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Hello Everyone, Here is another edition in the monthly "Amuse-Bouche" series. Just like a morsel (more like an entrée today) compliments of the chef, these small but critical scientific bites are intended to stimulate thinking about health. I hope you enjoy them. Start Me Up Let’s talk about poop. Most of us have struggled with constipation at some point, some of us for years. It is not trivial. It causes despair, touches mood, work, relationships, and exercise. There is plenty of advice, over-the-counter remedies, and pricey stool tests. What matters first is how the system actually works. Our gut is a continuous tube from mouth to anus: esophagus, stomach, small and large intestines, rectum, and anal canal. It is lined by mucosa and supported by its own nerves, muscles, blood supply, and immune tissue. Its jobs include digestion and absorption, reclaiming water and electrolytes, defending the barrier, protecting us from infections, making hormones and nerve signals, moving contents, and hosting the microbiome. Stool, or feces, is the end product of digestion: about 75 percent water and 25 percent solid. The solid portion is mostly microbes, undigested plant matter or fiber, shed intestinal cells and mucus, bile pigments, salts, lipids and proteins, and trace metabolites. We take what we need and expel the rest. Constipation is a big deal. In some people it can precede a Parkinson’s disease diagnosis by more than a decade. It can also result from serious problems such as bowel obstruction, cancer, or Hirschsprung’s disease. If constipation comes with abdominal pain, weight loss, nausea, vomiting, bleeding, fever, or chills, contact your doctor immediately. Today we will talk about the more common but certainly not trivial patterns: • Dyssynergic defecation, also called outlet constipation. Bowel contents arrive, but the anal sphincter and pelvic floor fail to relax or they tighten paradoxically.
• Inadequate defecatory propulsion. Intestinal movement and signaling are insufficient, so transit is slow.
Constipation is often framed as a supply issue, not enough fiber or water. In reality, it sits at the intersection of microbiome ecology, mucus and immune barriers, colonic motility, pelvic floor coordination, nutrition quality, overall muscle mass, and daily habits such as sedentary time, rushed mornings, and ultra-processed foods. The colon is less a pipe and more a city. There is traffic, which is transit. There are gatekeepers, the pelvic floor. There are municipal services, mucus and immune surveillance. There is a workforce, the microbes, turning leftovers into useful outputs. Stool is data, not just waste Form and ease reflect transit time, water handling, and fermentation balance. When transit slows, the colon reabsorbs more water and stool hardens. pH in the lower colon rises. Microbes shift from carbohydrate fermentation, which produces helpful short-chain fatty acids (SCFAs) like butyrate, toward protein breakdown, which produces ammonia, phenols, and indoles. That chemistry worsens odor and gas, feeds discomfort and shows up on stool tests. Two people on similar diets can have very different stool signatures because transit and pH differ. Stool reflects what passes by the intestines; it is not a full map of the gut. This is why direct-to-consumer microbiome tests are unreliable. Finding Candida or a specific bacterium does not prove disease. Change pace and chemistry and the stool follows. Mucus is an immune barrier, a city wall A healthy colon maintains two mucus layers. The inner, dense MUC2 layer keeps microbes at arm’s length. The outer layer houses them. Microbial fermentation of fiber and resistant starch, a type of resistant carbohydrate, in foods such as lentils and overnight oats produces SCFAs. SCFAs energize colonocytes and tighten cell junctions so there is less leakiness and fewer inflammatory molecules crossing into the body. Feed the wall or the wall gets used as food When fermentable foods are scarce, microbes eat mucus, thinning the wall. Emulsifiers common in ultra-processed foods and gel vitamins/capsules, for example carboxymethylcellulose and sometimes polysorbate 80, thin the mucus. SCFAs drop, diversity falls, and post-meal symptoms rise. A leakier barrier increases microbial components in circulation and raises inflammation. The gut neuromuscular system: timing beats force Most of the day the colon mixes contents. Long-distance propulsion arrives in bursts called high-amplitude propagating contractions (HAPCs), often after waking and after meals. Defecation requires the pelvic floor and external anal sphincter to relax as lower intestinal pressure rises to push stool down. If the doors do not open, which is pelvic floor dyssynergia, pushing harder just jams the lobby. When transit slows, protein breakdown increases in stool that lingers in the lower colon, disturbing pH and slowing the colon further. First-line treatment is skill, not pills The pelvic floor is a muscle and fascia hammock at the base of the pelvis, the bottom part of our core. During a bowel movement the pelvic floor relaxes and drops while colonic waves deliver stool to the rectum. The rectum is usually empty; delivered stool creates urge and should lower anal sphincter tone so evacuation is easy. When coordination fails, pressure meets a shut door. In that situation, simply adding fiber can worsen the traffic-jam. Pelvic floor physical therapy (PT) teaches relaxation at the right time and correct evacuation technique and is a mainstay when dyssynergia is present. You got the moves Movement, especially in the mornings and after meals, cues the colon’s waves. A small breakfast, coffee if you like, initiates