Constipation Q&A: From Pebble Poops to Megarectums

If you’re reading this, you’re probably familiar with the bloated, heavy sensation of being full of poop. Even if you look normal on the outside, it can make you feel all wrong on the inside. Exercise, sex, and even your favorite foods can lose their appeal.

Constipation-related symptoms are outrageously common. According to Origin’s 2024 Pelvic Health Study, 52% of women ages 18 to 59 report straining to poop within the past year. 48% report feeling like they couldn't get all the poop out. 29% experienced pain with pooping.

Brooke David, PT, DPT, PRPC, is a pelvic floor physical therapist at Origin Druid Hills in Atlanta who spent years suffering from chronic constipation as a child and young adult — an experience that made her want to become a pelvic health specialist and help other people solve their pooping problems.

We’re excited to share Brooke’s insights into how constipation often starts, why pooping when you feel the urge (and only when you feel the urge) is so important, and what causes the phenomenon known as a megarectum.

 Why is treating chronic constipation a passion for you?

Growing up, I always had issues around pooping. I was a very stressed individual. I played a lot of sports. I held a lot of tension and anxiety in my body that I did not realize was there or understand.

I would go to doctors and they would say, just drink more water. I was a student-athlete. I drank a ton of water. My dad was in nutritional medicine and functional medicine. And he would be like, take these supplements, but nothing really helped and so I'd always have pain or it would be hard to go to the bathroom.

‍How old were you when you cracked your constipation issues?

It wasn't until I took my first pelvic floor course and learned more about how our body doesn't like to be stressed and how that can impact our bowel movements. I learned that I needed fiber every day. I needed yoga, but it had to be relaxing yoga, not intense yoga. Meditation. Breathing. I had to let my body do its thing.

Another big thing I learned was not sitting on the toilet and forcing myself to go to the bathroom because it was the morning and I needed to poop before the day started. Instead, I learned to wait for the urge to poop, and then capitalize on it.

Are there different types of constipation?

Yes, there are different types of constipation and listening to a patient describe their symptoms can help pelvic floor PTs understand what’s needed to confirm a diagnosis. For example, slow transit constipation means that stool might move more slowly throughout the colon. And so those people might not have bowel movements every day.

Normally, people can have bowel movements every one to three days. So it can help to just understand that you’re someone that poops every three days, and normalize that. Then let's make sure we're doing all the things, including fiber, water, maybe some magnesium, and talking about what's in your diet.

So maybe I shouldn't assume something's wrong if I can't poop once a day?

Right. 100% My husband will be like, I think I have to go poop. I'm like, if you only "think" you have to go poop, you don't have to go poop.

I'm so glad you said that because I have a related question: Can you explain what sampling is?

Yes, for sure. I always ask my patients if they get an urge to poop — do they know when they need to go? Because what’s happening with that urge is that stool is dropping down into the rectum, putting pressure on the pelvic floor.

When that happens, sampling is a reflex that allows your body to understand if there is gas or stool that's in the rectum that is ready to be evacuated. When there is, you should be able to have control over what happens next: Should I pass the gas or should I go sit down and poop or do I hold it in?

Most of the time we want to listen to our body and take advantage of that reflex because that means stool is ready to go and it will be easier for you to defecate. I also tell my patients, you don't really want to sit on the toilet unless you have that feeling.

You mean poop can move in reverse?

Yes, if things are working normally, it should. Sometimes if we're really backed up, stool will linger in the rectum and create what we call a megarectum, which can make it harder to harder to evacuate.

What is a megarectum?

Megarectums happen over time, usually in people with chronic constipation. Our rectum is like a balloon. So before it's stretched out, it can hold and stretch and then go back to its normal size. But the longer it remains stretched, the harder it is for it to go back to its original size, which makes it less sensitive and responsive. You could have a megarectum full of stool, but have no idea that you have stool in there, so you don’t sit down to poop.

That's why I ask about if patients with chronic constipation are getting the urge, because if they're not, that tells me something might be going on. If they have a megarectum, they may need to go to a doctor and flush the stool out to reset the whole system.

It’s awful that something as simple as pooping can be so difficult for people to do.

When I worked in New York, I treated all of these men on Wall Street who got up at the crack of dawn, ate a quick breakfast, put themselves on the toilet so they could go to the bathroom, and then ran to catch a train into the city. They were forcing themselves because they wanted to go to the bathroom, not necessarily because they needed to go to the bathroom.

I joke with all my patients that there should be a hierarchy: Bowel movements are number one, you are number two. Bowels should reign supreme.

What are some other issues people deal with when it comes to constipation?

Issues can include outlet dysfunction, meaning the pelvic floor muscles aren't opening to allow stool to come out of the anus. Or people can have dyssynergic defecation, which occurs when the pelvic floor tightens up instead of lengthens when you try to push out stool.

It’s also possible to misread the signals your body is sending you. I think I have to poop, but maybe it's not actually my rectum talking. Maybe I'm feeling full in my stomach and I'm having gas and bloat, but that's putting pressure downward and making me feel like I have to poop.

It sounds like pelvic floor PTs are like poop detectives.

Yes. The best part of a PT visit is that we have the time to ask questions and really understand what's happening.

As a PT, I have to ask a lot of questions. How often are you having a bowel movement? Is it every day? What's happening if it's every day — because you can still be constipated even with your pooping every day.

Do you have to strain and push when you’re emptying? What's the stool consistency? Is it all coming out all together? Is it just pebbles? Is it a lot of loose stool? Are you getting enough fiber in your diet? Is there enough water in your diet? Are you taking laxatives? Are you getting an urge to go? Do you capitalize on the urge?

Most people, especially with constipation, want to tell me everything, which is incredibly helpful.

What does it mean if you’re pooping pebbles?

It can often mean that you’re dehydrated. Another explanation is that those pebble poops are leftover from a previous trip to the bathroom, when you didn’t fully empty your bowels. If you don’t fully empty, poop can linger behind and get dehydrated. That’s why you may sometimes poop pebbles followed by more well-formed stool.

Getting more fiber and water is clearly a must-do for easier pooping.

Fiber and water are essential for having a good bowel movement. We are supposed to be having anywhere from 25 to 30 grams of fiber a day. Fiber helps improve stool consistency and move our stool along.

While it’s much less common, some of my vegetarian or vegan patients are getting too much fiber, which is a whole other situation. Those patients will have very hard stools that may be hard to pass.

Water is needed because if we don't have enough, our body takes all the water from the stool. And the more dehydrated our stool, the harder it is for it to come out.

I’ve been to pelvic floor PT for constipation, and one thing that wowed me was how much I learned in just one visit.

The amount of education you can get in even the first couple of visits is huge. Nobody educates us about how our bowels work, what our bowels need, the importance of urges, or listening to our body, right? And again, this is the beauty of PT. We have that time to educate people.

Everybody poops — there should be no shame around it. As pelvic floor PTs, we’re here to figure out what your body needs to make pooping easier. What can we do to help you?