Knowing the Evacuation Drill

Like every other function of the human body, bowels are intriguing and pretty clever … when they’re working well, that is. When they’re not, they can not only dominate conversation (even in polite circles) but they can make life difficult for the suffering and for all those around them, including their doctors.

Dr Michael Levitt

Everyone has a bowel story and there’s a fair chance that colorectal surgeon Dr Michael Levitt has heard most of them.

When Michael is not at Osborne Park Hospital juggling surgical lists as OPH’s co-medical director or in his private rooms, he likes to write and, just to prove a point, his third book, The Happy Bowel, has just been published by Fremantle Press.

When Medical Forum caught up with him at OPH, he was reviewing the waiting list for colonoscopies. It was unsurprisingly long but getting shorter, he assured us. The irony did not escape him that a book which aims to empower people to understand and direct their bowel function better (rather than their bowels controlling them) might also have a positive impact on that long list.

“All three books have been about bowels, largely because I have too many stories to contain in just one,” he said. “And also because I see so many people in various states of desperation who think surgery is the only solution to their constipation/irritable bowel.”

“It’s not, for many of them.”

Knowledge is power

Bowel function is steeped in social and behavioural mythology which has been passed down the generations to arrive at a rather uncomfortable endpoint that proscribes what’s normal. The problem is, ‘normal’ is not normal at all.

Michael writes:

“In all of recorded human history, every truly satisfactory bowel action has had four things in common: it has been prompt, effortless, brief and complete. Wherever and by whomever it might have been produced, any human bowel action that has possessed all four of these characteristics will have represented a genuinely positive life experience for that person. And any individual who can say that they achieve such agreeable bowel actions on a majority of their visits to the bathroom can rightly claim to have a good bowel habit.”

“You need only ask yourself: ‘Do I regularly commence rectal evacuation with a minimum of delay? Does it involve a minimum of effort? Am I regularly able to leave the bathroom after just a short period of time? And do I leave feeling satisfyingly empty?’ If the answer to all of these questions is ‘Yes’, then you have an excellent bowel habit. If it’s not, then you are likely to be struggling.”

“Notice that what does not count here – or, at least, not to anywhere near the same extent – is stool frequency, or how many times a day or a week you empty your bowel. This is an extremely important point: How often you go is simply not as important as how easily and how completely you empty your bowel.”

“People who are having difficulty with their bowels – those who are not able to experience the simple but significant pleasure of having regularly satisfactory bowel actions – can almost always describe their difficulty with reference to one or more of these four characteristics… While many different factors and conditions can cause trouble with our bowels, they virtually all manifest as problems in one or more of these four key areas.”

Knowing the rules

And with this happy introduction, Michael continues to encourage readers to re-evaluate their perceptions, habits and behaviour when it comes to one of the body’s most whispered about functions.

He has three Golden Rules for happy, healthy rectal evacuation:

  • Golden Rule Number One: Never attempt to empty your bowel until the urge to do so is strong and true.
  • Golden Rule Number Two: Never, ever, take any distracting influences – newspapers, books, magazines, mobile devices – with you to the bathroom.
  • Golden Rule Number Three: The ideal consistency for a human stool is solid.

These rules have a companion set of ‘Three Ds’, which Michael says in a “simple behavioural approach to correct the faulty toileting behaviour associated with ‘speculative’ defecation:

  • Defer visiting the bathroom until the urge to go is strong and true.
  • Desist if rectal evacuation does not commence both promptly and effortlessly, rather than sit and strain get up and leave the bathroom immediately.
  • Distinguish between real urges and false alarms. It is the essence of correcting speculative defecation and its associated problems of straining, haemorrhoids and pelvic floor pain.

The Happy Bowel also looks at the use of laxatives (in Michael’s words, “I need statins to control lifestyle-resistant cholesterol, why wouldn’t someone with slow colonic transit need laxatives?”), medications that affect bowel function, alternative treatments (enemas, colonic irrigation, probiotics) and bowel problems in children, along with case studies and FAQs.

Take Home Message? When you’ve got to go … it’s good to go.

Illustration credit: Copyright Fremantle Press