Pelvic Floor Physical Therapy for Constipation and Rectal Pain: What I Shared With Colorado’s OB-GYNs
An honor to be in that room
This past weekend, I had the privilege of speaking to OB/GYNs from across the state at the Colorado ACOG conference. I'm still a little starstruck.
These are the physicians who deliver our babies, manage our pregnancies, and see women through every stage of life. Many of them have been referring patients to pelvic floor physical therapy for years. Being invited to stand in front of them and share what we do at Sage Physical Therapy meant more to me than I can easily put into words.
My talk was called More Than Fiber: The Pelvic Floor's Role in Managing Constipation and Rectal Pain. I picked that topic on purpose. Constipation and rectal pain are two of the most common complaints we treat, and they're also two of the most misunderstood. Patients often go years being told to eat more fiber, drink more water, or simply that "everything looks normal."
Meanwhile, the real problem is a group of muscles nobody has checked.
I walked away from the conference so encouraged. The questions were sharp and the conversations afterward were generous. It was clear how much these doctors care about getting their patients the right care. Collaboration between physicians and pelvic floor PTs is how patients get better faster, and I'm grateful to be part of it.
Since not everyone could be in the room, I want to share the heart of that talk here.
Your pelvic floor and your bowels
The pelvic floor is a sling of muscles at the base of your pelvis. It supports your bladder, uterus, and rectum. It also helps keep you continent, which means it holds things in until you're ready to let them out.
One muscle in particular deserves a spotlight: the puborectalis. It loops around the bottom of the rectum like a sling and pulls it forward, creating a bend. That bend is one of the main reasons we don't leak stool when we stand up or sneeze.
Here's the catch. To have a bowel movement, that sling has to let go. The puborectalis and the anal sphincter need to relax so the bend straightens out and stool can pass easily.
Like any muscle, the pelvic floor responds to stress, pain, posture, and even how we breathe. When it's tight, overactive, or uncoordinated, it can cause two very different problems: sudden, severe rectal pain, and stubborn constipation that no amount of fiber fixes.
Proctalgia fugax: the pain that disappears
Proctalgia fugax means "fleeting rectal pain," and the name fits. Here's how one patient described it to me:
"I wake up at 2 AM with a 10/10 stabbing pain in my rectum. I feel like I'm going to pass out, but 10 minutes later, it is completely gone."
That story is incredibly common. Attacks last anywhere from a few seconds to several minutes and often come on at night. Between episodes, people feel completely normal. That's exactly why it's so frustrating: by the time you see your doctor, there's nothing to find.
It's also far more common than most people realize. Research estimates that up to 8–18% of adults experience it. Only about 1 in 5 ever mention it to a doctor. Women are affected about twice as often as men.
Proctalgia fugax is believed to be caused by a sudden, intense spasm of the pelvic floor muscles, essentially a charley horse in the pelvis. Common triggers include stress, anxiety, sexual activity, and bowel movements. Many of the patients we see also hold tension in their pelvic floor all day without realizing it, which keeps those muscles primed to spasm.
It's important to have your doctor rule out other causes first, like fissures, hemorrhoids, abscesses, or anything more serious. Once those are ruled out, though, there's real help available.
What we find in PT: high resting tension in the pelvic floor, tender trigger points (often in the anal sphincter, the puborectalis, or a hip muscle called the obturator internus), and shallow breathing patterns that keep the pelvic floor from relaxing.
How we treat it:
Down-training: learning to notice and release tension, including "reverse Kegels" that gently lengthen the pelvic floor instead of squeezing it
Manual therapy: gentle internal and external release of trigger points, plus teaching you how to do this at home
360-degree breathing: expanding the ribs front, sides, and back, which naturally lengthens the pelvic floor
Habit changes: spotting the stress triggers and postures that lead to unconscious clenching
Strength and flexibility work: building a pelvic floor that's relaxed and resilient
Pelvic Floor Physical Therapy For Constipation
Remember that sling, the puborectalis? In some people, it does the opposite of what it should. When they bear down to have a bowel movement, the muscle tightens instead of relaxing. This is called dyssynergic defecation.
Picture pushing against a closed door. You can strain as hard as you want, but nothing is getting through. That's what's happening inside the body, and it's why fiber, water, and laxatives often don't solve the problem. In fact, adding more bulk can make some people feel even fuller, more bloated, and more uncomfortable.
In my talk, I shared the story of a patient I'll call SM. She's 45 and had been dealing with constant straining and a feeling that she never fully emptied. She often had to press on the back wall of her vagina to help stool pass. This is called splinting, and it's a big clue that the pelvic floor is involved. She had tried laxatives, a high-fiber diet, and drinking more water. None of it worked.
On her exam, her pelvic floor was tight. When I asked her to bear down, her puborectalis clenched instead of opening. She had no idea. From her side, she was pushing as hard as she could.
How we treat it:
Hands-on feedback: using gentle internal cues so you can feel the difference between squeezing and opening
Balloon training: a small balloon in the rectum lets you practice sensing fullness and passing "stool" with the right coordination, safely in the clinic
Toilet posture: a footstool (like a Squatty Potty) raises your knees above your hips, which relaxes the puborectalis and straightens the path
"Brace and bulge": learning to build pressure from your belly while keeping the pelvic floor relaxed
Abdominal massage: a simple clockwise "I-L-U" massage that follows the colon and helps things move
Smarter fiber: fiber still matters, but variety, timing, and fluids matter too
Once the outlet opens, everything else you've been trying finally starts to work.
Is pelvic floor PT right for you?
Turns out, there is pelvic floor physical therapy for constipation! Consider seeing a pelvic floor physical therapist if you:
Strain regularly or feel like you never fully empty
Press on your vagina or perineum to help stool pass
Have tried fiber, water, and laxatives without lasting relief
Get sudden, sharp rectal pain, especially pain that wakes you up
Have a normal workup but still have symptoms
Your symptoms are real, and they are treatable. You don't have to keep living with them.
I'm so grateful to the Colorado section of ACOG for the invitation, and to every physician who spent part of their weekend learning about the pelvic floor. When OB-GYNs and pelvic floor PTs work together, patients get answers sooner.
If any of this sounds familiar, we'd love to help. Reach out to us at Sage Physical Therapy at admin@sageptdenver.com to schedule an evaluation.
— Katherine Koch, PT, DPT, Owner, Sage Physical Therapy
