Constipation

What is constipation?

Constipation is characterized by less frequent, hard, or difficult-to-pass stools¹. It may be accompanied by other conditions, such as transient proctalgia.

What are the causes of constipation?

Constipation may be related to the functioning of the intestine or the muscles that expel stool, to certain medications, or to a^{medical condition.², ³}

• Secondary cause: Constipation sometimes accompanies another condition, such as a disorder of the nervous system, the intestines, or the thyroid. The evaluation also takes emotional factors into account, without assuming that they alone explain the symptoms.
• Some medications slow down bowel movements and can cause constipation; opioids used for pain are the best known⁴. If you’re taking any, talk to your doctor or pharmacist before making any changes.
• Functional cause: The bowel or bowel movements are difficult, but there is no underlying lesion causing the problem. A diet low in fiber may contribute to the symptoms². Stool movement may be slow, or the muscles may have trouble coordinating the evacuation³. Dehydration can also make it worse, especially when usual fluid intake is insufficient, but drinking more than needed does not always improve^{constipation5, 6}.

What are the symptoms of constipation?

Symptoms of constipation include hard stools, straining during bowel movements, less frequent bowel movements, and a feeling of blockage or incomplete emptying. Hemorrhoids or anal fissures may also be present.

• Hard stools or stools in small pieces;
• Infrequent bowel movements (often fewer than three times a week)², that take a long time to pass or leave you feeling as though your bowels haven’t been fully emptied.³
• Significant straining, frequent changes in position, or the need to use one’s fingers to pass stool: these difficulties should be described to the healthcare professional, who may also reconsider the use of laxatives;
• Feeling of incomplete emptying, blockage at the exit of stools;
• A weak or absent urge to have a bowel movement;
• Hemorrhoids, which are swollen veins around the anus, or anal fissures, which are small tears in the skin of the anus.

Your physical therapist can help you identify these challenges and work with other relevant professionals to choose the appropriate treatment.

How is constipation diagnosed?

A healthcare professional diagnoses constipation based on your symptoms, habits, medications, and a physical exam. A doctor may order tests depending on the signs observed or if initial treatments are not sufficiently effective. Some tests measure the pressure of the muscles around the anus or the ability to pass a small balloon; they are used to identify a defecation disorder.³

How can physical therapy help treat constipation?

Physical therapy for perineal rehabilitation can help adults with constipation better coordinate the muscles involved in passing stool when a disorder in this coordination has been confirmed. This problem, known as defecation dyssynergia, can occur when the pelvic floor muscles contract or fail to relax properly during a bowel^movement.^{⁷, ⁸} The physical therapist tailors advice, positions, and exercises to the specific difficulties observed. Training may use sensors to show you the pressure or activity of your muscles as you learn to coordinate them. This method is called biofeedback.

Your physical therapist will assess your habits, your posture while using the toilet, your breathing, and the way you contract or relax your pelvic floor. These observations help guide treatment and determine the need for further medical evaluation; however, they do not always identify a single cause.

The pelvic floor is a group of muscles at the base of the pelvis. It supports the bladder and the rectum, the final section of the intestine. The levator ani muscle also plays a role in urination, bowel movements, and sexual function⁹.

The puborectal muscle is part of the pelvic floor. It works with the anal sphincters—the muscles that control the opening and closing of the anus—during bowel movements⁹.

To have a bowel movement, the pelvic floor muscles must also be able to relax, not just contract. This relaxation helps expel urine and stool, along with the other muscles and nerves involved¹⁰.

Based on the assessment results, your physiotherapist will:

• Will suggest habits tailored to help make bowel movements easier;
• Will help you try out positions and ways to have a bowel movement that are suited to your challenges;
• Will teach you exercises to help you better coordinate muscle contraction and relaxation, which you can also practice at home;
• We may discuss manual therapy for the abdomen or pelvic floor muscles, depending on the examination and with your consent.

A trial involving 74 adults with functional constipation compared four weeks of abdominal massage with a sham treatment, with both groups receiving lifestyle counseling. The massage group showed greater improvement in symptoms, bowel movement frequency, and quality of life. These short-term results pertain specifically to abdominal massage and do not demonstrate the effect of all manual pelvic floor techniques.¹¹

The physical therapist may refer you to a doctor right after the evaluation if your symptoms warrant it, or during treatment if you are not making sufficient progress. Medication or other treatments may be used to supplement your rehabilitation.

When should you see a physical therapist for constipation?

A physical therapist can assess your difficulty passing stool, your sensation of blockage, or your repeated straining, especially if a pelvic floor disorder is suspected. The physical therapist can work with your doctor to determine the exact nature of the problem.

