented fake poop. Putting it that way is a little misleading, but mostly true. Technically, what he invented was a poop-shaped, silicone device that you can insert — under medical supervision — to help practice engaging the muscles in your rectum. Its name according to the patent is FECUM.
My understanding of my dad's work was pretty limited to the fake poop punch line until the past decade or so, when conversations kept popping up about a new-to-me part of the body: the pelvic floor. Newly-pregnant friends worried about it being suddenly in disrepair. Instagram influencers instructed me to download apps to track Kegel exercises. Turns out, my dad knows a thing or two about this complicated and often troublesome part of the body, and learning about it bears significance for my own health now and far into the future.
This is Embodied. I'm Anita Rao.
We are going to get to my dad and poop talk in just a little bit, I promise, but first, an anatomy lesson.
Ijeoma Nwankpa
The pelvic floor is a group of muscles that sits in the bottom part of our pelvis. So kind of think of it like a hammock, and it goes from the front of your pelvis, so like that pubic bone, up to your tailbone. It works on supporting your abdominal cavity. It works on the sphincters and control of your sphincters — so that's where you urinate or defecate — and then it also works with sexual function.
Anita Rao
Meet Ijeoma Nwankpa. She's a certified specialist in pelvic health, a sexuality counselor, and the owner of the Center for Pelvic Excellence Physical Therapy & Wellness. To be sure you know exactly the region of the body she's talking about, she has a visualization exercise.
Ijeoma Nwankpa
The easiest way I always tell people is like: Imagine you're in an elevator. You have to pass gas, and then you kind of squeeze a bit to not let it go in the elevator. Those are those muscles that are working — a little bit of glute — but those are those muscles that are working. That sphincter, your anal sphincter, to make sure nothing comes out, or like when you have to run to the restroom, you squeeze a little bit. Those are that group of muscles as well.
Anita Rao
This interconnected group of muscles that surround our bladder, bowels and uterus are intertwined with nerves and tissue and can be connected to issues ranging from back pain and stool leakage to urinary incontinence and painful sex. The source of these issues can feel like a mystery, until it's not.
Allyson Byers
I was in high school and got my period for the first time and tried to put a tampon in and it was just extremely painful.
Anita Rao
That's Allyson Byers, a writer and editor who specializes in health. The tampon experience was only the beginning for her. After pushing through pain for a while, she went to the doctor to get a pelvic floor exam and a pap smear.
Allyson Byers
I just screamed and cried so much. It was the worst pain I've ever experienced, and she told me: We'll just try again in a few years. I just assumed everyone had this pain, and then as friends started to have sex and talked about wearing tampons, I realized that not everyone experiences the type of pain I was feeling, and I thought maybe I'm just sensitive, or I just need to push through the pain. I did for a lot of years, just trying different things, and I moved to Los Angeles, and I found a gynecologist here, and I was told that it was anxiety and that I just needed to relax. And she even told me that before I engaged in penetrative sex I should drink or take like a Xanax or something, and I felt very weird about that and felt like I didn't want to have to drink or take something in order to have sex and relax. But, I took her advice, and it went terribly. I still had that pain, and finally, it was my talk therapist who suggested pelvic floor therapy and kind of finally found that in my late 20s, after just years of pain and just fear of having sex or putting a tampon in.
Anita Rao
Pelvic floor therapy — I've never been, but everyone I know who has wishes they'd known about it years earlier. In many European countries, it's standard protocol in the postpartum period. Here, most of my friends who've had babies had to figure it out on their own. Like, Erin.
Erin
This was never something that my doctors discussed with me beyond: Don't have sex for six weeks, and we'll talk about birth control after that six weeks comes and goes. And it's just like: Okay, but what about when I bend down? There's like a gravitational pull that kind of hurts. Is that normal? How do you then Google "gravitational pull on pelvic floor," you know? Like, do I know my own anatomy well enough to Google what is hurting?
Anita Rao
I most certainly have put similar medical quandaries into Google hoping it would give me results, but the better thing to do when it comes to a part of your body that's function is so important: seek out professional help. Here's what it was like for Allyson to go to pelvic floor therapy that very first time.
