Shy Bowel

Parcopresis or psychogenic fecal retention are the technical terms for holding your poo in when you should be pushing it out. It involves difficulty – or sometimes the complete inability – to have a bowel movement in a public toilet, due to an overwhelming fear of perceived scrutiny. People are going to hear what’s going on, they’re going to smell what’s going on, they may even see what’s going on, and you’re going to be exposed! In severe cases, the difficulty or inability can occur even in your own home. Shy bowel is classified as a psychological condition, but there are important physiological mechanisms in the digestive tract that are behind it. In this episode, I’ll explain the critical importance of dropping it while it’s hot – especially If you struggle with constipation or bowel irregularity.

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On today’s show: something that a lot of people suffer from without realizing it. It’s a really common GI problem – but most people don’t have any idea why it’s happening.  

To understand the origins of this condition, let me tell you about a patient of mine, Sherry. Sherry struggled with constipation her entire adult life, and most of her teen years. When she first came to see me, she had already tried a bunch of different supplements and a prescription medication to try and get things moving. Nothing helped. I put her on a tablespoon of fiber in the morning, 400 mg of magnesium in the evening, and an “osmotic cathartic” at night – that’s something that helps to draw water into the stool to make it softer and easier to pass. 

I told Sherry she needed to drink at least half her body weight in water every day – she weighed 150 pounds so that was about 75 ounces. I also made sure she was moving around enough to stimulate peristalsis – those wavelike contractions in your gut that propel things through. And I want to emphasize these two things: hydration and movement. A lot of gastroenterology is really just plumbing – and the best way to clear a clogged pipe is to run a lot of water through it. Same for the GI tract! So if you’re constipated – make sure you are flushing out your digestive pipes with lots and lots of water. Now the 2nd point about movement and gut peristalsis; let me sum it up this way: if you’re not moving – neither are your bowels!  

Sherry was doing all of it: hydrating, exercising, plus eating tons of fiber – and still no action. As I got to know Sherry better, it became clear that this was no ordinary case of constipation. There was something more complex at the heart of her inability to move her bowels. And then one day, after about a year of taking care of her, Sherry told me a story from her childhood that explained everything. 

Here’s what happened: she was in 8th grade and looking forward to going to the same sleepaway camp in the Catskills that both her older brothers had attended. Summer finally came and Sherry was one of the first campers to arrive. As part of the initial get to know each other festivities, the second day at camp involved a long hike with Sherry’s all-girls cabin, and the cabin next door which was all boys. They left early, and Sherry kind of felt like she had to have a bowel movement that morning – she had a little urge (you know, that “knock, knock” – I think someone’s at the door) – but she just didn’t have enough time, so off she went with her fellow campers. A couple hours into the hike, she really started to feel like she had to go – that knocking got a little louder and a lot more urgent – so when they stopped for a break, she thought: “OK, now’s my chance!”. She put some tissue in her pocket and went off and found an isolated spot in the woods, surrounded by trees for privacy, and she proceeded to squat down and do her business. 

And yes, you know what happened next….. A group of fellow campers – all boys – saw her leave and followed her. They came across Sherry with her underwear and pants down in the middle of having a bowel movement. The stool was literally exiting her bottom when they arrived – half in half out. Now, imagine what that felt like for a 13 year old girl. Indescribable. Horrendous for most adults, much less a teenage girl. Sherry was so humiliated by the experience that as soon as they got back to camp she called her parents, told them she was sick, and had them come pick her up and take her home. She never told a soul what had happened, she never went back to camp, and she never had a normal bowel movement again. The feeling of shame associated with moving her bowels was so firmly ingrained in Sherry that day, that from then on she could only have a bowel movement in absolute privacy, with no one around, including her own husband and children. She would wait until late at night when everyone was asleep to use the bathroom, not even flushing the toilet until the morning because she was so afraid of being discovered. Moving her bowels at work, in a restaurant, or when her family was around was totally out of the question.  

Sherry had an extreme case of a medical condition called “shy bowel”. The technical term is parcopresis, and it’s also known as psychogenic fecal retention. It involves difficulty or sometimes the complete inability to have a bowel movement in a public toilet, due to an overwhelming fear of perceived scrutiny (a fear that people are going to hear what’s going on, they’re going to smell what’s going on, they may even see what’s going on). In severe cases of shy bowel, the difficulty or inability can occur even in your own home, like with Sherry. 

