What To Do If Your Poop Is Too Big To Come Out And Hurts? (Dr. Farahat).

A sense of too big stool that is hard to come is a sign of severe constipation or stool impaction. It is better to relax your sphincters and to take a proper laxative or enema to pass stool without hurting your anorectal canal. 

The first question to ask: Is it severe constipation or fecal – impaction?

The feeling of hard stools stuck inside your anorectum is painful and overwhelming. Especially if you’re chronic constipation or an IBS-Constipation sufferer.

Before trying to pass the hard poop, answer an important question: Is it constipation or a fecal impaction?

The term constipation describes a small, hard, and dry stool that is difficult & painful to pass. Usually, you have fewer than 3 bowel motions per week (ref)

The hard poop can grow big, making it more difficult for you to pass.

And it can even grow more and more to form a large, hard mass inside your rectum or sigmoid colon. This ultimately leads to what so-called “fecal impaction”

It is important to know the difference to determine your next step.

Fecal impaction is a potentially serious condition that usually requires help from your doctor.

Questions I usually ask my patients to determine whether it is severe constipation or fecal impaction:

  • Do you have a “persistent urge” to poop that is not going away?
    A distinctive feature between usual constipation with hard stool and a true fecal impaction is the “persistent urge”.
    Feeling you have to empty your colon all the time but are unable and nothing comes out may indicate fecal impaction (ref).
    While with constipation, the urge to poop usually comes and goes, but doesn’t persist for long hours.
  • Do you have some “liquid poop” leaks while feeling constipated?
    With fecal impaction, liquid parts of the stool can leak around the impacted hard poop mass.
    This may cause some incontinence of stool and can be mistaken for diarrhea (ref).
    Liquid stool due to fecal impaction is associated with persistent urge and lower abdominal pain. Also, the leak is usually small in amount and not as explosive as usual diarrhea.
  • Do you have abdominal pain that is not going away?
    With fecal impaction, you may experience persistent abdominal pain that cannot go away. The pain increases after meals (ref).
    With constipation, the pain is mild or non-persistent (comes and goes).
  • Do you have a poor appetite, nausea, headache, general sick feeling, or even vomiting?
    Fecal impaction can lead to more complex symptoms and complications such as nausea, vomiting, headache, and malaise (general ill feeling). 
    Constipation rarely causes this.
  • Do you have thirst, rapid breathing, rapid pulse, or even fever and confusion?
    In severe cases of fecal impaction, it can lead to true intestinal obstruction or inflammation. This may end in dehydration symptoms (such as thirst, confusion, rapid breathing, or rapid pulse). if you experience any of these symptoms with the inability to pass stool, seek urgent medical help.

MORE: 4 Common Causes of Constipation Explained.

Step#1: Take the right “poop posture”

It is important to be in the right posture to relax your pelvic muscles.

  • You have to position your knees higher than your hips.
  • Slightly lean forward and put your elbows on your knees.
  • You can do this by either “sitting on” the toilet or using a footstool.
  • This posture may trigger you to stain more, so you have to remember to relax and only push poop out gently and only after you’re relaxed.
  • Always stay focused on relaxing your pelvic muscles and sphincters.

Step #2: Don’t force the hard poop out by straining, try this instead:

Why overstraining can hurt you:

Trying to forcibly pass the hard stool is risky. forcible passage of a too big poop mass can result in:

  • Forceful straining prevents the relaxation of your involuntary “internal anorectal sphincter”.
  • Anorectal fissure: a tear in the lining of the anorectal canal, which is a very painful condition that can lead to further constipation in the future.
  • A deeper tear can happen involving the muscles around your anorectal canal.
  • Anorectal prolapse: straining can cause the anorectal wall to stretch and protrude to the outside.
  • Even hemorrhoids can occur.

Instead, use the Power of “conscious relaxation” of your sphincters and pelvic muscles.

Unlike straining, conscious relaxing and deep breathing can help you avoid this painful experience.
You have two sphincters (muscle rings) around your anorectal canal (ref).

  • External sphincter: a voluntary muscle under your complete control.
  • Internal sphincter: an Involuntary muscle, and it can spasm if you try to push hard poop against it.
  • Also, some “pelvic floor muscles” contribute to the process of defecation. gaining control over these involuntary muscles can be life-saving

So, it is important to learn how to relax your Involuntary internal sphincter and pelvic floor muscles. To pass the big poop mass with the lowest risks and pain.

Here is how to relax:

  • Close your eyes: Closing your eyes will prepare you to start focusing on relaxation.
  • Start breathing, deeply: gaining control over your involuntary nervous system starts with respiration. slow, deep, conscious respiration help your decrease tension, stress, and gradually relieves the spasm in your sphincters and pelvic floor muscles.
  • Stop the Fear circle: the image of “extreme pain” inside your head is your biggest enemy. No relaxation will occur as long as you’re expecting severe pain. 
    You have to know that your sphincter can greatly expand and passes larger circumferences of stool. 
    The problem with your sphincter is not “the stretching capacity”. The real problem is with “failure to relax”.
  • Start imagining: the truth that if you start to progressively relax your sphincter muscle, you will pass the hard poop almost without pain.
    the moment when your brain starts realizing that “relaxation” will help to avoid pain is the first step to getting rid of the too-hard poop without pain.
  • Slowly and gently push: obviously, we are not in a yoga class, we need the poop out. So, after you feel relaxed, start a gentle puss while maintaining a relaxed state.
  • When the pain starts to increase, RELAX MORE: at a point of the slow pushing you’ll start feeling pain. 
    When you reach the point of intolerance to pain, hold the pushing. Don’t try to push back the poop up again. Instead, focus on breathing and relaxation more.
  • Proceed: after getting comfortable and relaxed again, start gentle pushing down again. usually, passing the first part is the hardest, then it will come easy.