Allyson Byers
I was so nervous to go. I think I just have been so traumatized by all the gynecologist appointments and doctors just doing a pap smear, doing a pelvic exam and not listening to me and my pain. So I went in there very apprehensive, but my physical therapist was great. We actually spent the first half an hour of the appointment just talking about the pelvic floor. I really had no idea of what it was or what it did. Then she asked if it was okay if we did a little tiny, mini exam. She was very upfront about: We can stop whenever, and if anything's uncomfortable, we can just sit and talk again. So I was ready to have that exam, but she just slowly, very gently, inserted her fingers very slowly, and she just talked with me and kept me distracted, and at the end, she was able to tell me: Your muscles are very tight, and it's not all in your head, and it's not just anxiety. You actually have something going on, and that was just so validating to hear that. And it just felt like finally somebody listened and could tell me that there was something actually wrong, and it wasn't just all in my head or made up. I just felt so comfortable and so validated.
Anita Rao
Pain doesn't have to be normal, and even if you've had a baby or two, you aren't destined to pee while laughing or coughing for the rest of your life. These symptoms can be warning signs that your pelvic floor is too tight or too weak.
Ijeoma Nwankpa
Think of the bladder like a balloon — a hard cover balloon — and you have your abdominal cavity, which is more of your lungs. So think of like, if you're exerting yourself or you're holding your breath, you're putting pressure from your lungs or your abdominal cavity on the bladder, and then because you have weak sphincters because the pelvic floor is weak, it's not able to hold the urine in at your urethra. So, it just like squirts out a bit, and there could be degrees where it's like full on 'wet your pants' or like little drops. I would say, as soon as you start noticing that, go see a pelvic therapist right away because it can get worse, and we also find in some places where it can be that your pelvic floor is too tight, which is essentially still a type of weakness that it's not working to it's full capacity and not able to sustain the closure of the sphincters at the urethra, because it's so stressed out all day from being so tight.
Anita Rao
So, if all of this is making you think: Well damn, maybe I should go to pelvic floor therapy. Ijeoma says it's probably worth exploring, and if you have insurance, you may have a set of sessions that are covered as long as you get a referral. If you don't have insurance, there are also clinics, like hers, that take cash and some that have sliding fee scales. For some people, one session is enough to get a sense of the problem and steps you can take. For others, you may need to go regularly for a few months. Allyson's process was longer.
Allyson Byers
So I was in PT actually for about eight months. I got dilators the first session, and I met with her once a month. Then, I did dilator work pretty much every other night. I tried to keep it on a schedule, so basically, it was a set of like six dilators, and the smallest one was smaller than a tampon. It was really tiny. I just kind of had to work on inserting those dilators and just kind of getting things loosened up a little bit and those muscles relaxed. So for me, it felt very much like persevering and dedication to this and making it a priority was really what helped my progress.
Anita Rao
Allyson, as we've been talking about — there's a lot of things that are hard to become aware of because things go undiagnosed for a really long time. People don't have a lot of sense of what might be normal and could be experiencing pain, and there's kind of an emotional toll to that as well. You, for so long, we're told "It's just anxiety," or "drink wine." How have you navigated the mental health toll and the emotional toll of ignoring that pain for so long?
Allyson Byers
I feel like now that I missed out a lot of years. I feel like in college when people were going into relationships, or in high school entering relationships, and in college — having sex — I really missed out on all of that. I feel now I'm just getting a very delayed start, and I felt really lonely and depressed and isolated, and I couldn't participate in conversations, and I didn't hear anyone talking about the pain I experienced. And so it just felt very isolating, and that I couldn't — I just felt like there was something wrong with me, or I was just too sensitive, or I didn't power through it enough, and so it felt really depressing and felt very much like: I'm never going to be able to be in a relationship or be able to move past a third date or whatever it may be and have physical intimacy.
And actually, because of PT, it's kind of interesting — because I became more comfortable, I was able to actually explore my sexuality and I came out as queer, and a lot of that is actually because of PT and being able to just become more comfortable with that area down there. I just learned how to explore pleasure, even if it wasn't penetrative sex, and just realizing that there was just so much more there. I lived in fear for so many years, and I lived in isolation for so many years when I really was having something that was pretty common happening to me.
Anita Rao
It is pretty common, and of course shows up for folks with penises too. If you're having pain during intercourse, or pain shooting into your testicles, it could be related to your pelvic floor. Also, if you're big into strength training or weightlifting, you put stress on your pelvic floor pretty frequently.
