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Letting Down the PressureTo teach toileting, it’s helpful to know the basics of how we eliminate (pee and poop), and how we learn to do these things. We encourage every parent to watch this video.
Associated Resources:
- “The Poo in You” (video): this simple video is helpful for both kids and adults to understand how digestion and elimination work, and what can stand in the way.
A full transcript of the video appears below.
Hello, my name is Kelly Savitri. I’m a nurse with the Vermont Continence Project. This short video is going to present some information about how our bodies eliminate waste, which is basically a polite way of saying pee and poop. I hope by the end of this video you will understand why this information is the foundation of helping our kids become successful with toilet learning.
The process of toilet learning starts when a person’s brain can recognize signals from the bladder and bowel, and then that person learns how to respond to those signals. So the first thing that we need to understand is how that process works in the body and where things can go wrong that make it difficult for someone to learn toileting skills.
First, let me explain how we create urine, or pee, and how we excrete it. Pee is produced in the kidneys. It travels down tubes called ureters and collects in the bladder. As the bladder fills, it stretches. Special nerves called stretch receptors in the bladder sense when it is full and send a message to the brain. We perceive this message as a feeling, which most of us learn to recognize as the need to pee.
Now we’ll talk about how the bowel works. Food enters the mouth and goes into the stomach where it gets broken up and mixed with our stomach acid and enzymes that allow us to digest it. At that point, it becomes liquid. And it stays liquid as it goes through a long, twisty tube called the small intestine. From there, it enters our large intestine, also called the bowel or colon, and it is still liquid. This liquid is what becomes poop. In the large intestine, water gets absorbed back into the body, so the poop moving through becomes more solid. The longer it stays in the bowel, the harder and drier it becomes. The last part of the colon is called the rectum. Just like the bladder, the rectum has stretch receptors. When the rectum fills with poop, it stretches. And those stretch receptors send a signal to the brain.
Again, we perceive this signal as a sensation. And it is that sensation that most of us learn to recognize as the feeling that we need to poop. There’s a little ring of muscle at the bottom of the rectum called the anal sphincter. The anal sphincter is a muscle that we can tighten to keep poop in or we can relax to let poop out.
There is also a group of muscles in our pelvis that we call the pelvic floor. Those muscles help us control when pee and poop comes out. While there are many muscles working in many different ways, a simple way to say it is that we contract the muscles to keep pee and poop in, and we relax them to let it out.
So what could go wrong with these systems? For most children, the answer is constipation. Many parents are surprised to hear that their child might be constipated, because constipation can be sneaky and can present in unique ways, especially in children. At the Continence Project, we have worked with hundreds of families and consulted with many pediatricians and specialists, and we have found that when a child is really struggling with incontinence, despite their parent trying all the conventional strategies, there’s almost always an issue related to constipation that needs to be addressed. This is true for typically developing children, as well as those with developmental delays or other identified diagnoses.
I’m going to talk much more in depth about constipation in upcoming videos, but for right now, I’m going to give you the quick summary of how chronic constipation affects a person’s ability to gain toileting skills. In this graphic, the yellow part of the cycle represents the mental and emotional effects of constipation that influence a child’s behavior. And the green cycle represents the physical changes that happen in a child’s body that make it difficult for a child to effectively recognize their body signals and respond to them. For today, I’m going to focus on the green part of the cycle, but I want you to know that we will talk about the yellow part of the cycle in future videos.
First, let’s define what we mean by constipation. Remember how the last part of the bowel stretches when it is full of poop, and then it goes back to its normal size when it empties? Constipation is what happens when the rectum does not fully empty. Usually, for adults, this is a short-term situation that resolves when a person eventually has a complete bowel movement. In children, we often observe that an episode of constipation can trigger an ongoing cycle where they might be able to pass some poop on a regular basis, but the bowel never fully empties, so the rectum becomes stretched out.
We use the term constipation a lot because that is the word that your healthcare provider is most likely going to use. But sometimes it is confusing because people think of constipation as a situation when no poop at all is coming out. We often hear parents say, “How could my child be constipated? I’m cleaning up poop all day long.” In this situation, it’s more helpful to think of it as incomplete evacuation. Even if your child has frequent bowel movements, they might still be experiencing the effects of an overstretched rectum because the bowel is never really fully emptying, and some stool is being left behind.
There are a lot of muscles involved in the digestive process. The whole digestive tract from the mouth to the anus has muscles that help move the food, and subsequent poop, through the digestive system. When someone has constipation, or incomplete evacuations, the muscles of the rectum are stretched out for a long time. Then they become weak and ineffective. That means that the longer constipation, or incomplete evacuation, goes on, the more difficult it is for the body to effectively push poop out. Remember how stretch receptors give you the urge to pee or poop? For those receptors to work, the bowel needs to go back to its empty state every time. When the bowel stays stretched out for a long time, those receptors stop talking to your brain. This is true even if some poop comes out. Remember, you can’t learn to respond to a signal that you don’t feel. So making sure that the bowel is fully emptying on a regular basis is our first and most important step in addressing incontinence.
Also, remember the muscles of the pelvic floor and anal sphincter? Those muscles can also be affected by the pressure of an overfull rectum constantly pressing on them, or from long-term withholding. So sometimes those muscles need retraining, as well as time to regain their normal function. In our psychographic, we call this situation ineffective or incomplete voiding and defecation.
Finally, remember how the poop is liquid when it enters the bowel, and it gets harder and drier the longer it stays there? Sometimes the hard, dry poop gets stuck in the rectum, causing an impaction. Eventually, the liquid poop starts to sneak around the impaction and leak out. This amount can be large or small. It often appears as streaks or smears in a person’s underwear because small amounts of liquid or solid stool comes out when the person passes gas. They may also have large bowel accidents. Often this is mistaken as diarrhea, but it’s actually a complication of long-term constipation called encopresis. In this situation, stool leaks out involuntarily, and a child often cannot even feel it. You might be wondering how incomplete evacuation affects urine incontinence.
We tend to think of the bowel and bladder as two separate systems, but they’re connected in some very important ways. The signals from the stretch receptors in the bladder travel the same nerve pathways as the receptors in the bowel. When the signals from the bowel are interrupted by incomplete elimination, the signals from the bladder can get messed up too. This usually shows up as a child either not recognizing that they need to pee, or not identifying it until it is extremely urgent, and they can’t get to the toilet in time. Also, the overly full rectum can press on the bladder, creating less space for the bladder to expand. This usually shows up as a child having lots of small pees frequently throughout the day.
The most important thing to understand is that this process is cyclical. When a child’s stretch receptors and muscles of the digestive system and pelvic floor become compromised because of constipation or incomplete evacuation, it slows down their elimination and makes it harder for them to poop, causing more constipation.
Don’t worry, we’re going to talk much more about how to identify whether constipation or incomplete evacuation is a factor in your child’s difficulty with toilet learning and what to do about it. In the next video, called Taking Bowel Data, my colleague will explain how to record the size, frequency, and consistency of your child’s bowel movements so that you can have an informed conversation with your child’s healthcare provider.
Thank you for taking the time to watch this. The information contained in this video is for informational purposes only. It is not a substitute for professional health or medical advice, diagnosis, or treatment. Always seek the advice of your physician, or other qualified healthcare provider.
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Letting Down the Pressure