HAPCs. Break up long sits with brief walking. Positioning matters to muscle function. The puborectalis muscle slings around the rectum to maintain continence. On a standard Western toilet, it cannot relax fully to make the colon a straight shot and maintains a bend. We can improvise with a stool under the feet or using a Squatty Potty which was created by the Stanford University pelvic floor division (their website is a great resource). Or use a footstool to keep knees above hips, lean forward with a soft jaw and belly and straighten this bend. Breathing slowly through the nose, humming and relaxing helps the anal sphincter release. If the sphincter not feel relaxed, try raising the knees a bit more. Straining or just adding fiber just increases the traffic-jam here and worsens the problem. Muscle mass always matters. Frailty, low protein intake, sedentary time, and a history of straining reduce both intestinal wall and pelvic muscle mass and performance. More protein, especially from legumes and beans, supports muscle mass and provides the right type of fiber. The Modern Life Stress tightens the outlet i.e. the pelvic muscles and the anal sphincter. During the SARS-CoV-2 (COVID-19) pandemic, I saw many more people present with constipation, urinary problems, and pelvic pain in my office. COVID pelvis entered the lexicon. Treatment strategies here included stress reduction, less sedentary time, and referral to pelvic floor PT to restore coordination. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen, alcohol, processed and sugary foods, and repeated antibiotics disrupt signaling and the microbiome. The crew, our microbiome, improves when fed diverse plants and resistant starch. Think lentils, overnight oats, and other legumes. Processed plant-based products do not count. Emulsifiers thin mucus. Antibiotics lower SCFAs; use antibiotics only when absolutely necessary. If you need them, increase overnight oats, lentils, psyllium, minimize processed foods, and definitely take short post-meal walks, if you don’t already. Probiotics are not a shortcut. If pH and diet are off, swallowing bacteria will not fix the terrain. Improve conditions with prebiotics and fiber, then the microbiome will thrive. No one should suffer Sophisticated and effective treatment exists for constipation. We match treatment to the cause and measure with tests when needed. If the anal sphincter cannot relax, pushing harder causes pain, hemorrhoids, fissures, and diverticulosis. Pelvic floor PT reduces outlet tone and retrains coordination. For fissures and hemorrhoids, a topical calcium-channel blocker such as diltiazem can lower pressure and aid healing while physical therapy works its magic. If outlet coordination is fine yet transit lags, we assess colonic transit and consider motility agents once fundamentals are in place. If you are still straining, feeling blocked, using your hands, or never feel finished after several weeks of PT and lifestyle change, it is time to test. High-resolution anorectal manometry (pressure map) and a seated balloon expulsion test show whether the anal sphincter relaxes on cue. Defecography imaging can reveal a large rectocele or internal prolapse where stool can get stuck. For outlet or coordination related constipation, biofeedback-based pelvic floor PT is the gold standard of treatment. Ask your provider for a referral to colorectal surgery if things are not improving with the above measures. This does not mean surgery; most care is non-surgical. Pin this on the fridge Morning: breakfast, footstool, slow nasal breathing, relax jaw, face, and body. Try humming. If no result in a few minutes, walk 10 to 15 minutes and try again. Abort at the first sign of straining.
Daytime: break up long sits even with a few minutes of movement.
Kitchen: psyllium, lentils, overnight oats, legumes and whole grains that build resistant starch.
Mindset: coordination over force. Gentle, super slow nasal breathing and humming. Coda: the logistics lesson In 1812 Napoleon drove a vast army into Russia seeking a quick, decisive battle. The Russians strategized, burned food supplies, starved Napoleon’s horses and soldiers, and let a bitter winter finish the job. Napoleon eventually had to retreat and lost hundreds of thousands of men. Only about 10,000 of 420,000 soldiers made it back. There is a great infographic available online which is one of the first and still one of the best ever created. Consider checking it out. Napoleon’s army did not fail for lack of courage. It failed because he did not care for it. He pushed hard without securing food, shelter, protection from the cold, or a plan that protected his troops. The result was an army that could no longer serve him when he needed it most. Our gut works the same way. The army is our microbes, mucus, nerves, and muscles. If we feed it, for example psyllium, overnight oats, and lentils that provide resistant starch, protect it, for example limiting emulsifiers and processed food and using antibiotics only when absolutely necessary, shelter it, for example regular meals and a predictable bathroom schedule, and use the muscles correctly, for example relaxing the anal sphincter and pelvic floor with PT when needed, it serves us reliably. Fix the logistics, and the system works. Care for the army, and the constipation often takes care of itself. Want to sign up for your own monthly Amuse-bouche op-ed series, in case this was forwarded to you? Go here. Consider forwarding this to a loved one-it may help someone you care about. Medical disclaimer: This article is education, not medical advice. Please contact your medical provider or a certified dietician for advice.
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