Correct Emptying Technique
Achieving the correct emptying technique requires good Normal Bowel Habits as well.
Many people experience difficulty with passing a bowel motion. Common symptoms include:
- Needing to strain to start and/or finish a bowel motion
- Feeling incomplete emptying following a bowel motion
- A sensation of a blockage before or during a bowel motion
- The need to place hand or finger support on the perineum (area between the vagina and back passage) or inside the vagina to assist a bowel motion to pass.
- The need to use fingers to stimulate the anus (back passage) and/or assist emptying the rectum.
These symptoms can be caused by:
- Poor relaxation of the anal and pelvic floor muscles
- Incorrect use of the abdominal muscles to assist with expelling the bowel motion
- Changes in the supports around the perineum, vagina or back passage
Your Physiotherapist will be able to assess your bowel emptying technique in a number of ways:
- They may ask to imagine you are passing a bowel motion whilst sitting on a chair and watch the way you are positioning your body and using your tummy muscles. Your Physiotherapist may also be able to place a hand on your tummy and assess whether you are using your abdominal muscles in the correct way.
- They may perform a vaginal and rectal examination to assess how your pelvic floor muscles are moving during a simulated attempt to pass a bowel motion, as well as determine whether the surrounding support structures are working well.
- They may use an assessment and biofeedback tool called Rectal Balloon Therapy, to test your rectal sensation and assist in retraining your bowel emptying technique.
Effective bowel emptying involves:
- Identifying bowel urge and responding in a timely manner if a toilet is available
- Relaxing the muscles around the anus promptly and completely
- Effective use of the diaphragm and abdominal muscles to expel the bowel motion.
Learning to coordinate and control these muscles takes time and patience!
Your Physiotherapist will help break this down into smaller tasks to help you succeed in achieving better bowel emptying technique, and reduce the negative side effects of straining to pass a bowel motion.
The 'Brace and Bulge' Technique
Firstly, your Physiotherapist will teach you the correct positioning for sitting on the toilet. This is detailed in another handout you will be provided - Normal Bowel Habits.
Once you have found the correct position for sitting on the toilet, you must learn the correct technique to expel the bowel motion with minimal straining. This technique is called the 'Brace and Bulge'. It is best to learn the two different components separately and feel confident practicing each on its own, before combining them together.
The 'Brace'
The 'Brace' component of this technique involves learning to increase the pressure inside your abdomen using your diaphragm and side abdominal muscles, rather than drawing in your front abdominal muscles. Drawing in your front tummy muscles causes the anus to tighten, therefore making it even harder for stool to pass.
'Bracing' involves:
- being able to take deep breaths using diaphragmatic breathing (please go to Diaphragmatic and Bibasal Breathing to learn more about this technique)
- pausing at the end of a breath in and widening your waist to the sides to create an increased pressure inside your abdomen.
To help learn the bracing technique:
- sit on a firm chair with your hands firmly in your soft waistline just above the level of your belly button and between your ribs and hip/pelvis bones.
- take some deep diaphragmatic breaths, and pausing at the end of a breath in,
- attempt to push your waist muscles out to the side,
- hold your hands still and firmly in place to feel for the movement small widening action.
- if this is not effective, you can try:
- wrapping a towel around your waist and providing a firm squeeze, then try to push your waist muscles sideways into the pressure of the towel.
- make a deep 'moooo' or 'Sssssss' sound with your voice - this can assist with diaphragm 'plunging' down towards your bowel to help gently initiate a bowel motion.
Listen to the recording at the bottom of this page to guide your practice.
The 'Bulge'
The 'Bulge' component of this technique involves learning to bulge your front tummy muscles forwards to keep them from drawing in.
As mentioned above, drawing in your front tummy muscles causes the pelvic floor and anal muscles to tighten, therefore making it even harder for stool to pass.
- Start by sitting in an upright, relaxed position. Think about keeping your chest high and not slouching - this is important to keep your front tummy muscles in a lengthened position.
- Let your tummy 'flop and drop' - let it relax out as much as you can.
- Complete a few deep diaphragmatic breaths. Thinking about letting your breath expand into your tummy may help with this.
- If your tummy muscles are tight, your Physiotherapist may give you some separate abdominal stretches to work on to help achieve a better bulge technique.
Combining the 'Brace and Bulge'
Once you have mastered each of these components, practice putting the two together, seated on a firm chair, with your hands on your waist like in the picture below:
Practice the following steps in order, ideally 2-3 times per day, to assist in perfecting this skill. As you become more confident in using this technique, you will be able to sit on the toilet in the correct posture and use the right muscles without having to place your hands on your waist.
1. Take some deep diaphragmatic breaths.
2. Pause your breathing after a full breath in.
3. Widen your waist muscles out to the side. You should feel the pressure into your hands.
4. Bulge your belly forwards, while keeping your waist bracing to the side.
5. Maintain the bulge of your belly forward as best you can, taking further breaths in as needed, aiming to pause at the end of an inward breath whilst widening your waist to the side.