Help patients win
the constipation battle
Best practice in the prevention
and treatment of constipation
in adults under 65 years
Authored by:
Marianne Wallis, Shona McKenzie, Sheridan Guyatt, Jennifer Rayner, Fiona Ellem, Elizabeth
Gass, Winsome St John and Roger Hughes.
Based on a systematic review conducted by:
Marianne Wallis, Elizabeth Gass, Ben Desbrow and Winsome St John.
National Continence Management Strategy
Department of Health and Ageing
Commonwealth of Australia
September 2003
About the Authors
A/Prof. Marianne Wallis
Chair, Clinical Nursing Research, a joint
appointment between Griffith University
and Gold Coast Health Service District
Ms Shona McKenzie
Continence Nurse Advisor
Royal Brisbane Hospital
Ms Sheridan Guyatt
Physiotherapist
Ms Jennifer Rayner
Stomal Therapist
Gold Coast Health Service District
Ms Fiona Ellem
Pharmacist
Gold Coast Health Service District
A/Prof. Elizabeth Gass
School of Physiotherapy and Exercise Science
Griffith University
The production of these guidelines was funded by a grant obtained from the Australian
Department of Health and Ageing, National Continence Management Strategy.
Published by the Griffith University Research Centre for Clinical Practice Innovation
PMB 50, Gold Coast Mail Centre, Queensland, 9726 or
Parklands Drive, Southport, Queensland, 4215, Australia
Copyright © 2003 Griffith University Research Centre for Clinical Practice Innovation
The procedures described in these Clinical Guidelines must only be used by people who
have appropriate expertise in the field to which the procedure relates. The applicability of any
information must be established before relying on it. While care has been taken to
ensure that these guidelines summarise available research and expert consensus, any loss,
damage, cost, expense or liability suffered or incurred as a result of reliance on these
procedures (whether arising in contract, negligence or otherwise) is, to the extent
permitted by law, excluded.
Dr Winsome St John
School of Nursing
Griffith University
Mr Roger Hughes
Nutrition Unit
School of Health Science
Griffith University
Contents
Prevention treatment chart
2
Management treatment chart
3
Guidelines for clinicians
4
Prevention of constipation in adults
8
• Diet and fluid intake
9
• Examples of fibre(soluble fibre)
11
• Exercise
12
• Effective bowel habits - bowel retraining
13
• Laxative therapy
15
Management of constipation in adults
16
Referral pathways
• General practitioner
18
• Registered nurses: general and specialist
23
• Physiotherapist
24
• Dietitian
26
• Specialist medical services
27
References
28
Appendices
30
• Appendix 1 – Levels of evidence used in
systematic review
30
• Appendix 2 – Assessment proforma, including
food and fluids chart
31
• Appendix 3 – Investigations
34
• Appendix 4 – Bowel training instructions
35
1
Prevention
Management
If your middle-aged client complains of constipation or has any risk factors for
constipation such as immobility, opioid ingestion or neurological damage
Assess the following and reinforce healthy lifestyle
Therapy for constipation in adults
Reinforce good habits
Refer for further
assessment/treatment
• Correct position for defaecation
• 30 minutes of exercise daily
• 8 glasses of water a day
• 25-35g of fibre daily
Dietary fibre and
fluid intake
8 glasses of fluid a day,
25-35g/day of fibre.
(See p. 10)
Exercise
Bowel habits
Regular activity within
ability – 30 minutes of
walking most days of
the week. (See p. 13)
Use the urge following
meals or first thing in
the morning. Adopt the
correct position.
(See p. 14)
Reassess in one to two weeks. If problem persists, assess
compliance with lifestyle change and use three step plan.
Step 1: Assess the degree of problem this is for the client –
if not affecting functioning, reinforce lifestyle changes
and refer client to a dietitian, nurse and/or
physiotherapist.
Step 2: If problem is affecting functioning to a small degree,
suggest incremental introduction of laxative therapy
under GP guidance and refer to a dietitian and/or
physiotherapist. (See p. 15)
Step 3: If affecting functioning severely, refer to GP for
specialist physician referral and/or colonic transit studies.
2
Prevention & management
General
Practitioner
Physiotherapist
Dietitian
Specialist Nurse
Progressive
introduction
of laxatives
(See p. 18)
Exercise program
Diet planning
Massage
Education
Bowel habit
training
Lifestyle
education
Biofeedback
Physician
Investigations
Pharmacotherapy
Further referral
Surgeon
Prevention & management
3
The size of the problem
Guidelines for clinicians
Introduction
These guidelines for clinicians are based on a systematic review of research literature that was
conducted by a multidisciplinary team. The efficiency, effectiveness and/or appropriateness
of five broad categories of interventions have been the subject of research studies focused
on the prevention and treatment of constipation in adults. These categories are:
• diet and fluid intake
• exercise
• drug treatments (laxatives)
• behavioural training using biofeedback
• surgical treatments.
The quality of the evidence for all of these interventions is variable, and despite its
prevalence, the literature indicates that the prevention and management of constipation in
middle-aged adults is often not based on research and remains inconsistent in practice.
These guidelines, which have been developed by a multi-disciplinary group of clinicians,
focus on the overall weight of the evidence in order to provide as complete a guide as
possible based on current knowledge. The criteria used to assess the level of evidence are
presented in Appendix 1.
In addition to the five areas of diet and fluid intake, exercise, drug treatments, behavioural
training using biofeedback and surgical treatments, clinicians also use a number of other
interventions. There is also much anecdotal evidence for the usefulness of comprehensive
assessment, positioning and toileting behaviour training. While information on these
strategies is included in these guidelines there is no research-based evidence for their
efficacy and at best they are risk-free suggestions that may be of some clinical utility.
Studies conducted in the United Kingdom (UK) and the United States of America (USA)
suggest that the prevalence of constipation is between 2% and 10%, in the general
population (Pettigrew et al., 1997; Tramonte et al., 1997) and up to 23% in older adults
(Donald et al., 1985). It is also more common in women than men (Tramonte et al., 1997).
One of the confounding issues when trying to examine the prevalence of constipation is the
definition of the term. Some studies employ predetermined criteria, such as the Rome II
definition (Thompson et al., 1999) (see Probert et al., 1995) while most others ask
participants to either self-assess or report bowel movement frequency or frequency of
straining at stool (see Heaton & Cripps, 1993; Thompson & Heaton, 1980). One study,
completed in the UK, assessed symptoms using both the Rome criteria and respondents’
self-perception of constipation. The results were very similar with 8.5% of respondents
indicating that they suffered from constipation and 8.2% of the same respondents having
symptoms that fitted into the Rome definition of chronic constipation (Probert et al., 1995).
