It is important to not strain/force/push when you defecate. Prevent this by using a stool under your feet during defecation. There is not a set height the stool needs to be as long as it brings your knees higher than your hips (90 degrees or less). If you have a high toilet then you will need a higher stool. Having your knees higher than your hips allows for the puborectalis muscle to relax, increasing the puborectal angle so the stool can evacuate easier with less effort.
Coordinating proper breathing with the relaxation of your pelvic floor muscles can be very challenging and why Biofeedback is useful. There is a technique called Belly Big, Belly Hard that can aide in proper defecation as follows:
PROPER SITTING POSITION:
- Knees slightly higher than hips (feet resting on small stool, especially patients who are shorter)
- Lean forward and rest your elbows on knees
- Assume proper sitting position (see above)
- Inhale to allow your belly to expand (Belly Big)
- Keep Belly Big but resume normal breathing
- Tighten abdominal muscles (Belly Hard) to keep Belly Big *
- Gently bulge your pelvic floor as your exhale to expel stool**
- NEVER HOLD YOUR BREATH AND BEAR DOWN
When you tighten your abdominal muscles it is to keep your Belly Big; you should not be pulling abdominals in or flattening them toward your spine—that will only tighten up your pelvic floor. When you are having a BM you want your pelvic floor to be relaxed/open (which is why you bulge).
As you are passing the stool, do this with your exhale, remember: Exhale w/ Effort. However, as you’re exhaling you are still keeping your Belly Big, Belly Hard—again, you are not flattening your abdominals w/ your breath (see above paragraph).
This takes time to learn as you will likely be breaking years of bad habits. Don’t get frustrated and give up—keep practicing.