Constipation is the most common chronic digestive disorder in the United States. It affects 4.53 million people and costs over $200 million for cathartics alone. 1 Accepted description of normal bowel voiding habits is a range of frequency from 3 times per day to consisting of hard stools, fewer than 3 bowel movements per week, or inability to expel stool, whether hard or soft. Symptoms of constipation are described as straining, abdominal pain and or bloating, pain with voiding, or a feeling of incomplete emptying. Constipation is usually the result of of a combination of factors.
Constipation is often a symptom of an underlying disorder. There are 3 primary categories of disorders: systemic factors that affect normal colonial and rectal function (including disorders in the pelvic floor muscle function and psychological factors. Systemic causes may include diabetes, hypothyroidism, hypercalcemia, severe electrolyte abnormality neurological disorders and other systematic disease processes. Colonic factors include a delay in transit of fecal matter through the colon, dietary causes, decreased colonic motor function, medication side effects, or loss of rectal reflex.1 Psychological causes are beyond the scope of this paper.
The colon is a poorly understood organ due to the difficulty in identifying normal colonic patterns (manometry or myoelectric) The colon is active infrequently, often predicable every 24 hours. 3 The contents of the colon should normally clear within 4 days. In constipation a colon often takes more than 10 days to empty its contents. 3 Fecal continence is a complex process involving sphincters and pelvic floor muscles. Maintaining continence is largely unconscious. The rectum is a storage compartment for stool. The pelvic floor muscles and two sphincters regulate fecal retention and defecation. The most important structures are the sphincters and the anorectal angle produced by the pelvic floor muscles.1 The sensory mechanism provides awareness of rectal filling and the nature of the rectal contents (air, solid, liquid), as well as impending desire to defecate or pass gas.3
Diagnostic testing for constipation includes a complete history and assessment of risk factors. A more complete examination is needed as symptoms include severe straining, incomplete evacuation, or anemia.3 Frank or occult blood in the stool indicates evaluation for carcinoma. Colonic transit studies, anorectal manometry or defacography studies may be indicated less frequently, but may diagnose muscle or neurological causes of constipation.
Current medical management of constipation includes patient education, behavior modification, drug therapy, and, less frequently, surgery. Patient education includes finding reasons to avoid prolonged use of irritant laxatives, how and when bowel movements usually occur and how to facilitate that process, and dietary causes of constipation. The elderly especially must be educated to have an adequate fluid intake of 8 glasses of water daily, as they frequently have a decreased thirst response, even in dehydration.3 Currently accepted recommendation for dietary fiber is 28-30 grams of fiber including both soluble and insoluble fiber. Behavior modification techniques include dietary changes that reflect adequate fiber and fluid intake, changing stool evacuation habits, and strengthening/ neuro re-education of both abdominal muscles and the muscles of the pelvic floor. Drug therapy includes use of stool softeners (preferably without irritant laxatives) to keep moisture in the stools, lubricants such as mineral oil, or bulking agents to help with constipation caused by required constipating medication. Enemas/ suppositories distend or irritate the colon and rectum and initiate a reflex evacuation. The most commonly accepted medications at this time are osmotic agents (non absorb able sugars which increase water content of the stools.) Surgery is seldom indicated and occurs in only 4 of 10,000 patients.3
An adequate intake of fluids and increase in fiber intake have both been proven to increase colonic motility and decrease transit time through the colon. Eating fats and spices have also been proven to improve colonic motility. Vigorous exercise has not been shown to have an appreciable effect on colonic motility, though movement activity during high motility periods may help peristalsis. Chronic straining and childbirth may cause denervation of the puborectus and external anal sphincter muscles. Pain from anal fissures, hemorrhoids or fistulaes may cause muscle spasms, avoidance of defecation, and ultimately constipation. 1
A physical therapist trained to treat muscles of the pelvic floor can be an instrumental part of the team treating constipation. A physical therapist can often spend more time than a physician’s office on behavior modification techniques, re- education of the abdominal and pelvic floor muscles, and can reinforce dietary management. A physical therapist who understands the function of the pelvic floor muscles, can assess the patient’s evacuation technique, dysfunction in the muscles, and can train proper technique, thereby enhancing other treatments for constipation, and often reducing the need for intervention.
- Benson, T. Ed, Female Pelvic Floor Disorders, Investigation and Management, W.W. Norton Company, Inc., 1992.
- Steege, J., Metzger, D., Levy, B., Chronic Pelvic Pain, An Integrated Approach, W.B. Saunders Company, 1998.
- Donatelle, E., Constipation: pathophysiology and treatment. American Family Physician, 1990; 42 (5): 1335-1343
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By: Cathy Conkler, PT