Australian prevalence data for constipation is lacking (Koch & Hudson, 2000). Recently, the
"Women’s Health Australia" (WHA) study, which surveys three different age group cohorts of
women, has collected data on self-reports of constipation in a middle-aged cohort of
approximately 14,000 women (WHA, 1997 – 2002). These data suggest that, in a general
population, constipation is experienced often in 3.6% - 8.7% of women and that the
prevalence increases with age (WHA, 1997 – 2002). The prevalence of constipation is much
higher in certain groups, such as those with neurological problems and it is very common in
those taking opioids especially those with a terminal illness (University of York, 2001).
Constipation not only affects the quality of life of the sufferer (O’Keefe et al., 1995) but also
has drug-related costs to individuals and to health services. In the UK it is estimated that
£46million per year is spent on laxatives and that this exceeds the amount spent on
hypnotics and anxiolytics (University of York, 2001).
These best practice guidelines have been developed to target the prevention and
management of constipation in adults aged between 40 and 65 years with no predisposing
medical conditions. They are designed for use by members of a multidisciplinary healthcare
team, including medical practitioners, pharmacists, physiotherapists, dietitians and nurses.
4
Guidelines for clinicians
Guidelines for clinicians
5
Defining constipation
The most commonly used definition in recent years is that developed by a multinational team
of gastroenterologists called the Rome II criteria (Thompson et al., 1999).
Rome II criteria for functional bowel disorders
The diagnosis of a functional bowel disorder always presumes the absence of a
structural or biochemical explanation of the symptoms.
Functional constipation
In the preceding 12 months, the person will have had, for at least 12 weeks, which do
not need to be consecutive, of two or more of the following symptoms.
1. Straining > 1/4 of defaecations
2. Lumpy or hard stools > 1/4 of defaecations
3. Sensation of incomplete evacuation > 1/4 of defaecations
4. Sensation of anorectal obstruction or blockage > 1/4 of defaecations
5. Manual manoeuvres to facilitate > 1/4 of defaecations (eg digital evacuation,
support of the pelvic floor)
6. < 3 defaecations per week.
Risk factors for constipation
The main risk factors associated with constipation in middle aged adults are
• inadequate diet and fluid intake
• reduced mobility and exercise
• drug treatments associated with an increased risk of constipation
• recent illness, surgery or lifestyle change
• other medical conditions (physical and psychological)
• increasing age.
(University of York, 2001; Petticrew et al.,1997)
Assessment
There is no research-based evidence for the effectiveness of assessment in the
overall management of constipation in middle-aged adults. There is, however, much
evidence that treatment based on accurate assessment and interpretation of findings
results in better client outcomes. Thus in order to determine the best course of action,
when a client is either at risk of constipation or is experiencing on-going constipation,
6
Guidelines for clinicians
it is advisable to have an accurate assessment of:
• current symptoms experienced by patient
• physical assessment – focusing on the abdomen and signs indicating hydration
• medical history with particular emphasis on bowel function
• bowel habits and toileting behaviour
• diet and fluid intake
• activity levels
• drug treatments associated with an increased risk of constipation
• recent illness, surgery or lifestyle change
• other medical conditions (physical and psychological).
It is important to allow the client to accurately describe signs and symptoms rather than to
accept an interpretation of the signs and symptoms.
Assessment guidelines
Below are suggested assessment guidelines. Appendix 2 provides a proforma that may be
copied for clinical use.
• Presenting symptoms - as described by the client.
• Duration of symptoms - as described by the client.
• Previous management - and effect of these on bowel function.
• Investigations – for example has the client undergone any bowel investigations?
eg. colonoscopy, X-ray, defaecogram, ultrasound or manometry. (See Appendix 3)
• Current medications – note especially medications with recognised constipating effect.
e.g. antacids, anticholinergics, antidepressants, opioids, antihistamines, antihypertensives.
• Medical / Surgical history - include gynaecological history in women.
• Bowel habits – including frequency, consistency, urge, sensation of complete/incomplete
emptying, bleeding, pain on defecation, abdominal pain and/or bloating.
• Toileting behaviour – straining, sitting position, feet supported, manual assistance, time
taken to empty.
• Faecal incontinence – flatus, liquid, solids and/or mucous.
• Diet / Fluid intake – ask patient to complete a 3 or 7 day fluid and food chart.
• Physical activity / exercise - ask patient to describe type of exercise and frequency.
• Physical assessment – palpation and auscultation of the abdomen and examination of
skin flaccidity and eye pressures (signs of hydration).
Send for medical / specialist review if:
• sudden change in bowel habits
• pain
• bleeding
• poor response to treatment, or
• if further investigation is required. (See Appendix 3)
Guidelines for clinicians
7
Prevention of constipation
in adults
If your middle-aged client complains of constipation or has any risk factors for
constipation such as immobility, opioid ingestion or neurological damage
Guidelines for prevention and management
of constipation
Prevention of constipation
The algorithm on the facing page summarises key features of the approach to the prevention
of constipation in people aged between 40 and 65 years. The evidence for the approach
represented in the algorithm is presented in this section.
Diet and fluid intake
Assess the following and reinforce healthy lifestyle
Dietary fibre and
fluid intake
8 glasses of fluid a day,
25-35g/day of fibre.
(See p. 10)
Exercise
Bowel habits
Regular activity within
ability – 30 minutes of
walking most days of
the week. (See p. 13)
Use the urge following
meals or first thing in
the morning. Adopt the
correct position.
(See p. 14)
There are very few well designed, double blind, crossover studies into the effect of increased
intake (i.e. provide subjects with food) and assess the impact of dietary modification on bowel
function. The systematic review revealed 12 studies that performed investigations using
non-constipated subjects (i.e. prevention) and of these, six were designated properly
designed randomised control trials (i.e. Level II). These six trials included a total of 187 subjects.
There were eight experiments designed to compare different management strategies related
to diet and only two of these were properly designed randomised controlled trials. These two
trials included a total of 44 subjects.
Reassess in one to two weeks. If problem persists,
assess compliance with lifestyle change and move to the
three step management plan.
Step 1: Assess the degree of problem this is for the client –
if not affecting functioning, reinforce lifestyle changes
and refer client to a dietitian, nurse and/or
physiotherapist.
Step 2: If problem is affecting functioning to a small degree,
suggest incremental introduction of laxative therapy
under GP guidance and refer to a dietitian and/or
physiotherapist. (See p. 15)
Step 3: If affecting functioning severely, refer to GP for
specialist physician referral.