So we've talked about two of the three main functions of the pelvic floor — sex and urination. So it's time now to bring in the poop expert. I told you that my dad created a patent for fake poop, but he also coined a term that's become a pretty big deal in the pelvic floor world: dyssynergic defecation. I can barely say it, but when he explains it, it makes much more sense.
Satish Rao (Anita's dad)
In simple language, it means that the act of pooping has become uncoordinated. It's no longer a coordinated process. And normally, most of us don't even think a second about how we poop, because we get an urge; we go to the restroom; and usually we take care of the business in less than five minutes, and we're out. This is a normal process for most of us, and we learn this almost serendipitously when we are young, and it essentially sticks with us for the rest of our life. But unfortunately, in about a third of adults, they have never learned this process properly during childhood. And in two thirds of adults with this problem, with dyssynergic defecation, they had normal pooping behavior during childhood, but something changed in adult life, which then led to a new pooping behavior where, unbeknown to them, they have learned to obstruct themselves. This obstructive process or in-coordinate process, what we call is dyssynergic defecation. And there are kind of three components to it. Some people have lost or are unable to generate a good pushing force. Others are paradoxically contracting the anal sphincter muscles that should normally be relaxing to allow poop to come out. And the third group, they are unable to relax the pelvic floor sufficiently to evacuate. So one or more of these mechanics have gone wrong, which then leads to this dyssynergic defecation problem.
Anita Rao
Okay, so we heard from someone who reached out to us who said that she had been struggling for a long time, actually multiple decades — could not figure out what was going wrong. She just kept being told over and over: You have constipation. You need to hydrate more. You need to really work on your digestive system. I found out eventually that she had been suffering from exactly what you just described, and here's a little clip from her. This is Annette.
Annette
I guess I had never really thought about the various muscles that are involved down there. I mean, a lot of us women are used to Kegel exercises and are familiar with that muscle, but the fact that they're whole sets of muscles — some of which have to relax; some of which have to work — because when we toilet train, we don't teach anyone how to like do that stuff. It's all totally unconscious.
Anita Rao
So there's Annette mentioning a lot of what you just said — this recognition that she had to relearn something that she maybe learned unconsciously at one point. So you work with folks doing biofeedback — really a mix of education and physical therapy so people can become more conscious of these muscles and how to coordinate them together. How does this process work?
Satish Rao (Anita's dad)
So, very good question. So first, was really identifying the problem, as you nicely said, and as Annette really described it quite well — and having recognized this problem in the early 90s, we then started really trying to correct this behavioral problem using standard physical therapy techniques, where you maybe used either visual feedback, auditory feedback, and verbal feedback. These are the three feedback techniques — predominantly by using visual and verbal — the visual meaning, we place a probe inside the rectum with pressure sensors, and when the person attempts to poop, there are pressure changes happening in the rectum muscles and the anal sphincter muscle or the opening muscle.
These pressure changes are then displayed on a monitor, and they can see in real time when they are attempting to poop, what is happening to the rectal pressure and the anal pressure — and if there's a normal pattern or there is an abnormal pattern. We show them what those patterns are, and we try and educate them to convert that abnormal pattern to the normal. And the second part of this whole process is not only the visual display, but there are multiple components. We practice with them the right posture sittings. We encourage them to use the squatty potty, which has become very popular — of course — that is elevating the feet. This elevation helps to both anchor the pelvic floor properly and prepares the pelvic floor to evacuate. Then we teach them diaphragmatic breathing techniques, and so the whole thing — we break down the whole act of pooping into five segments, and we work on each of those segments: posture, breathing, relaxation, and so on. The finite thing is very critical because it is not just strengthening the muscle or just relaxing the muscle, it is coordinating the muscle. In other words, upper half of the body is actually pushing and generating a push force. Simultaneously, the lower half of the body, which is the anal sphincter muscle and so on, has to relax. So it is a tricky movement. And for most of us, it's intuitive, as I said at the beginning, but when things go wrong, it is very hard to break this down. These folks have learned a new behavior, and it is our job using biofeedback techniques to unlearn the new behavior, or if they've never learned properly, to now learn a new, normal coordinated process. So that's what biofeedback therapy entails.
