Researchers at the Bristol Royal
Infirmary—a hospital in Bristol, England—developed a visual guide for
stools. It is called the Bristol Stool Form Scale, or BSF scale
for short. It helps skittish patients and doctors to distinguish normal
stools from abnormal without getting embarrassed over personal details.
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The normality of ones' stools is determined by
comparing them to the Bristol Stool Form scale, or the BSF scale for
short. The 'Bristol' in the BSF refers to the Bristol Royal Infirmary —
a hospital in Bristol, England -- from where this scale originated.
It is a self-diagnostic chart designed to help skittish
patients discuss this delicate subject with their doctors without
getting embarrassed. This is, essentially, what the Brits call getting
the “royal treatment…”
You just look at the picture, point to what
approximates the content of your toilet bowl, and your doctor tells you
whether your type is good or bad…
Type 4 and 5 are considered “normal”. I provide a
detailed explanation, and what to do to get your own type in order on
Also, if you are a parent or a guardian of a young
child, use this chart to fix minor problems well before they become a
major headache for you and a source of life-long trouble for your child.
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You just look at a simple chart,
point to what approximates the content of your toilet bowl, and your
doctor (or this page) tells you whether the form is right or wrong.
Type 1: Separate hard lumps,
Typical for acute disbacteriosis. These stools lack a
normal amorphous quality, because bacteria are missing and there is
nothing to retain water. The lumps are hard and abrasive, the typical
diameter ranges from 1 to 2 cm (0.4–0.8”), and they‘re painful to pass,
because the lumps are hard and scratchy. There is a high likelihood of
anorectal bleeding from mechanical laceration of the anal canal. Typical
for post-antibiotic treatments and for people attempting fiber-free
(low-carb) diets. Flatulence isn‘t likely, because fermentation of fiber
isn‘t taking place.
Type 2: Sausage-like but
Represents a combination of Type 1 stools impacted into a
single mass and lumped together by fiber components and some bacteria.
Typical for organic constipation. The diameter is 3 to 4 cm (1.2–1.6”).
This type is the most destructive by far because its size is near or
exceeds the maximum opening of the anal canal‘s aperture (3.5 cm). It‘s
bound to cause extreme straining during elimination, and most likely to
cause anal canal laceration, hemorrhoidal prolapse, or diverticulosis.
To attain this form, the stools must be in the colon for at least
several weeks instead of the normal 72 hours. Anorectal pain,
hemorrhoidal disease, anal fissures, withholding or delaying of
defecation, and a history of chronic constipation are the most likely
causes. Minor flatulence is probable. A person experiencing these stools
is most likely to suffer from irritable bowel syndrome because of
continuous pressure of large stools on the intestinal walls. The
possibility of obstruction of the small intestine is high, because the
large intestine is filled to capacity with stools. Adding supplemental
fiber to expel these stools is dangerous, because the expanded fiber has
no place to go, and may cause hernia, obstruction, or perforation of the
small and large intestine alike.
Type 3: Like a sausage but
with cracks in the surface
This form has all of the characteristics
of Type 2 stools, but the transit time is faster, between one and two
weeks. Typical for latent constipation. The diameter is 2 to 3.5 cm
(0.8–1.4”). Irritable bowel syndrome is likely. Flatulence is minor,
because of disbacteriosis. The fact that it hasn‘t became as enlarged as
Type 2 suggests that the defecations are regular. Straining is required.
All of the adverse effects typical for Type 2 stools are likely for type
3, especially the rapid deterioration of hemorrhoidal disease.
» Type 4: Like a sausage or snake, smooth and soft
This form is normal for someone defecating
once daily. The diameter is 1 to 2 cm (0.4–0.8”). The larger diameter
suggests a longer transit time or a large amount of dietary fiber in the
» Type 5:
Soft blobs with clear-cut edges
I consider this form ideal. It is typical for a
person who has stools twice or three times daily, after major meals. The
diameter is 1 to 1.5 cm (0.4–0.6”).
Fluffy pieces with ragged edges, a mushy stool
This form is close to
the margins of comfort in several respects. First, it may be difficult
to control the urge, especially when you don‘t have immediate access to
a bathroom. Second, it is a rather messy affair to manage with toilet
paper alone, unless you have access to a flexible shower or bidet.