8
Prevention of constipation in adults
Prevention of constipation in adults
9
All of the studies included in the systematic review showed that the intake of dietary fibre
(especially bran), in a variety of forms (i.e. dietary intake, fibre suspensions and fibre tablets)
improves bowel function (i.e. either stool frequency and/or weight or makes stools easier to
pass). This highlights the importance that increasing dietary fibre (25-35g/day) has in
preventing constipation.
Table I
The effects of differing sources of dietary fibre on bowel function indicate that insoluble
fibres (eg. bran, rye) produce greater increases in stools (i.e. size and/or frequency) than
soluble fibres (psyllium, partially hydrolysed gums) or resistant starches (legumes).
This, however, does not take into consideration long-term compliance. A number of studies
reviewed investigated differing methods to increase fibre intakes (Orr et al., 2000; Dettmar
et al., 1998; Bass et al., 1988; Hamilton et al., 1988). It appears likely that convenience is a
major factor in sustained high fibre intakes. See Table 1 on p. 11 for details of fibre content
of common foods.
Food
Three studies investigated the effects of increasing fluid consumption on bowel habit (Chung
et al., 1999; Anti et al., 1998; Ziegenhagen et al., 1991). The most recent of these studies
was only performed over a very short period (9 days in total and only 4 days of increased
fluid intake). They found no effect on bowel function following an increase in fluid intake.
Anti et al., (1998) investigated subjects with constipation. They found that increasing
subjects’ fluid intake (mineral water) to 1.5-2.0 litres/day enhanced the effects of a
concurrently increased fibre intake. The third study, Ziegenhagen et al., (1991) was
conducted on healthy subjects. Subjects showed no differences in response to a bran
supplement with or without the addition of 600mls of additional fluid. The conflicting results
indicated the possibility that, like fibre, fluid may affect the constipated individual differently
than those without the condition. From these results it would seem reasonable to
recommend to constipated clients that if they are going to increase their fibre intake it might
be beneficial to raise their fluid intake to 2 litres per day.
Recommendations for dietary fibre and fluid intake
• Daily dietary fibre intake of 25-35 grams/day – Level II evidence.
• This should be a combination of soluble and insoluble fibre - Level III evidence.
• It is important that the client finds a way of taking the fibre that is convenient.
The introduction of dietary fibre to prevent constipation is a long-term commitment and
any strategy needs to be sustainable – Level III evidence.
• Daily fluid intake of 1.5-2 litres (six to eight glasses of water) per day is recommended to
prevent constipation – Level III evidence.
10
Prevention of constipation in adults
Examples of fibre (soluble fibre)
Those sources of fibre in bold are soluble fibre, those in black are insoluble fibre.
Fibre
(gram)
Bread
(1 slice)
white
wholemeal
mixed grain
1.0
2.0
2.5
6.0
3.5
9.5
1.0
7.0
1.0
3.0
Bran/wheatgerm
(1 tablespoon)
oat
wheat
wheatgerm
2.0
2.0
1.0
Grains and Pastas
(boiled – 1 cup)
Barley
Wholemeal pasta
White rice
Brown rice
Fibre
(gram)
Fruit
Breakfast cereals
Muesli (1/2 cup)
Rolled oats (1/2 cup raw)
All bran (1/2 cup)
Cornflakes (1 cup)
Sultana Bran (1 cup)
Special K (1 cup)
Weetbix (2 biscuits)
Food
7.0
10.0
1.5
3.0
Apple (1)
Banana (1)
Dates (1cup dried)
Figs (5 dried)
Kiwi fruit (2)
Orange (1)
Prunes (5)
Pear (1)
Sultanas (1 tablespoon)
3.0
3.0
10.0
11.0
5.0
2.5
3.0
4.0
1.0
Vegetables
Beans, green (1/2 cup)
Carrots (1/2 cup)
Potato (1)
Sweet corn (1 small cob)
Tomato (1)
4.5
2.0
1.0
4.0
1.5
Legumes
(1/2 cup)
Baked beans
Kidney beans
Chickpea
Lentil
Split pea
6.5
6.0
4.5
3.5
3.5
Prevention of constipation in adults
11
Exercise
Approximately 300 years ago it was said exercise "helps to throw down wind from the
bowels … it also serves … as an evacuant, and a diversion by which artifices the humours are
put into conditions of flying off without the danger of bringing on spasms" (Puch, 1794 cited
in Sullivan, 1992). Unfortunately our lack of well-designed research studies means that we
are not much further on than this in our knowledge today.
Exercise is an anti-homeostatic stressor, with complex activation and interaction of many
body systems and with adaptive consequences if performed repeatedly and at sufficient
dosage. One of the consequences of exercise, particularly whole body exercise is activation
of the autonomic nervous system. Of particular relevance is activation of the sympathetic
nervous system in its role of redistributing blood away from non-exercising areas and
towards exercising areas. The gastro-intestinal system is an area that is, typically,
vaso-constricted during exercise, particularly if exercise is intense enough to elevate the
heart rate above 100 b.min-1 (Rowell & Shepherd, 1996). Therefore most studies that have
examined the role of exercise in preventing constipation have utilised light levels of aerobic
exercise. Unfortunately, to date, there is no evidence that would allow us to judge how much
exercise is enough and how much is too much, to have a positive influence on bowel function.
It is likely, however, that strenuous and/or prolonged exercise can have negative effects
on bowel function.
A wide range of responses within study groups typifies research studies in the area of
exercise and bowel function. Often differences are seen between responders and
non-responders. This phenomenon is common in exercise studies and could simply be a
reflection of methodological issues, such as small sample sizes. The responder/non-responder
difference is usually masked by the statistical interpretation of the results, with the focus on
mean scores.
Koffler et al., (1992) used strength-training exercise and demonstrated a significantly
accelerated whole body transit time (a valid estimate for constipation). This study may
suggest strength training to be a mode of exercise of choice. Interestingly in this study all
subjects showed the same trend. Complicating the impact of exercise on constipation are the
linked co-factors of diet and fluid intake, individual differences in absorbing and metabolising
food and fluids, colonic motility patterns, levels of physical fitness and levels of exercise
undertaken, all of which may affect the material presented to the colon and its passage along
the tract to the rectum.
Given that there is no clear and consistent evidence-based prescription of exercise that can
be offered for helping to prevent constipation, then it is best to look to The National Physical
Activity Guidelines for Australians. These guidelines recommend a level of activity based on
evidence that the specified level of activity or above is associated with general health benefits.
12
Prevention of constipation in adults
These health benefits include reduced risk of coronary heart disease, hypertension, diabetes
mellitus and colon cancer. There is also a reduced risk of premature mortality, reduced
depression and anxiety, improved mood and an increased ability to perform daily tasks.