You can schedule a physical therapy appointment without a prior medical consultation. However, some symptoms require prompt medical evaluation.

See a doctor right away if constipation is accompanied by blood in the stool, anal bleeding, or unexplained weight loss. Constant abdominal pain, vomiting, a fever, or an inability to pass gas require immediate medical attention. Do not assume that bleeding is caused solely by hemorrhoids.¹²

What can you do at home to relieve constipation?

Dietary fiber, adequate hydration, and regular physical activity can help relieve constipation. A comfortable position on the toilet can also make it easier for some people to have a bowel movement.

• Gradually add high-fiber foods to your diet and drink as needed. If a doctor has restricted your fluid intake, follow those instructions and discuss your constipation with him or her.
• Get regular physical activity, within your limits.
• In the bathroom, you can try using a small, stable stool under your feet, with your knees slightly higher than your hips, while leaning forward slightly. Maintain this position only if it helps you and remains^{comfortable .¹³, ¹⁴} The two studies cited involved healthy volunteers. A trial involving 41 people with constipation did not observe any improvement with a stool during a balloon evacuation test. Therefore, this position may not be suitable for everyone.¹⁵

To learn more

• Canada's Food Guide
• Physical Activity Guidelines for Adults Aged 18 to 64

References

1. You HS, Kim SE, Kim YS, Lee JY, Cha B, Na W, et al. [Functional Constipation]. Korean J Gastroenterol. 2025;85(4):467-474. ↩ Back to text
2. Jamshed N, Lee ZE, Olden KW. Diagnostic approach to chronic constipation in adults. Am Fam Physician. 2011;84(3):299-306. ↩ Back to text: 1st, 2nd, 3rd citations
3. Bharucha AE, Lacy BE. Mechanisms, Evaluation, and Management of Chronic Constipation. Gastroenterology. 2020;158(5):1232-1249.e3. ↩ Back to text: 1st, 2nd, 3rd, 4th references
4. Gyawali B, Hayashi N, Tsukuura H, Honda K, Shimokata T, Ando Y. Opioid-induced constipation. Scand J Gastroenterol. 2015;50(11):1331-8. ↩ Back to text
5. Arnaud MJ. Mild dehydration: a risk factor for constipation? Eur J Clin Nutr. 2003;57 Suppl 2:S88-95. ↩ Back to text
6. Wood LN, Markowitz MA, Parameshwar PS, Hannemann AJ, Ogawa SL, Anger JT, et al. Is It Safe to Reduce Water Intake in People with an Overactive Bladder? A Systematic Review. J Urol. 2018;200(2):375-381. ↩ Back to text
7. Rao SS, Valestin J, Brown CK, Zimmerman B, Schulze K. Long-term efficacy of biofeedback therapy for dyssynergic defecation: a randomized controlled trial. Am J Gastroenterol. 2010;105(4):890-6. ↩ Back to text
8. Chiarioni G, Heymen S, Whitehead WE. Biofeedback therapy for dyssynergic defecation. World J Gastroenterol. 2006;12(44):7069-74. ↩ Back to text
9. Gowda SN, Bordoni B. Anatomy, Abdomen and Pelvis: Levator Ani Muscle. StatPearls. 2022. ↩ Back to text: 1st, 2nd references
10. Bharucha AE. Pelvic floor: anatomy and function. Neurogastroenterol Motil. 2006;18(7):507-19. ↩ Back to text
11. Doğan İG, Gürşen C, Akbayrak T, Balaban YH, Vahabov C, Üzelpasacı E, et al. Abdominal Massage in Functional Chronic Constipation: A Randomized Placebo-Controlled Trial. Phys Ther. 2022;102(7). ↩ Back to text
12. National Institute of Diabetes and Digestive and Kidney Diseases. Symptoms & Causes of Constipation - NIDDK. ↩ Back to text
13. Sikirov D. Comparison of straining during defecation in three positions: results and implications for human health. Dig Dis Sci. 2003;48(7):1201-5. ↩ Back to text
14. Modi RM, Hinton A, Pinkhas D, Groce R, Meyer MM, Balasubramanian G, et al. Implementation of a Defecation Posture Modification Device: Impact on Bowel Movement Patterns in Healthy Subjects. J Clin Gastroenterol. 2019;53(3):216-219. ↩ Back to text
15. Trieu RQ, Prott G, Sequeira C, Jones M, Mazor Y, Schnitzler M, et al. Using a footstool does not aid simulated defecation in undifferentiated constipation: A randomized trial. Neurogastroenterol Motil. 2023;35(7):e14580. ↩ Back to text

Our physical therapists defined the research strategy, plan, and clinical content of this article. An AI tool assisted with the literature review and text editing to ensure consistency in content and writing style.