Otherwise, I consider it borderline normal. These kind of stools may
suggest a slightly hyperactive colon (fast motility), excess dietary
potassium, or sudden dehydration or spike in blood pressure related to
stress (both cause the rapid release of water and potassium from blood
plasma into the intestinal cavity). It can also indicate a
hypersensitive personality prone to stress, too many spices, drinking
water with a high mineral content, or the use of osmotic (mineral salts)
Type 7: Watery, no solid
This, of course, is diarrhea, a subject outside the scope of this
chapter with just one important and notable exception—so-called
paradoxical diarrhea. It‘s typical for people (especially young children
and infirm or convalescing adults) affected by fecal impaction—a
condition that follows or accompanies type 1 stools. During paradoxical
diarrhea the liquid contents of the small intestine (up to 1.5–2
liters/quarts daily) have no place to go but down, because the large
intestine is stuffed with impacted stools throughout its entire length.
Some water gets absorbed, the rest accumulates in the rectum. The reason
this type of diarrhea is called paradoxical is not because its nature
isn‘t known or understood, but because being severely constipated and
experiencing diarrhea all at once, is, indeed, a paradoxical situation.
Unfortunately, it‘s all too common.
Interestingly, the interpretations and
explanations of the BSF scale that accompany the original chart differ from my analysis. To
this I can only say: thanks for great pictures, but, no thanks
for the rest...
How to interpret BSF scale
To avoid referencing
non-descriptive numbers, I use the following definitions: types 1, 2 and
3 = hard or impacted stools. Type 4 and 5 = normal or optimal. Type 6 =
loose stool, subnormal, or suboptimal, and type 7 = diarrhea.
In such cases as acute hemorrhoidal disease, anal
fissure, or the inability to attain unassisted stools, loose stools (type 6)
are acceptable. It‘s a messy experience, but which would you rather have
— a bucketful of blood, pain, and a wound that won‘t heal, or a little
lukewarm douche afterwards?
To restore and maintain normal stools (from type 4 to
6), the colon and rectum must first be free from hard stools (from type
1 to 3). In our case, the opposite of “hard” isn‘t “soft,” but difficult
(not easy) or irregular.
As you can see from the illustration (and, perhaps,
already know firsthand) “hard” stools can be “small,” “regular,” and
“large.” Equally important, a “small” stool for one person can be
“large” for another, because the perception of size isn‘t determined by
a caliper, but by the aperture of one‘s anal canal. If the anal canal is
constrained by enlarged internal hemorrhoids, even “small” stools, such
as type 4, may be “difficult” to pass. Don‘t fall
into this trap. The rule is: If stools are hard as in
difficult, or not easy, or irregular, they are HARD,
Unless your stools are type 4 to 6 (normal), they are
impacted. Impacted stools can be small, large, hard, soft, dry, moist—it
doesn‘t matter. What “impacted” means is that they had a chance to pile
up and compress in the large intestine. Despite all of the nonsense
you‘ve been hearing about “formed” stools, if yours are “formed,” they
If we didn‘t have the Bristol Stool Form scale
illustration in front of us, and you asked me what are normal stools, I
would answer: normal stools are
not noticeable during defecation!
Again, for someone with an intact anal canal, this may
consist of formed stools as in type 4. For someone with hemorrhoidal
disease, this may only be loose stools as in type 5 or 6. In other
words, the normality differs from person to person, depending on the
degree of prior damage. It‘s pretty much similar to defining pornography
in the context of free speech: I can‘t tell you what pornography is, but
I can tell when I see it. Similarly, I can‘t tell you what normal stools
are, but you can tell when you don‘t have them.
As you can see from the BSF scale, normal stools don‘t
have to be round. After all, your anal canal isn‘t really round (when
shut, it‘s actually flat), particularly if you already have enlarged
internal hemorrhoids. So a flat shape is okay. In fact, when stools are
already round as in type 4, it means you already have a slight degree of
impaction. Otherwise their shape would be flattened up while passing
through the anal canal.