Further, there is improved muscle strength, balance and co-ordination and an associated
reduction in the risk of falling. Exercise also has recognised benefits for osteoporosis,
arthritis, the immune system, a range of other chronic disease states (including incontinence
and menstrual symptoms) and improved quality of life with ageing.
Recommendations for exercise
• The National Physical Activity Guidelines for Australians recommendation is 30 minutes of
moderate intensity activity (such as walking) most days of the week – Level III evidence
for effectiveness in preventing constipation.
• A physiotherapist with a strong background in exercise can make individualised exercise
prescriptions that will achieve specific desired goals for any one person. Referral to a
physiotherapist may be beneficial for people who find it difficult to implement a change
in exercise patterns – Level IV evidence.
Effective bowel habits - bowel retraining
Bowel retraining is a tool commonly used by physiotherapists and nurses to help their clients
prevent constipation. There are no randomised controlled trials or well designed cohort
studies that have been conducted to evaluate the effectiveness of bowel retraining.
Thus the following material is presented as expert opinion only.
Studies of human colonic activity tell us there are many mechanisms that assist in colon
transit and normal defaecation (Bassotti et al., 1995). Some of these are under behavioural
control and can be used to help develop effective bowel habits. There is an increase in colonic
muscle activity associated with waking up and the urge to defaecate often follows this
increase in motility. Gastro-colonic reflex also causes an increase in contractile activity in the
bowel following food ingestion. This effect can last up to 3 hours (Bassotti et al., 1995).
Normal defaecation begins with an urge to defaecate. The main receptors for this sensation
are stretch receptors in the puborectalis muscle. Emptying is optimal when the urge is
present as this indicates the rectum is full and the internal anal sphincter is relaxed.
If defaecation is socially convenient the levator ani, puborectalis and external anal sphincter
relax. This relaxation of the pelvic floor increases the anorectal angle. The anorectal angle is
further straightened when the hips are flexed greater than 90 degrees as with squatting.
Leaning forward enhances the effect of gravity on the rectal contents. When the rectum is
empty and the increase in intra-abdominal pressure ceases the tonic activity in the pelvic
floor muscles re-appears (Rasmussen, 1994).
Prevention of constipation in adults
13
Straining to defaecate involves strongly contracting the abdominal wall inducing posterior
pelvic tilt. This poor defaecation pattern results in excessive perineal descent and inadequate
release of the anal outlet. Straining over an extended period can lead to long-term damage
to pelvic nerves and muscles and soft tissues.
Recommendations for toileting behaviour
• The most effective time to empty the bowel is when the urge to defaecate is first
experienced. First thing in the morning or following a meal are common times to get this urge.
• Do not strain to empty the bowel. This will stretch down on the muscles supporting the
pelvic area and not empty the bowel effectively.
• For optimal muscle activation and effective use of gravity the correct position to sit on
the toilet is to lean forward with feet supported so that the hips are flexed > 90 degrees;
forearms resting on abducted thighs; back straight (maintaining a normal lumbar curve).
Diagram of correct position
Laxative therapy
If a client has any of the risk factors for constipation it may be useful to utilise some laxatives
to prevent the development of constipation. Evidence from four systematic reviews suggests
that both fibre and laxatives modestly improve bowel movement frequency and
decrease pain in adults with chronic constipation (Petticrew et al., 1997; Tramonte et al.,
1997; University of York, 2001; Wallis et al., 2002). However, there is insufficient evidence
to establish whether fibre is better than laxatives or which laxative (laxative class) is superior.
It is not currently possible to determine the effectiveness of different types of laxatives
(Petticrew et al., 1997; Tramonte et al., 1997; University of York, 2001; Wallis et al., 2002).
The evidence from systematic reviews also indicates that constipation should be managed
with a stepped-care approach. Increase dietary fibre, then introduce laxatives starting with
the cheapest option first (Petticrew et al., 1997; University of York, 2001; Wallis et al., 2002).
More research is required to determine the effectiveness of dietary change and the
comparative effectiveness of bulk and non-bulk laxatives (Petticrew et al., 1997; Tramonte
et al., 1997; University of York, 2001).
In order to prevent constipation in patients with predisposing factors, for example, opioid
medication usage, reduction in mobility due to illness, etc. it may be necessary to use bulk
forming laxatives in the short term until normal patterns of bowel emptying can be resumed
or lifestyle changes can be made.
If this is the case patients need to be given advice about which agents to use and how to
maximise the usefulness of the laxative. (See recommendations below.)
Recommendations for bulking agents
Bulking agents absorb water and expand to increase the bulk and moisture content of the
bowel motion. The bowel is then stimulated by the presence of the bulky stool.
Always drink a full glass of water with each dose, to allow the laxative to work properly and
prevent intestinal blockage.
1. Elbows on knees
Allow 1 to 3 days for this to work.
2. Lean forward
3. Feet on a stool
Prevention of constipation
Changes made to diet and/or fluid intake, exercise and bowel retraining need to be trialled for
2 – 4 weeks before moving on to further constipation-prevention strategies such as the
administration of laxatives.
Examples
• Ispaghula husk (fybogel)
• Psyllium (metamucil, agiofibe)
• Sterculia (granocol, normacol plus)
• Methylcellulose.
Side effects include
• Flatulence and abdominal cramps.
NB A gradual increase in dose is advisable to avoid flatulence and distension.
Level I evidence of effectiveness.
14
Prevention of constipation in adults
Prevention of constipation in adults
15
Management of constipation
Management of constipation
in adults
If your middle-aged client complains of constipation or has any of the risk factors
such as immobility, opioid ingestion or neurological damage and despite behavioural change
continues to experience constipation, commence further assessment and treatment.
Refer for further
assessment/treatment
• Correct position for defaecation
• 30 minutes of exercise daily
• 8 glasses of water a day
• 25-35g of fibre daily
If an otherwise healthy adult complains of on-going, bothersome constipation, a repeat
assessment of presentation, symptoms and antecedents is generally considered good clinical
practice (see Appendix 2). If, after reinforcing the good habits with respect to fibre intake,
fluid intake, exercise levels and toileting behaviour indicated in the table below, there is no
further improvement then treatment or referral will be necessary.
Good habits
Recommendations for dietary fibre and fluids
Therapy for constipation in adults
Reinforce good habits
Refer to the algorithm on the facing page for stepwise approach for the management of
constipation in people aged between 40 and 65 years.
• Maintain a daily intake of 25-35g of fibre per day and a mixture of soluble and insoluble fibre.
