Rebuilding the Urge: Where to Start
Restoring bowel urgency is one of the most important portions of a bowel retraining program. When a patient no longer has a normal bowel movement urge due to prior postponing, the slowness of their system, chronic use of enemas, or idiopathic causation, helping the patient retore the natural bowel movement urge may be the immediate focus of the treatment.

Restoring defecatory urge is one of the first steps in the treatment process. Reviewing and understanding colon physiology and determining where the focus of treatment should start, especially in complex patients, is key. Synthesizing new treatment ideas and use of modalities to assist with colonic motility can be one of the first steps to help the patient improve their defecatory urge.

For complex cases, this can involve mapping out where motility is most compromised. Is it a problem of peristalsis? A nervous system misfire? Inflammation in the gut interfering with communication pathways? Or is it something else?

Here’s where innovative thinking and a comprehensive approach come into play.

Treatment Tools and Modalities to Restore Motility
There are many ways to support and enhance colonic motility and restore bowel urgency. These can include:

• Neuromuscular stimulation and biofeedback therapy: These help retrain the pelvic floor muscles and encourage a coordinated bowel response.
• Rectal balloon training: Assists in retraining muscle function and can also enhance patient confidence during bowel movements.
• Behavioral techniques and bowel habit training: Regular scheduling, posture optimization during defecation (hello, squatty potty!), and mindfulness around urges.
• Manual therapy and visceral mobilization: Often used by pelvic floor therapists to reduce adhesions or fascial restrictions.
• Abdominal massage and diaphragmatic breathing: Gentle but effective ways to stimulate internal movement and improve gut tone.

Gut Microbiota: The Missing Piece of the Puzzle
A healthy gut flora is essential to regular and urgent bowel movements. The microbiota helps regulate everything from stool consistency to inflammatory responses in the colon. A disrupted microbiome, such as one lacking microbial diversity or populated by too many pathogenic strains, can slow transit and dull natural urges.

Dietary diversity is key to nurturing a thriving gut ecosystem. Encouraging patients to consume the following foods can make a significant difference in restoring microbial balance and improving colon motility:

• Fiber-rich vegetables and fruits
• Fermented foods (like kefir, kimchi, sauerkraut)
• Resistant starches (like cooled potatoes or green bananas)
• Prebiotic foods (such as garlic, leeks, and onions)

Hormones and the Colon: An Overlooked Connection
Sex hormones, particularly estrogen and progesterone, have a notable impact on gut function. Many individuals report changes in bowel patterns during their menstrual cycle, and hormonal shifts during menopause or andropause can contribute to constipation or erratic bowel habits. Understanding this connection is essential when working with patients whose symptoms appear to cycle with their hormonal changes.

Hormonal imbalances or deficiencies may require a referral for endocrinological evaluation or functional medicine support, especially if gut symptoms persist despite other interventions.

What You'll Learn in the Bowel Pathology and Function Course
Bowel Pathology and Function is a remote course designed for healthcare providers looking to sharpen their skills and deepen their understanding of bowel function restoration. Through a mix of physiology review, clinical tools, and real-world strategies, participants will walk away with a clear plan for helping patients recover their natural urge to defecate.

This bowel course will help you identify where the focus of the patient’s treatment needs to be addressed. Getting to decide where their efforts should be focused and what part of the system seems to be slow or inefficient and helps the healthcare provider narrowing the treatment focus.

Session learning objectives include:

1. In-depth review of colon physiology – Understand the mechanics of motility, nervous system input, and the role of pressure gradients.
2. Use of supportive modalities – Learn how to employ tools like electrical stimulation, manual therapy, and breathwork to enhance gut movement.
3. Microbiota and diet strategies – Dive into microbial diversity and how to coach patients on food choices that support a healthy microbiome.
4. Sex steroids and gut health – Examine the influence of estrogen, progesterone, and testosterone on gut motility and bowel pattern changes.

Restoring bowel urgency isn’t just a digestive issue - it’s a quality-of-life issue. Whether you’re a clinician or a curious patient, understanding the full picture—from gut mechanics to hormones to microbes—can unlock powerful healing. And sometimes, it’s the “down and dirty” details that lead to the biggest breakthroughs. Join me June 7-8^th for Bowel Pathology and Function.