Anita Rao
So one of the things that I think about a lot when it comes to poop and the toilet is that it's one of the few experiences that you really only ever have alone. So it's hard to know if something's going wrong, necessarily, or how you compare to other people and what the norm is. What the standard is? And I know from talking with you that that can mean that diagnosis and seeking treatment can take a long time. People come in describing diarrhea, but actually they're talking about stool leakage and they don't want to admit that, or they haven't really come to understand the distinctions of that. So as someone who's working to think about the pelvic floor and how it relates to the bowel, but also how to get people to be able to start these conversations, I'm guessing you have to do some initial work to make people comfortable kind of acknowledging that it's okay. How do you make people comfortable talking about poop in their pooping habits, when it's something that's super private?
Satish Rao (Anita's dad)
Very good question, and it is both an art and a science of practicing medicine. I mean, we can read up a ton in the books and literature, and through Dr. Google, but ultimately, when you have to practice medicine, I think there is an art to the whole thing. So first and foremost, listen to the patient. Second, is to try and figure out what are they trying to say — and many times they may not use the right words. And as I said, diarrhea is an often a de facto word that is used by many people when they also have stool leakage. So very many times I use their terms. For example, I would ask them: Is your diarrhea so urgent, sir, that you don't make it to the restroom? When we use those kinds of phrases and language, they say: Yes, doctor, that is my problem — and this individual's already seen five doctors. Everybody has done a workup for diarrhea, but nobody has done a workup for leakage, and that is this gentleman's problem.
And same with the pooping issues. People will use the word: Oh, doctor, I'm constipated. Immediately [when] everybody thinks of constipation the equation in most physicians or healthcare providers mind is: Oh, they have infrequent bowel movements. Now, studies after studies have now shown that infrequent bowel movement is also infrequent in constipated people. For the majority of patients, when they talk of constipation, it's one of those other symptoms which is: straining to pass stool; using fingers to assist stooling; passing hard stools; a feeling of incomplete evacuation — are much, much more common and prevalent than infrequent bowel movement. But everybody thinks about constipation as infrequent bowel movements, and they're trying to speed up and give laxatives and so on, which is okay. But that is not addressing the root cause, which is dyssynergic defecation that affects 40 percent of patients with chronic constipation. It is a huge number of people who have this problem. And just like Annette, I'm so happy that she got the right care she deserves , but it took a long while, and [there] are so many, many people out there [like her].
Anita Rao
Drink your water. Take your meds, and get yourself to the doctor if peeing, pooping or having sex are not free of pain or discomfort. If you've listened this far, and are sitting there thinking: Well, I'm all good. Great! But there's still stuff you can be doing now, preventatively, to set yourself up for future success. And as it happens, Kegels are not the answer. Here's Ijeoma.
Ijeoma Nwankpa
So there's things you can do preventively. Number one, stop holding your breath with everything. Don't hold your breath to poop. Don't hold your breath. Like, don't hold your breath with exercise and things like that because again, that adds extra pressure to your pelvic floor, and you're just causing it to weaken right away or tighten up on you. Prevention could be just working out and working on your core naturally. So I definitely say teaming up with a personal trainer, someone that will work with you and watch your form, just for a few sessions or even just seeing a pelvic therapist like — Hey, I just want to make sure I'm good and make sure I'm moving forward, because I would say that's the best preventive thing because seeing someone, getting something individualized for you, because this is not like one size fits all because everybody's different. I don't push Kegels on people. Kegels are not for everyone. So we have to make sure you are a candidate for that. So I'm not that PT that does that with people, like: Go do a Kegel. Let's do 100 a-day. No, because then you end up making things worse and it can be unnecessary. So holding your breath and core exercise.
Anita Rao
Embodied is a production of North Carolina Public Radio WUNC — a listener supported station. If you want to lend your support to this podcast and WUNC's other shows on demand, consider a contribution at wunc.org now. Incredible storytelling like you hear on Embodied is only possible because of listeners like you.
This episode was produced by Kaia Findlay. Jenni Lawson is our sound engineer and Quilla wrote our theme music. The show is supported by Weaver Street Market, a worker and consumer owned cooperative, selling organic and local food at four triangle locations in North Carolina, now featuring online shopping with next day pick up: weaverstreetmarket.coop. And remember if you enjoyed the show and want to support us, share about us on social media and tag us. It helps new folks find our show and it means so much. Until next time, I'm Anita Rao — taking on the taboo with you.