The 3 Ps of pooping and how to optimize them, according to a Harvard doc

By Kristen Rogers, CNN

(CNN) — When did you last discuss how to poop or how digestion works? Dr. Trisha Pasricha wants to know, because if you’re like pretty much anyone who has ever walked into her clinic, that moment was probably when your parents were potty training you.

While pooping in the toilet as a toddler is an openly celebrated feat, as we age, this basic bodily function becomes shrouded in disgust, embarrassment and secrecy — no wonder understanding our physiology or seeking help can be difficult for many of the 40% of Americans who say their daily lives are disrupted by their bowel health.

“Even I, as a gastroenterologist, still see this every day,” said Pasricha, a physician scientist at Beth Israel Deaconess Medical Center and assistant professor of medicine at Harvard Medical School in Boston. “Patients come to my clinic, and they’re so mortified to put words to their problem.”

These issues can include bloating or pain after eating, constipation, pain during bowel movements, diarrhea and more. And one of the ways Pasricha helps her patients is by informing them of what she calls the three critical Ps of pooping: propulsion, pliability and pelvic floor. The concept is one of many subjects in her new book, “You’ve Been Pooping All Wrong: How to Make Your Bowel Movements a Joy,” released Tuesday.

Pasricha developed the three Ps concept after realizing many people didn’t have a good one for understanding how their bodies worked, she said. Many factors are involved in the process of food going from stomach to toilet, which is why adding fiber may fix your friend’s poop problem but not yours, Pasricha said.

With this information, you can more easily and systematically assess which of these three issues explain your problem and whether you have implemented all three simultaneously, she explained. “To have a good bowel movement, you need all three Ps to be aligned.”

Subpar bowel health has also been linked with issues such as hemorrhoids, cognitive decline, dementia, chronic kidney disease and Parkinson’s disease. So, familiarize yourself with the three Ps and how to optimize them all.

Propulsion

Propulsion refers to the internal, voluntary pressure and the involuntary or induced contractions that push stool forward into the rectum — the last segment of the colon — and outward, Pasricha said.

That voluntary pressure is the “Valsalva maneuver” we all do after sitting on the toilet, she explained — wherein you exhale against a closed mouth and bear down or strain, for ideally just a moment. “This raises the pressure in our chest and abdominal cavity, which then has nowhere else to go but downward,” Pasricha wrote in her book.

Several times daily, the colon has strong high amplitude propagated contractions, or HAPCs, which are the most important contractions for bowel movements, she added. These contractions cause the urge to poop, and sometimes they’re spontaneous. But a few classic triggers are eating, exercising and drinking coffee.

Because our colon operates on a circadian rhythm, some of the greatest contractions of the day occur in first hour or so after waking.

Doing the Valsalva maneuver during these contractions is how you optimize the propulsion factor, Pasricha said. Ignoring urges and doing the maneuver at other times means more straining, which can be painful, time-consuming and consequential in terms of hemorrhoids and damage to the muscles involved in pooping.

Pasricha knows anxiety around pooping at work or a friend’s house, in public, or while traveling often prevents honoring the call.

Her patients feel more comfortable pooping in these environments when there is toilet spray or air freshener available, she said. People can carry their own, and hosts should stock their bathrooms with those products. Reading or using headphones to listen to music can block out the external world — but don’t use your smartphone on the toilet beyond that purpose, since that may keep you sitting and straining longer, Pasricha said.

Some people cough or play music aloud to cover any sounds of their bowel movements or find a more private bathroom in their office.

But at the end of the day, Pasricha said, normalizing people doing human things in our homes without judgment and overcoming this embarrassment are important. Poop procrastination hurts you more than whoever you’re worried about offending, she added, as they’re not the one who will be constipated later.

If you need to poop on a schedule for whatever reason, such as work or school, following a regular routine for your day can help your colon contractions get accustomed to that timing.

Pliability

Pliability refers to stool softness, which influences how easily it can move through your body, Pasricha said.

