The Vasalva Maneuver And Diabetes: Recipe For Disaster
This week, someone I know told me that he recently discovered that his friend's diabetic boss had died on the toilet. I offered my condolences, hung up the phone after our conversation, and immediately ran to my laptop to conduct research on diabetes and toilet deaths.
I turned to my Olde English Bulldogge, Molly, who was lying on the couch next to me, and said, "I really am an asshole." She opened one eye, yawned as if to say "Yeah, we know," and went back to sleep with her tongue partially hanging out of her mouth.
Of all the phenomena associated with pooping, death on the toilet elicits the most ambiguous of reactions from we Poopreporters. Someone is dead and a family is mourning, but there is a toilet death . . . a weirdly, inappropriately, fascinating toilet death . . . and we want to know what might have happened. In this case, the deceased was a diabetic. Was there a connection between the toilet death and her diabetes, I wondered? The answer I found online is a possible yes, and that connection might be the Vasalva Maneuver.
The Vasalva Maneuver is a technique used by people who are experiencing difficulty pooping, such as those who are chronically constipated from health-related issues or from drugs associated with chronic pain; or by people who are experiencing a differentiation between the pressure inside the body and outside the body, such as those in an airplane. If you have ever felt the pressure in your ears increase during a descent during a commercial flight, you might have tried to pop your ears by closing your nose and mouth and forcing air against up into your chest cavity. You are performing the maneuver! The maneuver works like this: When you push up with your abdominal cavity against a closed mouth and nose, you experience a sharp increase in blood pressure. The hoped-for response is that poop will leave the body or your ears will pop.
But what happens to the body while one is pushing? If you know a bit about anatomy, then know the heart has four chambers, and they are separated by a vertical membrane. The lower chambers are called ventricles, and the upper chambers are called atria (atrium singular). De-oxygenated blood flows into the right atrium from all over the body via a very large vein, the superior vena cava. It passes to the right ventricle and is pumped to the lungs via the pulmonary artery, the only artery in the body that carries de-oxygenated blood. In the lungs, the blood receives oxygen and releases carbon dioxide, and it comes back to the heart oxygenated via the pulmonary vein, the only vein in the body to carry oxygenated blood. The pulmonary vein enters the heart at the left atrium, passes the left ventricle, and exits to the body via the immense and amazing three-pronged Aorta.
When someone uses the Vasalva Maneuver, the first thing that happens is that the left atrium of the heart empties of blood. The second occurrence is the amount of blood going back to the heart decreases because of the increased pressure in the chest cavity. The heart loses the ability to pump blood, and in response the blood vessels in the body constrict, causing a greater increase in pressure. When the person opens his mouth or or exhales, the vessels in the chest cavity will return to their normal size, and the left ventricle experiences a lower influx of blood. The body's blood flow and pressure should return to normal after the person discontinues the maneuver, however. So for a small amount of time, someone has managed to increase chest cavity pressure, which should force something in the body out: two eardrums, the last drops of pee in his bladder, or some poop.
When someone is a diabetic, he may be suffering from a form of neuropathy, which is an impairment of some part of the nervous system or nerves. Inflammation or autoimmune susceptibility can cause nerve damage, as can an injury, but a diabetic will most likely experience neuropathy from high blood glucose and/or low insulin levels. This is known as diabetic neuropathy. Diabetic neuropathy can affect the nerves in the extremities, or "peripheral" (hence the need for less restrictive diabetic socks); the shoulders and hips, or "proximal"; the eyes, facial muscles, or abdominal, or "focal"; or the nerves in the heart or liver, or "autonomic." It is the autonomic damage that we are discussing here.
People with diabetes have a higher chance of suffering damage from pushing when they take a shit. This occurs because the diabetic person using the Vasalva Maneuver (or pushing to crap) recovers more slowly after letting up internal cavity pressure; his heart receives less oxygen than the normal person's during this period of measurable diastolic pressure, a state called brachycardia, and the lack of oxygen can cause a heart attack or a stroke. Furthermore, the diabetic's slower recovery from pushing to crap due to his less active--or damaged--nerves can in turn cause more damage to his nerves. A vicious cycle ensues from being constipated or from having less control over one's bowels. Sooner or later, the chronic, diabetic poop-pusher will experience such a low diastolic pressure after pushing that the ensuing lack of oxygen may result in his bathroom demise. And while I will never know the exact cause of my friend's friend's boss, it is entirely possible that she experienced a heart attack that occurred in this very manner.
For those of you who are interested, here is a link to a study on this very topic that dates all the way back to 1967, written by Nathanielsz, Ross, and Ross: Abnormal Response to Vasalva Maneuver in Diabetics.