Flat stools scare doctors a great deal because type 2,
3 and, to a lesser extent, type 4 may indicate the presence of a colorectal
tumor. But that's because few doctors have ever observed normal (type 5)
Here is what's actually happening: think of the colon
as a round mold. Then, it‘s easy to imagine why a tumor may change
impacted stools from the round shape to a flat shape. This rare
occurrence doesn‘t apply to type 5 stools, because their shape is formed
primarily by the shape of the anal canal, not the colon‘s “mold.”
To rule out a tumor scare — don‘t panic! Withhold your
stools for few days to give them the opportunity to get molded. Observe
their shape, and calm yourself down and your doctor.
Abnormal stools are any stools that require straining
and/or you feel pressure from stools passing through the anal canal.
Abnormal stools may be small or large size-wise,
depending on fiber consumption, and frequency of defecation.
Normal stools can be loose or slightly formed (Such as
BSF type 5).
stools (between BSF type 4 and 6) aren‘t perfectly round.
Normal stools for one person may be abnormal for
another. The degree of normality is determined by the anatomy of the
Normal stools require zero effort and zero straining
Normal stools pass through the anal canal without any
perception of pressure.
Of course, once you have damage to the anal canal,
achieving absolute “normality” may be hard. So you may have to accept a
small degree of “abnormality” such as type 6 stools. This is no
different from accepting gray hair, wrinkles, dental implants, and so
You may also have to live with the fact that after a
certain degree of prior damage, caused by fiber, you won‘t be able to
attain “unassisted” defecation and “normal” stools because of
irreversible nerve damage, stretching of the large intestine,
significantly enlarged hemorrhoids, and similar factors. I‘ll teach you
how to overcome this problem as well without fiber and laxatives.
In fact, if I didn‘t know how to attain this seemingly
impossible goal, I wouldn‘t be touching this subject or this site. I
only got into this game when I was assured of a winning hand.
What is latent
A generation or so ago the term “costivity” was broadly
used to describe hard stools and straining, while the term
“constipation” was used to describe “irregularity,”
meaning “a failure to move the bowels daily.”
Since then, the terms costivity and constipation
have blended into one, while the “failure to move the bowels for
three consecutive days” has became the 'official' definition of
On the other hand, painful and bloody stools within
days has become a mere irregularity, or a doctor-speak for “don't
bore me with your problems until the fourth day.”
In practical terms, this means that the definition of
“constipation” has become too vague and unspecific — a situation akin to
doctors not knowing the location of your heart or liver. Indeed, how can
you get proper treatment, when constipation for you means “pain while
moving the bowels,”, while it may mean the “failure to move the bowels
for three consecutive days” for your doctor!
For this and other practical reasons I reclassified constipation (see
Fiber Menace, p.p. 97-128 for more details) into three distinct stages: functional (reversible),
latent (hidden), and organic (irreversible):
This condition commonly follows a stressful event, surgery, colonoscopy, diarrhea, temporary
incapacity, food poisoning,
treatment with antibiotics, the side effects of new medication — the circumstances that damage
intestinal flora, interfere with intestinal peristalsis, or both. A person
becomes irregular, stools correspond to the BSF scale type 1 to 3, and
straining is required to
move the bowels. The person resorts to fiber or laxatives for help.
Latent constipation. If the intestinal flora,
stools, and peristalsis aren't properly
restored following adverse event(s), functional constipation
eventually turns into
latent form (i.e. hidden), because
fiber‘s or the laxative's effects on stools creates the impression of normality
The stools become larger, heavier, and harder, usually the BSF type 3, straining more intense,
but for as long as you keep moving your bowels every so often, and without
too much pain, there is still an impression of regularity. This is, by
far, the most dangerous form of constipation because of what happens
As time goes by,
large and hard stools — between type 2 and 3 — keep enlarging internal
hemorrhoids and stretching out the colon. This, in turn, reduces
the diameter of the anal canal even more, causes near complete anorectal nerve damage,
and slows down or cancels out completely the propulsion of stools
alongside the colon (motility). At
this juncture, the person no longer senses a defecation urge, and
becomes dependent on intense straining and/or laxatives to complete a bowel movement. If you
don't use 'hard' laxatives, you fail to move the bowels even with a good
helping of fiber. That is, in fact, what most people mean nowadays when
they say: “I have been diagnosed with constipation.”