• Fluid intake of 1.5 –2 L per day.
• Refer to prevention guidelines.
Recommendations for exercise
The National Physical Activity Guidelines for Australians recommendation is 30 minutes of
moderate intensity activity (such as walking) most days of the week.
Toileting habits
General
Practitioner
Physiotherapist
Dietician
Specialist Nurse
Progressive
introduction
of laxatives
(See p. 18)
Exercise program
Diet planning
Massage
Education
Bowel habit
training
Lifestyle
education
Biofeedback
Attempt defaecation when the urge to defaecate is first experienced. Do not strain to empty
the bowel. Sit on the toilet leaning forward with feet supported so that the hips are flexed
> 90 degrees; forearms resting on abducted thighs; back straight (maintaining a normal
lumbar curve).
Referral pathways
If the client continues to experience constipation or if the client finds it difficult to maintain
lifestyle change it may be necessary to refer to one of the following clinicians.
Physician
Investigations
Pharmacotherapy
Further referral
Surgeon
16
Management of constipation in adults
Management of constipation in adults
17
General practitioner
Table 2
The general practitioner can guide the client in a stepped approach to the introduction of
laxatives should they be needed and can also refer clients with severe problems on to
specialist gastroenterological medical services for assessment and treatment.
Weekly cost of laxatives
Class
Preparation
Laxatives are the most commonly prescribed pharmacological interventions for the treatment
of constipation. Laxatives are associated with increases in bowel movement, frequency and
improvements in the symptoms of constipation.
Bulk forming
laxatives
Bran
Isphaghula husk
Psyllium
Sterculia
Key findings from systematic review
Faecal
softeners
Liquid paraffin
Docusate
sodium
Stimulant
laxatives
Bisocodyl
Senna
Examples as
trade
Trade name
Name
Cost per week
at usual number
of daily doses
Side effects
Effects
~$3.00
$4.67
$3.90
$4.20
Flatulence
and abdominal
cramps.
Agarol
Coloxyl
$5.42
$2.24
None with
short term use.
$1.68
$1.12
$2.33
Abdominal cramps,
flatulence,
electrolyte
imbalance (with
prolonged use).
Liquid paraffin
Durolax
Senokot
Coloxyl and
Senna
Laxettes
Agarol
Osmotic
Polyethylene
Movicol
$7.00
Flatulence,
laxatives
Glycol
Lactulose
Duphalac
$12.40
intestinal
cramping and
diarrhoea.
Laxative medications
• Both fibre and laxatives modestly improve bowel movement frequency and decrease pain
in adults with chronic constipation.
• Insufficient evidence exists to establish whether fibre is better than laxatives or which
laxative (laxative class) is superior. It was not possible to determine the effectiveness of
different types of laxatives.
• Bulk laxatives and osmotic laxatives are associated with increases in frequency and
improvements in stool consistency and symptoms of constipation. A bulking agent in
combination with a stimulant may be a useful combination.
• Constipation should be managed with a stepped-care approach. Increase dietary fibre,
and then introduce laxatives starting with the cheapest option first. (See Table 2)
• More research is required to determine the effectiveness of dietary change and the
comparative effectiveness of bulk and non-bulk laxatives.
Fybogel
Metamucil
Normacol
$5.44
$8.24
Recommendations for laxative prescription
A stepped approach should be used in which bulking agents are introduced first, followed by
either softening or stimulant laxatives with osmotic laxatives used if other laxatives fail or if
side effects (such as flatulence) reduce adherence – Level I.
Evidence
There is no compelling evidence that one laxative is better than another so the cheapest
alternative should be tried first.
18
Management of constipation in adults
Management of constipation in adults
19
The stepped approach to laxative use in constipation
There is no evidence to suggest that laxatives prevent constipation in middle-aged people.
The information given on laxatives is for management of existing constipation using a stepped
approach as suggested in the algorithm included in these guidelines. First changes to diet,
fluid intake and exercise should be attempted. If this does not work laxatives should be
introduced class by class. Laxatives are divided into four classes: bulking agents, faecal
softeners, stimulant laxatives and osmotic laxatives. For the purpose of these guidelines
suppositories and enemas are separated into a fifth class.
NB Laxatives should not be taken within two hours of medication, because the desired effect
of the other medication may be reduced.
Bulking agents
The evidence suggests that there is an improvement in bowel frequency with the use of
bulk laxatives. Evidence from systematic reviews suggests that bulk laxatives are associated
with an increase in frequency of one to two bowel motions per week compared to placebo.
They also soften stools by increasing stool water content and one study found that bulk
laxatives have a greater overall laxative efficacy in subjects with chronic idiopathic constipation.
patients. Overall symptom improvement was greater with treatment of stool softeners but
the effect compared to placebo did not reach statistical significance (Hyland & Foran, 1968).
Recommendations for stool softeners
Faecal softeners help liquid mix into the stool; this softens the stool and permits easier
defaecation. These are best used to prevent straining or when hard stools are present.
Allow 1 to 5 days for these to work. Liquid forms may be taken in milk or fruit juice to
improve the flavour.
Examples
• Docusate sodium (Coloxyl)
• Poloxalkol (Coloxyl drops)
• Liquid paraffin (Parachoc, Agarol).
Stimulants
The systematic review did not reveal any consistent evidence that stimulant laxatives are
more effective than non stimulant laxatives. However, they did produce a mean increase of
2.6 bowel movements per week.
Recommendations for bulking agents
Bulking agents absorb water and expand to increase the bulk and moisture content of the
bowel motion. The bowel is then stimulated by the presence of the bulky stool. It is necessary
to drink a full glass of water with each dose, to allow the laxative to work properly and
prevent intestinal blockage.
Allow 1 to 3 days for this to work.
Examples
• Ispaghula husk (Fybogel)
• Psyllium (Metamucil, Agiofibe)
• Sterculia (Granocol, Normacol plus)
• Methylcellulose.
Side effects include
• Flatulence and abdominal cramps.
Recommendations for stimulant laxatives
Stimulant laxatives stimulate intestinal motility via an irritant effect. Stimulants may cause
abdominal cramping. Prolonged use is not recommended. While there was level II to level III
evidence that stimulant laxatives produced an increase in bowel movements, no consistent
evidence was found that stimulant laxatives are more effective than non-stimulant laxatives.
Allow 6 to 12 hours for these to work.
Examples
• Bisacodyl (Durolax, Bisalax)
• Senna (Senokot, Coloxyl and Senna, Nulax, Prune and Senna, Laxettes with Senna,
Bioglan, Agiolax)
• Phenolpthalein (Figsen, Laxettes, Veracolate)
• Liquid paraffin (Parachoc, Agarol)
• Castor oil (not recommended).