References:

Banibakhsh A, Sidhu D, Khan S, Haime H, Foster PA. Sex steroid metabolism and action in colon health and disease. J Steroid Biochem Mol Biol. 2023 Oct;233:106371. doi: 10.1016/j.jsbmb.2023.106371. Epub 2023 Jul 28. PMID: 37516405.

Barbara G, Barbaro MR, Marasco G, Cremon C. Chronic constipation: from pathophysiology to management. Minerva Gastroenterol (Torino). 2023 Jun;69(2):277-290. doi: 10.23736/S2724-5985.22.03335-6. Epub 2023 Feb 2. PMID: 36727654.

Seo M, Bae JH. [Nonpharmacologic Treatment of Chronic Constipation]. Korean J Gastroenterol. 2024 May 25;83(5):191-196. Korean. doi: 10.4166/kjg.2024.044. PMID: 38783620.

Scott SM, Simrén M, Farmer AD, Dinning PG, Carrington EV, Benninga MA, Burgell RE, Dimidi E, Fikree A, Ford AC, Fox M, Hoad CL, Knowles CH, Krogh K, Nugent K, Remes-Troche JM, Whelan K, Corsetti M. Chronic constipation in adults: Contemporary perspectives and clinical challenges. 1: Epidemiology, diagnosis, clinical associations, pathophysiology, and investigation. Neurogastroenterol Motil. 2021 Jun;33(6):e14050. doi: 10.1111/nmo.14050. Epub 2020 Dec 2. PMID: 33263938.

Yang C, Hong Q, Wu T, Fan Y, Shen X, Dong X. Association between Dietary Intake of Live Microbes and Chronic Constipation in Adults. J Nutr. 2024 Feb;154(2):526-534. doi: 10.1016/j.tjnut.2023.11.032. Epub 2023 Dec 9. PMID: 38072155.

AUTHOR BIO
Lila Bartkowski-Abbate, PT, DPT, MS, OCS, WCS, PRPC

Lila Abbate, PT, DPT, MS, OCS, WCS, PRPC (she/her) is the Director/Owner of New Dimensions Physical Therapy with locations Roslyn, Long Island, and the Noho Section of New York City. Dr. Abbate graduated from Touro College in Dix Hills, NY with a Bachelor’s of Science (BS) in Health Sciences and a Masters of Arts (MA) in Physical Therapy in 1997. She completed her Advanced Masters in Manual Orthopedic Physical Therapy (MS) at Touro College, Bayshore, NY in 2003 and continued to pursue her Doctor of Physical Therapy (DPT) at Touro in 2005. Dr. Abbate is a Board-Certified Specialist by the American Physical Therapy Association in Orthopedics (OCS) 2004 and Women’s Health (WCS) 2011. She has obtained the Certified Pelvic Rehabilitation Practitioner (PRPC) from Herman & Wallace Institute, 2014. She is a Diane Lee/LJ Lee, Integrated Systems Model (ISM) graduate and completed the New York series in 2012.

Dr. Abbate has been an educator for most of her physical therapy career. She has full-time faculty experience at Touro College, Manhattan Campus from 2002 to 2006 teaching the biomechanical approach to orthopedic dysfunction and therapeutic exercise as well as massage/soft tissue work that highlighted trigger point work, scar management, and myofascial release.

She is currently on faculty as a Lecturer at Columbia University teaching the private practice section Business & Management course (since 2016) along with the Pelvic Health elective (since 2012). She teaches nationally and internationally with the Herman & Wallace Pelvic Rehabilitation Institute teaching advanced courses of her own intellectual property: Orthopedic Assessment for the Pelvic Health Therapist, Bowel Pathology Function, Dysfunction and the Pelvic Floor, Coccydynia & Painful Sitting: Orthopedic Implications. She was a co-writer for the Pudendal Neuralgia course and teaches the Pelvic Floor Series of Pelvic Floor 1, 2A and 2B and Pregnancy, Postpartum. She has written two book chapters in 2016: Pelvic Pain Management by Valvoska and Healing in Urology: Clinical Guidebook to Herbal and Alternative Therapies by Chughtai.

She is a member of the American Physical Therapy Association, the National Vulvodynia Association, the American Urogynecology Association, and the International Pelvic Pain Society. Dr. Abbate is also a Senior Physical Therapy consultant for SI Bone, a sacroiliac joint instrumentation company.

