Episode 195 - Pelvic Floor Physiotherapy in the Management of Colonic Dyssynergia with Varsha Bhikha
Constipation is a very common clinical problem in our community, characterised by infrequent bowel motions or difficulty passing stool. It affects an estimated 24% of adults, with up to 18% of adults regularly using laxatives. Constipation may be secondary to slow colonic transit, pelvic dyssynergia, pelvic floor disorders associated with organ prolapse, or all of the above.
Slow transit constipation or colonic inertia reflects an abnormally long length of time for waste material to pass through the colon after entering through the ileocaecal valve. This is usually defined as less than three bowel motions per week or a transit time of 72 hours or more. This contrasts with pelvic dyssynergia, also referred to as anismus or obstructed defaecation, which is a functional defaecation disorder in which the muscles involved in defaecation fail to coordinate properly.
Normally during defaecation, the pelvic floor muscles relax, as does the anal sphincter, and rectal pressure increases. In pelvic dyssynergia, the anal sphincter and puborectalis muscle paradoxically contract or fail to relax adequately, resulting in difficulty evacuating stool. This is seen in 25–50% of patients with chronic constipation, is more common in women, and may overlap with features of irritable bowel syndrome. Separately, pelvic floor dysfunction through pelvic organ prolapse, such as rectocele development, is a further mechanism at hand responsible for defecatory difficulty.
Pelvic floor physiotherapy helps target the root causes of bowel dysfunction associated with pelvic dyssynergia by restoring the coordination, strength and relaxation of pelvic muscles. It treats conditions like faecal incontinence, dyssynergic defecation (where the anorectal muscles tighten instead of relaxing, as discussed above) and incomplete colon emptying by using muscle re-training, biofeedback and postural adjustments. Importantly, pelvic floor physiotherapy helps to reduce reliance on medication or surgery and can be highly effective, with rehabilitation and biofeedback therapies showing significant symptom improvement in a large majority of patients.
In more detail, pelvic floor physiotherapists teach patients to properly contract or relax the anal sphincter and pelvic muscles based on the underlying dysfunction. These exercises help release tension and ease obstructed defecation, as well as building strength to prevent faecal incontinence.
Biofeedback techniques employed rely on therapists using anorectal manometry or ultrasonography to help patients visualize and control their pelvic floor activity in real time, improving coordination during bowel movements.
Additionally, simple but highly effective adjustments are suggested to toilet mechanics, such as using a footstool to elevate the knees above the hips and leaning forward or backwards, which helps align the rectum and relax the pelvic floor.
Further, incorporating breathing techniques with central core coordination by learning deep, diaphragmatic breathing and avoiding breath-holding helps to minimize dangerous downward pressure (straining) and relaxes the pelvic floor naturally.
Finally, therapists also review and reinforce the importance of dietary fibre intake, fluid consumption and daily bowel habits to ensure optimal stool consistency.
In our gastroenterology practice, we see pelvic floor physiotherapy and rehabilitation as essential partners in the management of the conditions discussed above. To take a deeper dive into this subject, we are joined by physiotherapist Varsha Bhikha. Varsha completed her Bachelor of Physiotherapy at Monash University in 2013 and then went on to complete a Post-Graduate Certificate in Pelvic Floor Physiotherapy in 2016. She has gained extensive experience in both Musculoskeletal and Pelvic Health Physiotherapy and works in both the maternity ward at Saint John of God Hospital Berwick and within private practice settings. Varsha also has a broad-based experience in treating women prenatally and postnatally and has further expertise in Clinical Pilates. Please welcome Varsha to the podcast.
References:
Park et al., (2026). Biofeedback therapy and pelvic floor physical therapy in the treatment of constipation and fecal incontinence are very different in real-world practice. Neurogastroenterology & Motility, 38(8), e70412. https://doi.org/10.1111/nmo.70412