    Conscious relaxation of your pelvic floor muscles not only will help you to get the hard poop out, But also, will prevent serious events such as fissures, hemorrhoids, or prolapse.

    Remember, fear of pain is your worst enemy, fear will result in nothing but more spasm and more pain.

Step #3: Failed with the above? , Use your Gloved fingers.

Sometimes, the hard stool is just too hard. After a period of time, the trapped stool turns into a solid and very hard mass that can be impossible to pass.
This can occur to you whether you are having chronic constipation or having a recent attack of constipation.

So, it may be a proper time to get some help from your fingers; gloved fingers certainly.
Using your fingers can help you with:

  • Relaxation of your sphincters. inserting your “lubricated, gloved finger” with circular motions inside your anorectal canal can help relaxation of the sphincters
  • Lubrication: Use your finger to introduce a lubricant lube, gel, or oil. This helps easier passage of the hard poop.
  • Manual dis-impaction of the hard poop mass.

And here is EXACTLY how you can dis-impact the too hard poop manually:

  1. Use a powder-free latex glove Plus any lube or gel.
  2. Put some lube or gel on your gloved “index finger”.
  3. Sit on the toilet in a squatting position or use a footstool.
  4. Start relaxing and deep breathing to help relax your anorectal canal.
  5. Insert your index finger (with lube) into your anorectal canal slowly and start a circular motion to relax your sphincters.
  6. Slowly progress until you feel the hard poop mass.
  7. Try to assess its size, and how hard is it? If it’s too hard to be broken down by your finger, call for medical help.
  8. if you’re able to break it down with your finger and get the small fragments out, continue to do this until your anorectum is empty.
  9. Use a spooning motion by flexing your finger inside your anorectum to help it break down and to push out of your poop.

CAUTION: Never use Hard objects such as a small spoon or anything similar to dis-impact stools. This may cause serious harm or injury to your anorectum and anorectal canal.

Step #4: Try the mineral oil enema/oral PEG combination.

Mineral oil enemas are by far the most effective type of enema for hard stools or stool impaction. And this is because (ref):

  • Has a laxative effect
  • Softens the hard poop and prevents water from sealing in.
  • Has a Lubricant effect.
  • Safe, but it is not recommended to use it for more than one week.

And here is how you can use the combination of mineral oil enema and the oral PolyEtheylineGlycol (PEG):

  1. Lie down on your left side with your knees bent.
  2. Remove the cap from the enema applicator tip.
  3. Insert the tip slowly into your anorectum and squeeze the bottle to empty all the contents.
  4. wait for 10 to 15 minutes.
  5. Whenever you feel the urge to poop, try to relax your sphincters using instructions in step #2.
  6. Also, you can use your finger to break down the poop that is pre-softened with the mineral oil enema.
  7. Once you feel initial relief (passing the initial hardest part of the poop), you can now use oral PEG (don’t use oral PEG from the start or with failure of the mineral oil enema.
  8. DON’T use mineral oil enemas if you have intense abdominal pain, vomiting, or fever.
  9. If the mineral oil enema fails to bring the hard poop out, it’s time to ask for medical help.

Step #5: A visit to the ER; when, and what to expect

When will you need urgent medical help?

If you encounter any of the below symptoms or signs, please ask for help from your doctor. This is especially important if you are older than 65:

  • Failure of the above measures to pass the too-hard poop out.
  • Signs of intestinal obstruction: such as distension or bloatingabdominal pain, nausea, or vomiting.
  • Signs of dehydration: such as extreme thirst, too fast breathing, too-fast heartbeats, dizziness, confusion, or sweating.
  • Low blood pressure.
  • Fever.
  • Any serious medical illnesses: such as cancers or brain stroke associated with constipation.

What to expect at the Emergency Room (ER):

  1. Your doctor will take a brief history to assess the cause, the complications, and possible complications.
  2. Your doctor will perform a physical examination to assess your vital signs, abdomen, and he may perform a local examination by inserting his gloved fingers
  3. You may be asked for some investigations such as an abdominal radiograph.
  4. your doctor May perform a trial of fecal dis-impaction: using lubricant gel and gloved fingers
  5. Some centers have a dis-impaction tool that helps injection of water into the hard poop. Also, this tool (video below) helps the break down of the hard poop mass.

  6. If the above fails, your doctor may perform a colonoscopy or sigmoidoscopy to help relieve fecal impaction.
  7. In severe cases with too large and hard poop masses in the anorectum, your doctor may require surgery under general anesthesia.

7- The long Term Relief: Revisit your Constipation.

After relieving the hard poop, your priority is to figure out why this happened, put a plan to regain your colon health.
we will release an ultimate guide on how to relieve constipation and prevent further stool impaction, stay tuned.