The diagnosis of chronic constipation may seem like a simple concept; however, bowel patients can be a challenging group within our pelvic health population. The interesting part about treating these patients is that constipation can result in a variety of complaints. Diaz et al confirmed this in their 2023 research. Their article shared that “Constipation encompasses several subtypes, each with its unique characteristics and underlying factors.”(1) Common complaints can include frequency, size, length, and consistency which can become overwhelming for the practitioner to decide which clinical complaints seem the most important to focus on.

Knowing how to effectively treat these patients and ask the right questions is valuable in the scheme of pelvic floor rehab, secondary to overlapping symptoms and etiology of chronic constipation. Consideration needs to be taken into account for any outside factors that can also contribute to patient complaints. For example, taking different prescription medications, supplements, and eating different foods can all influence the patient's stool frequency and formation (2). Realizing where this issue stems from is the deep-dive question to get a handle on their complaints.

Bowel frequency can be one of the biggest clinical challenges for clinicians to educate patients to master – consistency is key! Understanding what their normal frequency should be, or what it should be now, is part of the clinical judgment skill when setting goals. If your patient is only getting a natural bowel movement urge every 10 days, their goal of daily BMs, at first, should be emotionally readjusted so that they don’t feel like they have failed their rehabilitation goals.

Learning colon physiology helps to understand normal vs abnormal motility and can be helpful in treating your patient’s constipation. In my course, Bowel Pathology and Physiology we discuss the physiological reflex that controls the lower motility of the GI tract following a meal (3). When patients present with chronic constipation, they may be experiencing a profound loss of the gastrocolic reflex. The course is filled with clinical pearls and research tidbits that help to improve or slow down colonic motility. Join me in the next course offering on September 14-15, 2024 to learn more.

Resources:

1. Diaz S, Bittar K, Hashmi MF, et al. [Updated 2023 Nov 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513291/
2. Araújo MM, Botelho PB. Probiotics, prebiotics, and synbiotics in chronic constipation: Outstanding aspects to be considered for the current evidence. Front Nutr. 2022 Dec 8;9:935830. doi: 10.3389/fnut.2022.935830. PMID: 36570175; PMCID: PMC9773270.
3. Mawer S, Alhawaj AF. Physiology, Defecation. 2023 Nov 13. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 30969554.

AUTHOR BIO

Lila Abbate, PT, DPT, MS, OCS, WCS, PRPC

Lila Abbate is the Director/Owner of New Dimensions Physical Therapy. She graduated from Touro College in Dix Hills, NY with a Bachelor of Science (BS) in Health Sciences and a Master of Arts (MA) in Physical Therapy in 1997. She completed her Advanced Masters in Manual Orthopedic Physical Therapy (MS) at Touro College, Bayshore, NY in 2003 and continued to pursue her Doctor of Physical Therapy (DPT) at Touro in 2005. Dr. Abbate is a Board-Certified Specialist by the American Physical Therapy Association in Orthopedics (OCS) 2004 and Women’s Health (WCS) 2011. She obtained the Certified Pelvic Rehabilitation Practitioner (PRPC) from the Herman & Wallace Institute in 2014. She is a Diane Lee/LJ Lee, Integrated Systems Model (ISM) graduate and completed the New York series in 2012.

Dr. Abbate has been an educator for most of her physical therapy career. She has experience as a full-time faculty at Touro College, Manhattan Campus from 2002 to 2006 teaching the biomechanical approach to orthopedic dysfunction and therapeutic exercise as well as massage/soft tissue work that highlighted trigger point work, scar management, and myofascial release. She is currently on faculty as a Lecturer at Columbia University teaching the private practice section Business & Management course (since 2016) along with the Pelvic Health elective (since 2012). She teaches nationally and internationally with the Herman & Wallace Pelvic Rehabilitation Institute teaching advanced courses of her own intellectual property: Orthopedic Assessment for the Pelvic Health Therapist, Bowel Pathology Function, Dysfunction and the Pelvic Floor, Coccydynia & Painful Sitting: Orthopedic Implications. She was a co-writer for the Pudendal Neuralgia course and teaches the Pelvic Function Series, and Pregnancy/Postpartum Series. She has written two book chapters in 2016: Pelvic Pain Management by Valvoska and Healing in Urology: Clinical Guidebook to Herbal and Alternative Therapies by Chughtai.

Lila is a member of the American Physical Therapy Association, the National Vulvodynia Association, the American Urogynecology Association, the International Pelvic Pain Society, and is also a Senior Physical Therapy consultant for SI Bone, a sacroiliac joint instrumentation company.