NB A gradual increase in dose is advisable to avoid flatulence and distension.
Faecal softeners
There are very few studies that compare stool softeners to placebo. One randomised controlled
trial examined the role of stool softeners in preventing constipation in elderly nursing home
20
Management of constipation in adults
Side effects include
• Abdominal cramps
• Flatulence
• Electrolyte imbalance (with prolonged use).
Management of constipation in adults
21
Osmotic laxatives
Registered nurses: general and specialist
Laxatives with an osmotic effect appear to be consistently associated with significant
improvements in frequency, consistency, straining and pain compared to placebo (University
of York, 2001).
Nursing is a profession that is skilled in providing primary care, health education and health
promotion. Nurses can provide ongoing client education about normal function, diet, exercise,
medications, procedures and therapies. They have particular skills in assisting clients to
manage their health conditions and therapies within their own particular circumstances,
capabilities and contexts.
Recommendations for osmotic laxatives
Osmotic laxatives encourage bowel movements by drawing water into the bowel, hydrating
and softening the stool.
Allow 2 to 48 hours for this to work.
Registered nurses are registered health care professionals with university degree
qualifications. Specialist nurses have postgraduate and/or specialist qualifications in ostomy
and/or continence nursing.
Each dose should be taken in or with a full glass of water or fruit juice. A more rapid effect
will be achieved if the dose is taken on an empty stomach, with a full glass of liquid or more.
Accessing nursing services
Examples
• Sorbitol 70% (Sorbilax)
• Lactulose (Duphalac, Actilax)
• Magnesium salt (Epsom salts)
• Movicol (Polyethylene Glycol - PEG).
Nursing services can be accessed via a local private or public hospital, home visiting nursing
services and community health services such as a community health centre.
Side effects include
• Flatulence
• Intestinal cramping
• Diarrhoea
• Magnesium and phosphate containing preparations should be used with caution or
avoided in patients with renal insufficiency, cardiac disease, electrolyte imbalances and in
patients on diuretic therapy.
Suppositories and enemas
There is no evidence that suppositories or enemas have any long-term effect on constipation
or the patterns of bowel emptying. They are only appropriate for distal faecal impaction.
Recommendations for suppositories and enemas
Allow 15 to 30 minutes for these to work.
Examples
• Bisacodyl (Durolax)
• Combination products (Microlax, Travad)
• Glycerine
• Docusate sodium (Rectalad).
22
Management of constipation in adults
Management of constipation in adults
23
Physiotherapist
Physiotherapy is a profession with specialised skills in assessment of muscle dysfunction and
muscle retraining and activation. In the case of obstructed defaecation the process involves
assessing muscle dysfunction and retraining the abdominal and pelvic floor muscle timing
and activation.
Australian physiotherapists are registered health care professionals with university degree
qualifications. Physiotherapists who are members of the Australian Physiotherapy Association
(APA) are expected to undertake continuing professional development programs. Some
physiotherapists have specialist expertise in continence management. The Continence
Foundation of Australia (CFA) can provide details of these physiotherapists.
The overall management of the physiotherapy client involves:
• assessment of motor behaviour and physical condition,
• analysis and identification of the client’s problems,
• development of a treatment program,
• management of the treatment or training program, and
• evaluation of progress and modification of treatment if necessary.
Bowel retraining and biofeedback
inpatient environment. However, most studies demonstrate that provision in an outpatient
setting, or an outpatient setting supplemented with home therapy can be just as effective.
Biofeedback is an expensive therapy in terms of personnel and equipment and is not readily
available to the general public in many centres. The simplest form of biofeedback is that
provided by a physiotherapist using basic muscle re-education and positioning as a form of
muscle retraining. Other biofeedback treatment strategies that have been developed include
intrarectal balloon training, intra-anal electromyography (EMG), perianal EMG or some
combination of these strategies. These treatments can be conducted in in-patient settings or
the patient may be taught to use the particular strategy (more common with EMG) and will
then practice the biofeedback at home.
Accessing a physiotherapist
To access the services of physiotherapists clients can contact their local public or private
hospital or community health centre.
Physiotherapists in private practice can be located
• through the local Yellow Pages
• via the website of the Australian Physiotherapy Association www.physiotherapy.asn.au
• by calling the CFA on 1800 33 00 66.
Effective bowel habits used to prevent constipation may also be effective in the
management of constipation, however, there is no research-based evidence to support this
contention. Bowel training and the use of the correct position may be useful as well as
muscle retraining / biofeedback (see Appendix 4).
Biofeedback is used to train the puborectalis muscles of the pelvic floor to relax at
defaecation. In the case of difficulty in emptying the bowel or obstructed defaecation it
involves retraining the striated muscles used in opening and emptying the bowel. It is
theorised that some patients have paradoxical contraction or non-relaxation of the
pubrectalis muscle at defaecation and that this leads to anismus and constipation.
Not all constipation is a result of these disorders of the anorectum, rather these patients are
a sub-group with obstructed defaecation. Biofeedback is not an effective treatment of all
forms of constipation. Biofeedback can be used to teach patients to recognize and
consciously influence the anal sphincter mechanism.
Generally very positive results have been reported for biofeedback. However, many studies were
poorly designed, retrospective, had no randomisation, limited control of extraneous variables,
and had small samples. It is also not certain which groups benefit most from biofeedback.
There is also little account taken of the impact of concurrent factors in the success of
biofeedback, such as education, support, etc. Originally biofeedback was carried out in an
24
Management of constipation in adults
Management of constipation in adults
25
Dietitian
Specialist medical services
Dietitians are health professionals who have specialised knowledge related to human nutrition
and specialised communication skills designed to help people attain and maintain health.
Dietitians translate scientific information related to food, nutrition and mealtime behaviours
into practical advice about how to modify a diet to achieve healthy outcomes. As experts in
food and nutrition advice dietitians provide individual or family counselling, health policy
advice and consultancy services to industry groups.
For clients who have severe constipation, bleeding from the rectum or signs of bowel
obstruction, referral by the general practitioner to a specialist gastrointestinal physician will
be necessary. These physicians, who specialise in gastrointestinal disease, will be able to
investigate the aetiology and contributing factors to severe bowel dysfunction.
Once investigations have suggested a diagnosis of severe rectal dysfunction the physician
may refer the client to a colorectal surgeon.
The Dietitians Association of Australia (DAA) oversees the Accredited Practising Dietitians
(APD) program. APDs have gained a qualification in an accredited university course,
undertake ongoing professional development and commit to uphold the DAA Code of
Professional Conduct.