Shy bowel is different from the normal embarrassment many people have about bowel movements – I mean, no one wants to have a bowel movement in public, but with shy bowel, the extreme need for privacy can impose severe lifestyle limitations. 

Shy bowel is classified as a psychological condition, but there are some important physiological factors that can cause it. One of those is holding; and one of the first questions I ask constipated patients is whether they were holders when they were younger. In other words: when they felt an urge to go, did they frequently ignore it? Kids spend a lot of time at school where the bathrooms may not be that clean or that private. A lot of my patients tell me they never, ever used the bathroom at school when they were kids, and as a result, they now struggle as adults with constipation.

But what’s the link between shy bowel and constipation? Let’s do a quick review of what happens when you have a bowel movement (this is going to be much less gross than you think!).

Your rectum is a reservoir that stores the stool before it exits. It’s about six inches long, with a diameter of one to two inches and it’s super distensible – like a balloon, it can inflate to dramatically increase its storage capacity. How good is your rectum at holding stool? Really good: the volume at which most people can feel a bowel movement in their rectum is about 1 and a half tablespoons, but the maximum volume is about 28-30 tablespoons – and that’s a lot of stool. So, that sounds pretty good: your rectum isn’t that big, but it can expand to 20 times its normal size, so you can wait around all day to have a bowel movement and that shouldn’t be a problem, right? No. Wrong. Big problem. 

Let me explain: two sphincters, which are essentially muscles, wrap around your rectum like a sheath and they are responsible for the important job of keeping your stool in and getting it out. Your INTERNAL sphincter is under involuntary control, like your blood pressure or heart rate. It’s normally in a contracted state, and that keeps things closed tight to prevent leakage. When it relaxes, that lets the stool out. Your EXTERNAL sphincter is under voluntary control – you can relax or contract it whenever you want, depending on whether you’re trying to push stool out, or hold it in. 

Having a bowel movement involves BOTH voluntary and involuntary actions. Your internal sphincter relaxes to release the stool, and your external sphincter contracts to push the stool out. When it’s working well, it’s a beautiful thing: you feel the urge, you go sit on the pot, and the stool glides effortlessly from your rectum into the bowl. 

But here’s the thing – for it to work well, you MUST heed that call when it first happens. Ignoring the urge and holding your stool in when it’s trying to come out can cause all sorts of problems, including something called reverse peristalsis, where instead of exiting, your stool goes back up into your colon in the wrong direction (prairie dogging). The longer you hold your stool in, the more water gets reabsorbed from it, and the harder and drier it gets, making it even more difficult to push it out. And you’ve probably experienced that – after holding your stool all day what finally comes out is a dry hard fossilized poop. When you do this over and over, you confuse your sphincters and end up retraining your muscles to do the opposite of what they’re supposed to be doing, so that when you actually want to have a bowel movement – you may not be able to.  

Diagnosing my patient Sherry with shy bowel was just the beginning of the journey. It took months of behavioral therapy and physical therapy to retrain her muscles – and her mind – so that she could feel relaxed enough in the bathroom to have a bowel movement. 

Although we often see the foundation for parcopresis laid down in childhood, shy bowel can develop in adults too. When we first got married, my husband was very reluctant to have a bowel movement if I was hovering nearby. And he was totally scandalized by the fact that I could have a bowel movement with the bathroom door cracked open while having a conversation with him. He’s still much more private about bowel movements and passing gas than I am, but I’ve gotten him to relax a little about some of that stuff and his bowel habits have gotten more relaxed too. He still needs the door closed but it’s OK if I’m in the general vicinity. 

When it comes to YOUR bowel habits and staying regular, I want you to remember three things: 

1.     Everyone poos – bowel movements (even ones that are smelly and noisy) are nothing to be embarrassed about. Everybody’s doing it.

2.     If you struggle with constipation and you’ve tried everything, consider looking into physical therapy, biofeedback, or other relaxation techniques to see if that might help

3.     You must heed that call and drop it while it’s hot!

So that’s it for this edition of the Gutbliss podcast on shy bowel.