So, as you can see, you can indeed use fiber to coax
your bowels into regularity for a good while, but at the expense of
enlarged stools. At some point in that 'while,' you'll also end up with
damaged bowels, and a life-long dependence on more and more fiber, and
How long that 'while' may last depends on how early you
get started with this crazy therapy. If you are in your teens today,
you'll pay the price in your early forties, if you are in your early
forties, damnation will come by your early fifties. If you are a woman,
things will go downhill even faster for reasons explained on this page: Why Women Get Constipated More
Often Than Men?
How to overcome constipation by “normalizing” stools
Constipation rarely happens out of the blue in
otherwise healthy adults. It is
usually preceded by decades of semi-regular stools that are either
too large, or too hard, or both. These abnormal stools cause gradual
nerve damage and enlargement of the colon, rectum, and
hemorrhoidal pads until one day the bowels refuse to move as was meant by
nature — once or twice daily, usually after a meal, and with zero effort
or notice. Therefore, it's best to recognize and eliminate abnormal
stools long before they
bite you in the ass, literally and figuratively.
To attain small stools and effortless bowel movements
immediately— use the
Colorectal Recovery Program.
The duration depends on the degree of acquired colorectal damage. The
goal is to eliminate straining, reduce pressure on internal hemorrhoids,
and restore anorectal sensitivity.
For a comprehensive, life-long recovery, start from this
You may also find relief by reviewing the answers to the following questions:
Q. Why do women get constipated more often than men?
Q. What is the difference between irregularity and constipation?
Q. Is constipation dangerous for my health?
Q. How often should I move my bowels?
Q. Why do some foods cause constipation?
Q. Does stress cause constipation and why?
Q. Does alcohol cause constipation?
Q. Why does anal sex cause constipation?
Q. What causes traveler's constipation?
Q. Why is my infant constipated?
Q. Why is my toddler suddenly constipated?
Q. What are the causes of constipation in older children?
Q. What is the connection between autism, infant constipation and diarrhea?
Q. What is the connection between constipation and the epidemic of juvenile diabetes?
Q. Why do doctors recommend fiber to treat constipation?
Q. Why doctors aren‘t recommending a recovery protocol similar to your Colorectal Recovery Program?
Q. Is it true that dietary fiber prevents or relieves constipation?
Q. Can I relieve constipation by drinking more water?
Q. Is it true that regular exercise stimulates intestinal activity?
Q. Is it true that toning up lax muscles helps to relieve constipation?
Q. Is it true that animal fat causes constipation?
Q. Why do Atkins-style diets (i.e. low-carbohydrate) cause constipation?
Q. What is the best diet for constipation relief?
Q. Why do antibiotics cause constipation?
Q. Does smoking cause constipation?
Q. Why does colonoscopy cause constipation?
Q. Why does surgery cause constipation?
Q. Why does hot weather cause constipation?
Q. Can constipation cause acne?
Q. What are the causes of constipation during pregnancy?
Q. Why does constipation cause enlarged internal hemorrhoids?
Q. Why does constipation cause anal bleeding?
Q. Why does constipation cause bloating and flatulence?
Q. Why does constipation cause chronic fatigue?
Q. Can constipation reduce my immunity?
Q. Can constipation cause bad mouth odor?
Q. Is it true that old stools can cause “encrustation” of the large intestine‘s walls?
Q. What is the connection between constipation and appendicitis?
Q. What is the connection between constipation and colorectal cancer?
Q. What are the most
common side-effects of traditional laxatives?
Of course, you may opt to do
nothing, continue to strain and use fiber and/or laxatives, and we'll
meet again several years from now, except the next time around it will
be even more difficult, involved, and expensive to return to normality.
That's, unfortunately, the nature of the beast — as the years pass,
colorectal disorders related to abnormal stools become more severe, and
the damage— irreversible!
but true — the content of your toilet bowl predicts your future with
more certainty than a crystal ball. With that in mind, read up, look
down, and stay well!