Colorectal surgeons have skills in surgical techniques designed to correct mechanical bowel
dysfunction that contributes to constipation and also in the use of biofeedback.
A consultation with a dietitian will generally include a dietary assessment, nutritional
assessment and education regarding the most appropriate dietary modification for the
individual. Further consultations may be necessary to monitor progress and to provide
support and encouragement to the individual.
Dietitians may work in a public health facility or in private practice. They may have
consultation rooms in public and private hospitals, nursing homes, community health centres
or private practice centres.
Accessing a dietitian
To access the services of dietitians clients can contact their local public or private hospital or
community health centre.
Dietitians in private practice can be located:
• through the local Yellow Pages
• via the website of the Dietitians Association of Australia www.daa.asn.au
• by calling the APD Hotline on 1800 812 942.
The results of systematic reviews (Knowles et al., 1999; Wallis et al., 2003) indicate that
failure of a prolonged trial of laxatives, fibre and exercise may mean that treatment of slow
transit constipation with either total colectomy or ileorectal anastomosis is required. There is
level III evidence that this treatment will effectively treat the constipation (Wallis et al., 2003).
However, the other symptoms of bloating and flatulence may remain (Locke et al., 2000).
Recommendations for surgical treatment of constipation
Surgical treatment of constipation should only be considered when a prolonged trial of diet
modification, increased exercise, laxatives and biofeedback have been unsuccessful.
If surgical treatment is pursued the following should be noted.
• Careful diagnosis of the underlying cause of the chronic constipation is imperative and
selection of patients for surgical treatments is one of the most important factors in the
success of the procedure.
• Paradoxical puborectalis contraction and descending perineum syndrome should probably
not be treated with current surgical techniques.
• Total colectomy with ileorectal anastomosis may be useful for slow transit constipation
and a reversible stoma formation may have merit for some patients.
• The continent colonic conduit is a procedure that may be of use in helping patients with
severe chronic constipation manage their condition more successfully.
Level I evidence for the above recommendations.
Accessing a specialist physician or surgeon
A referral from a general practitioner is always required before a specialist medical service
can be accessed.
26
Management of constipation in adults
Management of constipation in adults
27
References
Rowell, L. G., & Shepherd, J. T. (Eds.). (1996). Exercise: regulation and integration of
multiple systems. New York: Published for the American Physiological Society by
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Sullivan, S.N. (1992). Overcoming runner's diarrhoea. Physician & Sportsmedicine, 20(10),
63-64, 66-68.
Anti, M., Pignataro, G., Armuzzi, A., Valenti, A., Lascone, E., Marmo, R., Lamazza, A., Pretaroli,
A. R., Pace, V., Leo, P., Castelli, A., & Gasbarrini, G. (1998). Water supplementation
enhances the effect of high-fiber diet on stool frequency and laxative consumption in
adult patients with functional constipation. Hepato Gastroenterology, 45(21), 727-732.
Bassotti, G., Germani, U., & Morelli, A. (1995) Human colonic motility: physiological aspects.
International Journal of Colorectal Disease, 10(3),173-180.
Chung, B. D., Parekh, U., & Sellin, J. H. (1999). Effect of increased fluid intake on stool output
in normal healthy volunteers. Journal of Clinical Gastroenterology, 28(1), 29-32.
Donald, I.P., Smith, R.G., Cruikshank, J.G., Elton, R.A., & Stoddart, M.E. (1985). A study of
constipation in the elderly living at home. Gerontology, 31, 112-118.
Heaton, K. W., & Cripps, H. A. (1993). Straining at stool and laxative taking in an English
population. Digestive Diseases and Sciences, 38(6), 1004-1008.
Koch, T., & Hudson, S. (2000). Older people and laxative use: literature review and pilot study
report. Journal of Clinical Nursing, 9(4), 516-525.
Koffler, K. H., Menkes, A., Redmond, R. A., Whitehead, W. E., Pratley, R. E., & Hurley,
B. F. (1992). Strength training accelerates gastrointestinal transit in middle-aged and
older men. Medicine and Science in Sports and Exercise, 24(4), 415-419.
Locke, G. R., 3rd, Pemberton, J. H., & Phillips, S. F. (2000). AGA technical review on
constipation. Gastroenterology, 119(6), 1766-1778.
Markwell, S., & Sapsford, R. (1995). Physiotherapy management of obstructed defaecation.
Australian Journal of Physiotherapy, 41(4), 279-283.
O’Keefe, E. A., Talley, N. J., Zinsmeister, A. R., & Jacobsen, S. J. (1995). Bowel disorders impair
functional status and quality of life in the elderly: a population based study. Journal of
Gerontological and Biological Science in Medical Science, 50(4), M184-189.
Thompson, W. G., & Heaton, K.W. (1980). Functional bowel disorders in apparently
healthy people. Gastroenterology, 79, 283-288.
Thompson, W. G., Longstreth, G. F., Drossman, D. A., & Heaton, K. W. (1999).
Functional bowel disorders and functional abdominal pain. Gut, 45(Suppl II), 1143-1147.
Tramonte, S. M., Brand, M. B., Mulrow, C. D., Amato, M. G., O'Keefe, M. E., & Ramirez, G. (1997).
The treatment of chronic constipation in adults. A systematic review. Journal of General
Internal Medicine, 12(1), 15-24.
University of York. (2001). Effectiveness of laxatives in adults. Effective Health Care,
7(1), 1-12.
Womens’ Health Australia (1997a). Data book for the baseline survey of the Australian
Longitudinal Study on Women’s Health, Young cohort, 18-23 years. (2nd ed.).
The Research Institute for Gender and Health, University of Newcastle.
Womens’ Health Australia (1997b). Data book for the baseline survey of the Australian
Longitudinal Study on Women’s Health, Mid age cohort, 45-50 years. (2nd ed.).
The Research Institute for Gender and Health, University of Newcastle.
Womens’ Health Australia (1997c). Data book for the baseline survey of the Australian
Longitudinal Study on Women’s Health, Older cohort, 70-75 years. (2nd ed.).
The Research Institute for Gender and Health, University of Newcastle.
Womens’ Health Australia (2002a). Data book for the 2000 Phase 2 survey of the
young cohort (22-27 years). Australian Longitudinal Study on Women’s Health.
The Research Institute for Gender and Health, University of Newcastle.
Womens’ Health Australia (2002b). Data book for the 1998 Phase 2 survey of the
mid age cohort (47-52 years). Australian Longitudinal Study on Women’s Health.
The Research Institute for Gender and Health, University of Newcastle.
