Sex and food are our two major drives and they are also two major factors associated with IBS, but only one of them is ever really talked about. Sex remains private and secret, but is all the more powerful for that. When asked, a third of women and a much smaller fraction of men with IBS admit sex is a problem, but that still seems an underestimate. They report that IBS erodes any desire they have for sex, that intercourse itself is painful and sore and that afterwards their stomach is upset for days. Although many tell how sex makes their pain and bloating worse, some women have told us that having sex can bring on an attack of diarrhoea. An episode of incontinence can kill any passion in seconds. Constipation on the other hand can make penetration difficult and painful.
Sex is the drama and the bedroom the theatre. Like the irritated bowel, sex is a complex interplay of action and emotion. During the build up to sex, feelings of desire increase activity in the parasympathetic nerves, the same system that facilitates digestion and bowel movement. Desire also releases the love hormone, oxytocin, which facilitates attachment and alters reproductive physiology. These actions cause the clitoris to swell and become sensitive, increase vaginal blood flow, secretion and sensitivity, relax the vaginal muscle fibres, and inhibit the tone in the striated muscles of the pelvic floor and perineum, all of which make a woman receptive. But it is not just a matter of physiology, she also has to be open emotionally. If there is too much fear or distrust, the physiology just won’t work. Analogous actions in men cause the penis to swell and become rigid by increasing the blood flow into that organ and reducing its outflow, trapping it in the spaces between a network of gristle. Desire also increases secretion of fluid rich in potassium from the seminal vesicles and the prostate gland while contractions of the vas deferens propel that fluid to a the urethral bulb, a reservoir, just below the prostate gland. Fear and distrust will inhibit all of these actions, most noticeably deflating the penis.
The regular stimulation of the penis, clitoris and vagina during intercourse increase these effects. Oxytocin builds along with an admixture from the sympathetic nervous system, the excitation mounts to a crescendo and at orgasm, seminal fluid is pumped by regular contractions of the bulbo-cavernosus muscle through the urethra and deposited high up in the vagina. If the timing is right, similar orgasmic contractions occur in women, enhancing excitation and bonding.
Couples often feel relaxed and sleepy after intercourse. During this post coital slumber, oxytocin relaxes the cervix and rhythmically contracts the uterus causing the pool of semen at the back of vagina around the cervix to be sucked into the uterus and up into the Fallopian tube, where, if sex has occurred around the time of ovulation, the sperm may encounter an ovum and conception take place.
A woman can remain on a high sexual plateau and receptive for some time and may achieve orgasm several times, each time increasing the chance of conception. Meanwhile her partner may have become refractory, lost interest and gone to sleep. You might think that would allow women to sneak out of bed and seek another partner increasing their chance of conception. Similar phenomena occur in some promiscuous mammals and birds. Physiology does not conform to morality and is ever opportunistic.
That’s all very interesting, you may well exclaim, but what has it got to with my IBS? Well the excitation during arousal can spill over into other abdominal or pelvic organs via neural connections in the spinal cord, increasing the sensitivity of the bowel and bringing on symptoms of IBS, which painfully distract from the enjoyment. It might also stimulate contractions and secretion in the bowel so that orgasm could be accompanied by release of more than sperm. This can make what should be the very epitome of pleasure, a crisis of fear and shame.
IBS is always accompanied by a degree of anxiety. There may also be negative or ambivalent feelings around the idea and act of intercourse: Will I be good enough? Does he really love me? Do I love him? Do I really want to do this? Is it my duty? Am I scared of getting pregnant? There are more conflicting thoughts and feelings around the idea of sex than any other physiological function. It is not just a physiological function, the attachment and identification with the beloved, the way they look, the way they talk, our phantasies can all fuel the experience, heightening the tension and enjoyment, but inducing negative feelings that so easily spoil things, inhibiting the tumescence and lubrication during arousal, contracting the muscles around the vagina (vaginismus) suppressing orgasm or precipitating it, or just making it a job rather than a pleasure. ‘Kevin and I are going to try for a baby again tonight.’
Anxiety during intercourse would generate conflict in the gut in the same way as anxiety during a meal; an antagonism between the sympathetic and parasympathetic branches of the autonomic nervous system. There is so much to go wrong and so much shame and embarrassment and guilt.
Sex is also a major cause of trauma. More sexual abuse and coercion goes on behind bedroom doors or in hotel rooms than we would ever want to hear about. Vulnerable young girls, barely out of puberty and some even younger may be exposed to Internet grooming, peer pressure on social media, sexual abuse and coercion and disinhibiting recreational drugs. Traditional regulators of sexual behavior; the church, the law, parents and the school are no longer effective. Too many women have had any enjoyment of sex damaged by traumatic sexual experience early in life. As a result sex has forever more been tainted by fear, so that pleasure is suppressed, so much so that affected women close down and become non receptive, dry and tight so that sex is painful if not impossible. Since the neural control of the rectum and the vagina is very similar, analogous effects may well occur in the bowel, causing lack of secretion, impaired peristalsis and paradoxical contraction of the anal sphincter (anismus), all of which make defaecation very difficult. It has been reported that upwards of 40% of women who suffer from unexplained anorectal disorders have had a history of sexual abuse (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780137/). Anal intercourse is also more common than is usually acknowledged, adding the possibility of physical damage to the rectum and anus to the psychological trauma.
Sexual trauma does not only affect young girls; boys and young men can be affected too. It has been estimated that as many as 10% of men are openly homosexual and some are predatory (though, I hasten to add, this is not a stereotype). Vulnerable young boys can be anally raped and otherwise abused, most notably but not only, in institutional settings. Vulnerable young men may also be traumatised by the sexual demands and ridicule of predatory women. In the area of sex, everything is possible and most happens. What should be a pleasure garden can become a war zone and can result in disturbances in bowel and bladder function in both sexes.
I have focuses on the psychological aspects of sexual and rectal dysfunction because that is most common, but it is important not to ignore the possibility of a physical illness affecting both. Unless you have obvious symptoms such as discharge or bleeding, it is unlikely that you have any other disease, through some possibilities need to be considered. Endometriosis often causes pain especially at the time of menstruation, though has a disturbance in the motility of the Fallopian tube analogous to the disturbances in colonic motility in IBS allowed the shed endometrium to be reflux end through the tubes and stick to loops of intestine? Ovarian cysts might conceivably make sex uncomfortable and can be associated with bloating. Polycystic ovaries (Stein Leventhal syndrome) can impair sexual function, cause infertility and often IBS. And recent research suggests that disturbances in elastic tissue associated with double jointedness (Ehlers Danlos Syndrome) may make sex difficult and induce constipation. But common things occur commonly and the connections between a person’s experience, their emotion and pelvic function would seem to occur much more frequently.
For most people, the reversal of sexual and bowel function requires first an acknowledgment of the problem and then working with the body by rhythmic movements, walking, dancing, eye movement desensitization, tapping on acupuncture points, drawing , making music, whatever works for the individual to gain a confident sense of their own identity that will enable them to explore and talk about what has happened. In time, with this approach, the emotional tension may wear away and body relax and begin to function normally, but sometimes it may require a person to feel strong enough to remove themselves from a situation that retraumatises them. See ‘Don’t be a victim, be a survivor’ and ‘Take Back Control of Your Life’.