Poossessed /pəəˈzɛst/ adjective

the change in personality and negativity expressed by an individual when they really need to poo but are forced to hold it in for various reasons (e.g constipation, hygiene, convenience). This is a reversible state through the simple act of defaecation.

*credit to my friend Ox Wiz for this perfectly descriptive term

This is no joke. I’ve seen it in friends and family. The tell tale sign is the huge grin and excessively elevated levels of positivity upon their return from the porcelain throne. Whether it’s constipation or the wilful avoidance of defaecation due to a social anxiety or hyper-cleanliness, it’s unhealthy to have such attachment. Let’s not underestimate the emotional distress of constipation. We’ve all experienced the problems it causes in mood, and the ability to focus or socialise. But the long term physical implications of chronic constipation are even more profound.

What is constipation?

Most people don’t even realise they’re chronically constipated. I’m astounded by the number of patients that tell me “I haven’t opened my bowels in 4 days, but that’s normal for me”. A quick Google search will reassure you that it’s ‘normal’ to open your bowels anywhere between 3 times per day to 3 times per week. But this is based on interviews with a ‘normal’ modern population where constipation and its consequences are rife. So although it may be ‘normal’ to go a day or two without pooping, it’s certainly not healthy.

Just as an aside, I’m very sceptical of ‘normal’ ranges for all health parameters which is why I keep writing it in quotations. Too often ‘normal’ is used as equivalence by doctors and patients for the ‘healthy’ range, or a range to be aspired to. This assumes the population average to be healthy, which it quite clearly is not. The fact that 1/5 of the ‘normal’ UK population are obese tells you what a ludicrous assumption this is.

What are the medical implications of chronic constipation?

Bowel Cancer

Diverticular disease (can have life threatening complications)

Haemorrhoids

Rectal prolapse

Anal fissures (painful cuts at the anus caused by hard stool and excessive wiping)

Anal fistulae and abscesses (painful infections near the bottom)

Pseudo-obstruction/bowel dysmotility

Constipation itself accounts for a huge number of patients we see in A&E and these complications are common reasons for admission to hospital. If you’re interested in the prevalence or impact of constipation on the NHS then please check out the following report: https://www.coloplast.co.uk/Global/UK/Continence/Cost_of_Constipation_Report_FINAL.pdf

image from Cost of Constipation Report (Coloprost)

That’s enough about the problem, let’s get to the bottom of it…

What causes constipation?

Like most diseases, constipation is multifactorial. Some contribution will come from a genetic predisposition to sluggish bowels or an underlying bowel disease. If that’s the case then optimisation of the following factors is even more vital for you. Here is why constipation may be an issue for you and what you can do to fix it:

Dietary causes

Main culprit here is dehydration. No matter how many times we’re told to take 8 glasses of water per day, ain’t nobody got time for that. Try to incorporate a few glasses into your daily routine. I take two glasses of warm water first thing in the morning and 2 before going to bed (leave it at least 30 minutes before you eat or after you’ve eaten so that you don’t dilute your digestive juices). Maximise your fibre intake with fresh fruit and vegetables and cut down on your dietary protein (especially red meat) which slows digestion.

2. Lifestyle causes

Regular exercise and activity will help to promote bowel motility. This is one of the reasons that the elderly tend to be even more afflicted by constipation. But other lifestyle practices may also be constipating you. Many people avoid pooing at work or public places and will hold it in until getting to the comfort of their own home. This is a dangerous habit. The body has reflexes and feedback to tell you when to go poo. These reflexes subsequently promote gut motility. If you make a habit of ignoring these then they will stop working and your gut will become more and more sluggish. Even in the short term, holding the faeces in means build up in the large bowel where water is absorbed. The longer it waits there the more water will be absorbed and the harder the stool will become. This leads to more straining and more pooblems.

My first move when I start work at a new hospital is to scope the place out and find my poop spot. It’s got to be a nice secluded toilet where I won’t be disturbed for 5 minutes. And preferably it’ll have a sink placed within the cubicle itself; I’ll explain this one later. Shout out to my level 7 staff toilet at Ealing Hospital!

3. Emotional causes

Your bowels have feelings too. In a reversal of the mood altering state of poossession, your mood can actually affect your bowel habits. When in an emotionally hyper-alert or anxious state your bowels will tend towards irritability and over-motility due to the hormonal changes. This will cause diarrhoea. Conversely, depression of mood leads to depression of all the bodily functions, including the bowels. It’s a vicious cycle, so address any emotional disturbance early by seeking help and support from friends and family or your doctor. Given our relatively advanced understanding of physical health compared to mental health it may be easier to break this cycle by optimising the physical side of things through diet and exercise.

4. Habitual causes

Even once we get to the toilet, that’s just the beginning of our struggles. To have a truly healthy pooping experience we need to address some bad habits. The position adopted on Western toilets is unnatural for the curvature of the rectum. The squatting position is far better and will reduce straining and its undesirable consequences (haemorrhoids, prolapse, fissures). Fear not, there’s no need to go getting a hole in the ground installed in your bathroom.

Instead you can use a foot stool beneath the bowl to adapt your posture. There’s even a specially designed curved “SquattyPotty” which slides nicely around the bowl. I wish I was as punny as this guy, I mean talk about potty-humour…

Squatty Potty

The other bad habit we have in the West is our use of toilet paper. As a friend once put it to me, “if you had dog poo on your arm would you feel clean having wiped it off with tissue or would you not wash it with water?”. As much as I hate to link to the Daily Mail, I have to share this one… http://www.dailymail.co.uk/health/article-5025367/Doctors-warn-toilet-paper-does-little-remove-feces.html

I feel like most people are aware that it’s not really the cleanest solution and so they’ve forced their bowels to adapt to their lifestyle such that they will only poo before they plan to shower. But once again we must turn to the East for some better habits where people will wash their bottom after pooping. If you’ve ever been on holiday to the Mediterranean, Middle East or Far East then you may have been baffled when you went to the toilet and saw a hose, or bidets or even a fountain jet shooting out the bowl. Well, now you know. But for lack of these awesome lavatory luxuries, why not just take a bottle or cup into the toilet and wash your bottom there and then? And now you know why I always try to secure a spot with an in-cubicle sink ;)

You could even get a clip-on bidet…

Tushy Bidet

Apologies for the looooong post, but I just couldn’t hold it in.

Even as a doctor, it can be a real strain to get patients to open up about their bowel habits. But we’re all friends here so feel free to comment below. And if you’ve enjoyed the poo-related puns or had any of your own that you’ve been holding in all the while then now’s the time to relieve yourself…

Keep pooping,

The Preventician