When your small bowel absorbs all the nutrients it can from food, poop is what remains. One of the colon’s main jobs is to pull water from your stool and into your bloodstream to keep you hydrated, Pasricha explained. But stool also needs hydration in order to properly travel from your colon to your rectum, hence fiber’s importance. It won’t be broken down in your small bowel, so it will travel into the colon and retain water and thus be softer and easier to pass.

The National Academy of Medicine recommends women consume 2.7 liters (91 ounces) of fluids daily, and that men have 3.7 liters (125 ounces) daily. This recommendation includes all fluids and water-rich foods such as fruits, vegetables and soups. Since the average water intake ratio of fluids to foods is around 80:20, that equates to a daily amount of 9 cups for women and 12 ½ cups for men.

For fiber, the Dietary Guidelines for Americans historically have recommended that adults consume 22 to 34 grams daily generally dependent on age and gender. You can get that from various fruits, whole grains, nuts and seeds, and vegetables. Gradually increasing your fiber intake is best since your body needs to adjust.

If getting enough dietary fiber isn’t possible, try a psyllium husk fiber supplement, Pasricha recommended.

The biggest mistake you can make with pliability is consuming lots of water and fiber but still holding poop in, Pasricha said. The longer you do that, the more water gets sucked back into your bloodstream and the harder the stool gets, making passing it more difficult — so the advice for navigating timing and embarrassment is again relevant here.

Pelvic floor

Imagine trying to squeeze toothpaste out of its tube, but you don’t take the cap off, Pasricha said.

That cap is the pelvic floor, the set of muscles that stretches from the pubic bone to the tailbone, holds all of your insides together, and assists with functions involved in pooping, peeing and sex. Problems in this area can lead to issues such as incontinence, pelvic organ prolapse or pain during sex.

Your colon exits through the pelvic floor, Pasricha said. When you’re doing the Valsalva maneuver that generates pressure, your sphincter relaxes. But the more you strain, the more the muscles contract rather than loosen up — and if this is a regular occurrence, that tightening can become a long-term issue, causing chronic constipation.

A few things can strengthen your pelvic floor, Pasricha said. One is raising your knees above your waist while on the toilet, via a device designed for that purpose or a stack of books, a trash can or a stool.

This position allows the puborectalis muscle, which is responsible for keeping your poop inside, to fully relax. Whether you have a problem or not, everyone will poop better this way, Pasricha said — because the typical position of sitting at a 90-degree angle makes that muscle partially choke off your colon. This is why people in eastern countries, like India, historically squatted to poop in ceramic holes in the ground, she added.

If you can’t get your knees high enough for a squat-like position, just leaning forward and widening your legs can also help, Pasricha suggested.

In cases of chronic constipation due to pelvic floor dysfunction, just eight to 10 weeks of a type of physical therapy called biofeedback can retrain the muscles, she said.

Biofeedback gives “real-time physiological feedback that trains them to shift behaviors,” Pasricha wrote. “A therapist may use electrodes on the skin outside the anal sphincters to measure muscle contractions. As you watch the recordings, you can see exactly how what you’re doing — such as where you direct force while bearing down — is helping or hurting.”

When to call a professional

If you understand the influences on your gastrointestinal health, you can adapt without seeing a gastroenterologist or starting medication, Pasricha said. “I’m very pro medication … but there’s so much more that’s within your power than you realize at first.”

If you’re still not seeing improvement after more than two to three months of working on integrating the three Ps of pooping on your own, Pasricha advised seeing a doctor — which you should do right away if you’re experiencing pain or bleeding. And you don’t have to wait for a crisis to get a doctor involved, because while you may think you just need more fiber, for example, your colon may not be doing those critical contractions — a problem only detectable by a professional with testing.

You can ask your general physician for a referral for a gastroenterologist or a neurogastroenterologist for more complicated issues, Pasricha said.

Knowing your body can be “incredibly empowering,” she added. “What I want for everybody is to just live a life where their bowel habits are not in any way hijacking their social calendar, not stopping them from doing the things they love.”

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