Constipation
What is Constipation?
Definition: Constipation is hard or lumpy stools, with a reduced frequency of bowel movements or a sensation of incomplete evacuation or blockage, with straining at stool and some may also report abdominal pain and bloating.
How common is constipation?
Chronic constipation is very common affecting 1 in 6 people. In the elderly, almost one-third are affected by it. Elderly women have 2 to 3 times higher rates than elderly men.
Constipation also affects a person’s quality of life and wellbeing and there is an increased prevalence of depression, anxiety, and social dysfunction in these patients.
Why does constipation occur?
This could happen if the bowel motility or movement slows down and the stools remain in the large bowel for a longer time. This leads to a greater absorption of water and dries up the stools and then the downward movement becomes difficult.
It could also happen if there is any outpouching of the colon such as diverticulosis or if there is a bulging of the rectum towards the vagina called the rectocele. For the latter, the patient usually has to press inside the vagina to push back the bulge for the stools to come out.
In some cases, the sphincter mechanism of the anal canal just does not relax to allow the stools to come out.
How do we manage constipation in our practice at AUGM
- Fiber: We instruct the patients to increase the fiber in their diet and we counsel her as to which fiber would be better for her and what dosage.
- Laxatives: there are several types of laxatives such as stimulant, emollient or osmotic laxatives. We instruct the patients as to which one would be best suited in her case.
- Specific medications: There are several categories of medications for constipation such as secretagogues, bile acid transport inhibitors or prokinetics. Patients are advised as to which one to start and at what dosage.
- Pelvic floor therapy: This is especially useful in women who cannot relax the sphincter in order to expel the stools. We have a special Physical therapist who works with the patients to make them understand the coordinated mechanism between rectal contraction and sphincter relaxation so that the stools can be expelled successfully. This is done by our Physical therapist and usually involves 1-2 sessions per week for 6 weeks.
How do we diagnose constipation in our practice?
HISTORY
- There is a specific criterion called Rome IV criteria that we follow based upon the patient’s history to define constipation
- We make sure that the patient does not have any underlying medical conditions that could predispose her to constipation such as low thyroid levels, diabetes, neurologic conditions such as Parkinsons disease.
- We always review the patient’s medications to make sure that she is not taking anything that could lead to constipation such as: narcotics, iron supplements or anticholinergics.
- The patient should have had a screening colonoscopy especially if she has any warning signs such as blood in the stools or weight loss or bloating.
EXAMINATION
- We do a thorough assessment of the vaginal and rectal area.
- We assess for any bulges or prolapse.
- Rectal examination is very important as it looks for impacted stools, internal rectal prolapse and assesses the ability of the rectal sphincter to relax during straining at a bowel movement.
TESTING
- Bristol Stool Scale: This is a pictograph that the patient keeps to tell us what type of stools she is passing.
- Anorectal manometry: records the pressures of the anal canal and the rectum while holding and straining.
- Balloon expulsion test determines the ability of the patient to be able to expel a water filled balloon in adequate time. If this is slow or she is unable to expel, it could mean that she has difficulty in relaxing the anal sphincter and that could be the cause of her constipation.
- Colon transit study: This is an X ray test that looks at how many radio-opaque beads are left behind in the large bowel after a few days.