Petticrew, M., Watt, I., & Sheldon, T. (1997). Systematic review of the effectiveness of
laxatives in the elderly. Health Technology Assessment, 1(13).
Womens’ Health Australia (2002c). Data book for the 1999 Phase 2 survey of the
older cohort (73-78 years). Australian Longitudinal Study on Women’s Health.
The Research Institute for Gender and Health, University of Newcastle.
Probert, C. S., Emmett, P.M., & Heaton, K.W. (1995). Some determinants of whole-gut
transit time: a population based study. QJM Monthly Journal of the Association of
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Ziegenhagen, D. J., Tewinkel, G., Kruis, W., & Herrmann, F. (1991). Adding more fluid to
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28
References
References
29
Appendices
Appendix 2
Assessment proforma
Assessment guidelines for constipation management
Presenting symptoms
Appendix 1
Levels of evidence used in systematic review
The levels of evidence referred to throughout these guidelines relate to those used for the
systematic review referred to in these guidelines. The level of evidence represented by the
articles was assessed by two independent assessors using criteria based on the National
Health and Medical Research Council’s (2000) criteria described in "A Guide to the
Development, Implementation and Evaluation of Clinical Practice Guidelines".
These levels are
Level I Evidence obtained from a systematic review or meta-analysis of all relevant
randomised controlled trials.
Level II Evidence obtained from at least one properly designed randomised controlled trial.
Level III - 1 Evidence obtained from well-designed pseudo-randomised controlled trials
(alternate allocation or some other method).
- 2 Evidence obtained from comparative studies with concurrent controls and
allocation not randomised (cohort studies), case control studies or interrupted
time series design with a parallel control group.
- 3 Evidence obtained from comparative studies with historical control, two or
more single arm studies or interrupted time series design without a parallel
control group.
Level IV Evidence obtained from case series (either post-test or pre-test and post-test),
opinions of respected authorities, descriptive studies or reports of expert committees.
➔ Presenting symptoms (as described by the client)
Duration of these symptoms
Previous management and effect of these on bowel function
Investigations (has the client undergone any bowel investigations eg. colonoscopy, X-ray,
defaecogram, ultrasound, manometry)
Current medications (use * to denote recognised constipating effect eg. Antacids;
anticholinergics; antidepressants; opioids; antihistamines; antihypertensives)
Medical / Surgical history (include gynaecological history in women)
Bowel Habits
➔ Frequency (normal is between 3/day and 3/week)
➔ Consistency
➔ Urge
normal
loose/watery
reduced
➔ Sensation of complete emptying
30
Appendices
soft
formed
lumpy
hard
no urge
always
mostly
sometimes
never
Appendices
??????????
31
Bleeding
Pain
no
no
Food and Fluids Chart
yes – when?
yes – when?
(If Yes to bleeding and pain – further investigation necessary)
Date
Straining
always
mostly
sometimes
never
Sitting position
leaning forward
leaning back
upright
Feet supported
no
yes
Manual assistance
digital evacuation
support pelvic floor /perineam
Time taken to empty
➔ Faecal incontinence
flatus
liquid
Morning
Lunch
Afternoon
Dinner
Evening
solids
FOOD
➔ Emptying pattern –
•
•
•
•
•
Breakfast
yes – when?
FLUID
no
mucous
(Severe constipation / faecal impaction is a frequent cause of FI – further
investigation is recommended)
FOOD
➔ Abdominal discomfort / bloating
Refer to fluids / food chart for fibre and fluid content of diet. Ask client to complete for a
minimum of 3 days. (See next page).
whole body or
endurance or
muscle groups
strength
FLUID
Sessions per week
Length of each session
Intensity
not out of breath
out of breath
out of breath and sweating
➔ Physical assessment
FOOD
Type (mainly)
FOOD
➔ Physical activity / exercise
FLUID
➔ Diet / Fluid intake
Send for medical / specialist review if
Sudden change in bowel habits
Pain
Bleeding
Poor response to treatment
Reassess using ➔ points, 4 – 6 weeks after initiation of management program. Refer to initial
assessment for comparison.
32
Appendices
FLUID
Assess hydration and abdomen for masses and abnormal bowel sounds.
Record all food and drinks consumed over a ___ day period. This record will help to determine
if your diet lacks certain fibre types and / or fluids.
Please also note if any foods seem to improve or worsen your symptoms of constipation.
??????????
Appendices
33
Appendix 3
Investigations
Appendix 4
Bowel training instructions
Investigations
Uses
Digital anal examination
Assessing structural abnormalities and / or impacted faeces.
Plain X-ray
Assessing impaction of the large bowel.
Endoscopy
Visualisation of internal gastrointestinal tract to check for
abnormalities, inflammation, neoplastic changes.
First adopt ‘The Correct Sitting Position’.
(See diagram p. 14). - This sitting position facilitates optimal muscle action for
defaecation: feet supported, forearms resting comfortably on thighs and the back straight
with the normal lumbar curve.
Defaecating proctogram Assessing adequacy of rectal emptying, perianal descent,
anorectal angle, rectal prolapse/rectocele.
RELAX the tummy and back passage.
(Levator ani, puborectalis and external anal sphincter relax increasing the Anorectal angle)
Endo-anal ultrasound
Assessing integrity of anal sphincter (can also assess via MRI).
Ano-rectal manometry
Assessing sphincter muscle functions - sensation of distension,
resting and squeeze pressures, effectiveness of ano-rectal
inhibitory reflex.
BULGE the tummy muscles forward and feel the waist WIDEN.
(Increases intra-abdominal pressure (IAP) using contraction of external obliques followed by
internal obliques, transversus abdominus and diaphragm)
Colonic transit studies
Radio-opaque markers record faecal matter transit through colon.
EMG
Electromyography.
Instructions to help the client adopt the correct action to empty the bowel
HOLD this position while the bowel opens.
REPEAT ➔ RELAX ➔ BULGE forward & WIDEN at the waist ➔ HOLD and REPEAT
until empty.
Do not strain down at the back passage.
(Straining recruits rectus abdominus and co-activates the pelvic floor and posteriorly tilts
the pelvis)
This emptying process should take no longer than 1 minute.
To finish, tighten in and up at the back passage.
(Contracts the pelvic floor)
This emptying pattern increases intra-abdominal pressure while correctly coordinating the
ano-rectal muscles for effective defaecation (Markwell & Sapsford, 1995).
General pelvic floor strengthening exercises are also encouraged to improve support of
the rectum and muscle awareness.
34
?????????
Appendices
Appendices
??????????
35
CRICOS Provider Number 00233E
Funded by the National Continence
Management Strategy