Is my poo normal?
The fascination with faeces has driven hundreds of neologisms, euphemisms, and connoisseur-like descriptors about the characteristics of our bowel actions. We use varying terms (poo, crap, stool, sh*t, squirts, faeces) to help us to discuss something that, in reality, is a universal, mundane, quotidian bodily function. It concerns all of us, from time to time, because it is a fundamental arbiter of health. But what is normal, what is the relevance of a change from normal, and what should one do about it?
Firstly, how is poo measured? The two fundamental axes when describing bowel habit, and thus evaluating how usual or otherwise one’s bowel habit is, is form and frequency. What is the consistency of your bowel action and how often do you move your bowels?
To provide scientific rigor and scales for measurement, we need more definitions. To describe our stool consistency, we use the well validated Bristol Stool Form Scale (BSFS)1. This is familiar to many and uses a 7-point scale ranging from Type 1 “separate hard lumps, like nuts” to Type 7 “watery with no solid pieces”.
Bowel frequency is often reported as the number of bowel actions per week. In a recent large population study of 4775 people reporting “normal” bowel patterns, it was found that about 95% of people (i.e. within two standard deviations) move their bowels between three and 21 times weekly2. That is, they moved their bowels at least three times per week but no more than three times per day or the “three and three” rule of thumb. “Three and three” is the Goldilock’s zone of pooing!
In terms of stool form, women were slightly more variable than men, but most reported a BSFS of between three and five. A little over half of the population reported the Type 4, “like a sausage or snake, smooth and soft”, the Nirvana of all bowel actions! But please appreciate, that almost 50% of normal patients reported some variation from this at some point in time – abnormal is the new normal! We are here to help.
50%of normal patients reported some variation in bowel habit
In terms of abnormal bowel habit, we usually complain of either diarrhoea, constipation, or a combination of both. These terms, have precise clinical definitions, but, of course, in the community these mean different things to different people.
Central to our understanding is again the combination of form and frequency. Helpful reference points for constipation are infrequent or hard bowel actions (<3 per week and/or passing Type 1 and 2 stools at least 75% of the time), sometimes accompanied with the need for straining or the sensation of incomplete evacuation2,3,4.
For patients complaining of diarrhoea, it is important to establish how frequent or soft their bowel actions are (>3 per day and Type 6 and 7, at least 75% of the time), again sometimes associated with problematic urgency to defecate and occasional faecal soiling of their underwear3,4,5. Inherent to these definitions is duration, one soft stool, does not a diarrhoea make.
Symptoms also need to be interpreted within a broader context. It is vital to clarify exactly what is meant by change in bowel habit – whether there are dietary or other triggers, whether there has been recent travel or changes in medication, such as antibiotics, and whether there are other important features, in particular rectal bleeding, nocturnal symptoms, bloating and/or abdominal pain. Persistent symptoms, lasting weeks to months, are more important than brief disturbances.
Family history, particularly of inflammatory bowel disease, coeliac disease, and cancer, also can influence baseline risk and therefore forms an important part of the assessment. Following on from history, physical examination can provide information about abdominal tenderness, possible weight loss, palpable masses, and other signs.
Based on the above assessment, your GP and specialist gastroenterologist/colorectal surgeon may perform other selected stool and blood tests5. Endoscopy and colonoscopy may be required to help provide a definitive answer for some symptoms.
Even if you have no symptoms, your doctor will try to ensure that you are up to date with your bowel cancer screening. In Australia, biennial faecal occult blood testing (testing your poo for blood) is recommended from 45 years of age (ask your GP) and you get a free kit sent to you in the mail from age 50.
The central tenet of “trust your gut” is a good one. As physicians, we serve at the pleasure of our patients and symptoms that seem unremarkable to some, can cause significant distress to others.
In many cases your care may involve a multi-disciplinary team that can include dietitians, physiotherapists, psychologists, gastroenterologists, surgeons, and even, on occasion, chefs. You can rest assured that all causes of altered bowel habit, whether functional (related to diet, microbiome, motility, and perception), infectious, inflammatory, neoplastic, metabolic, or iatrogenic (caused by medical treatments) are manageable.
Australia is at the forefront of bowel health research and practice, and you should feel comfortable in sharing your concerns, trusting your gut, and seeking timely, evidenced-based care. You need not suffer in silence or embarrassment any longer. We’ve heard it all.
- Lewis SJ and Heaton KW. Stool form scale as a useful guide to intestinal transit time. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol. 1997 Sep;32(9):920-4.
- Mitsuhashi S, Ballou S, Jiang ZG, Hirsch W, Nee J, Iturrino J, Cheng V, Lembo A. Characterizing Normal Bowel Frequency and Consistency in a Representative Sample of Adults in the United States (NHANES). Am J Gastroenterol. 2018 Jan;113(1):115-123. doi: 10.1038/ajg.2017.213. Epub 2017 Aug 1