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Constipation

Constipation is defined as difficulty, delay or pain on defaecation. It reflects either a slow colonic transit and/or impaired rectal emptying.
© Association for Continence Advice. CC BY-NC 4.0
The term constipation describes a symptom. It comes from the Latin constipare which means crowded together.
Constipation is defined as difficulty, delay or pain on defaecation. It reflects either a slow colonic transit and/or impaired rectal emptying.
Constipation can cause stools to be hard and lumpy and either unusually large or small. The individual is not passing stool regularly and is not able to completely empty their bowel.
The severity of the constipation varies between individuals from a slight problem that does not cause disruption to life to a severe problem which has a major impact on the individual’s social and personal functioning.

Types of Constipation

  • Primary or idiopathic constipation (not related to a condition or pathology) – could be linked with immobility, poor diet, slow colonic transit, and pelvic floor abnormalities.
  • Secondary constipation (another disorder is the cause of the constipation) – this could be a metabolic, psychological or neurological disorder
  • Functional constipation – this presents as a persistently difficult, infrequent or feeling of incomplete defaecation
  • Obstructive defaecation syndrome (ODS) – a feeling of an anal blockage on more the a quarter (25%) of occasions and prolonged defaecation (more than 10 minutes to complete evacuation) or need for self-digitation on any occasion and in individuals with neurogenic bowel dysfunction
  • Anismus or dyssynergic defaecation – a failure of co-ordination between the anal sphincter and pelvic floor muscles during defaecation and a failure of normal relaxation. More common in women. Sometimes a hidden cause of chronic constipation.
  • Faecal impaction – loading of the rectum and often the descending colon which the individual is unable to evacuate.
    This can result in impaction with overflow of spurious diarrhoea. A common problem with frail older people and individuals with neurogenic bowel dysfunction. Often misdiagnosed as diarrhoea.
For further information, read the article Management of lower bowel dysfunction, including DRE and DRF. RCN guidance for nurses (available from Royal College of Nursing website)[1].
This article gives guidance on how nurses can positively help patients with bowel disorders and maps out the wide range of skills required for specific aspects of bowel care, while helping to facilitate best practice.

Symptoms of constipation

Symptoms of constipation include:
  • Abdominal pain
  • Infrequent and incomplete evacuation
  • Abdominal distention
  • Nausea
  • Headaches
  • Mood swings
  • Poor concentration
  • Malaise and lethargy – less common
  • Frequently there is a history of a high use of laxatives
Studies have identified a link between functional gastro-intestinal disorders and physical or sexual abuse. This links to assessment and the release of emotions when discussing.
For further information, read the article Constipation (available from Medscape’s website)[2].
Please note: to read the full article you will have to register (however it is free of charge).
Clinical practice points. Clinical signs of constipation are a distended abdomen, reduced bowel sounds, on digital rectal examination a gaping anus or impacted rectum. See Figure 4.9 for an illustration of rectal loading.

Causes of constipation

MechanismCause
Insufficient volume of stool in the large bowelInsufficient fibre in diet, poor fluid intake
ImmobilityLack of exercise results in a less active bowel, longer transit times. Mobility problems, difficulty getting to the toilet
EnvironmentalIssues that prevent defaecation – lack of privacy, dirty toilet, no toilet paper, height of toilet
Laxative abuseOver use of laxatives can damage the nerves in the colon and cause an atonic bowel
MedicationsDiuretics, iron, analgesic opiates, anticholinergics, antidepressants, aluminium (antacids), anti-Parkinson drugs, antihypertensives
PregnancyHigh progesterone levels decrease the motility of the gastrointestinal tract
Metabolic conditionsDiabetes mellitus, hypothyroidism, dehydration
Abnormal neurological controlSpinal and nerve injury affecting autonomic nervous system, Hirschsprung’s disease, psychological factors which cause an inhibitory effect on the autonomic nervous system
ObstructionCongenital abnormality (stenosis, anorectal malformation), haemorrhoids, diverticular disease, tumours

Causes of constipation in older people

The primary cause of faecal incontinence in elderly people is overflow incontinence secondary to constipation and faecal impaction.
This is treatable and preventable but often over-looked and not correctly diagnosed or effectively treated.

Risk factors for constipation

Risk factors for constipation include:
  • Low fluid intake
  • Lack of fibre in diet – this results in decreased faecal bulk, which results in decreased peristalsis
  • Faddy eater/high intake of convenience foods
  • Lack of structured meal times and not having breakfast
  • Change in routine/lifestyle/eating habits – travel, pregnancy, shift work
  • Lack of toileting routine for bowels
  • Lack of opportunities to use the toilet to defaecate when urge is present
  • Limited privacy when using toilet
  • Deferring defaecation or withholding the urge to defaecate
  • Painful defaecation
  • Reduced mobility or lack of exercise
  • Having a high temperature
  • Being under- or overweight
  • Anxiety and depression
Did you know? Constipation is a common side effect of medication, particularly codeine, morphine, iron, anti-depressants, anti-epileptics, aluminium antacids, diuretics, Parkinson’s medications.

Diagnosing constipation

Rome IV criteria for functional constipation:
  1. Must include 2 or more of the following:
    a. Straining during more than one-quarter (25%) of defaecations
    b. Lumpy or hard stools (Bristol stool chart 1 or 2) more than one-quarter (25%) of defaecations
    c. Sensation of incomplete evacuation more than one-quarter (25%) of defaecations
    d. Sensation of anorectal obstruction/blockage more than one-quarter (25%) of defaecations
    e. Manual manoeuvres to facilitate more than one-quarter (25%) of defaecations (such as digital evacuation or support of the pelvic floor)
    f. Fewer than three spontaneous bowel movements per week
  2. Loose stools are rarely present without the use of laxatives – this must be for the last three months with symptom onset at least six months prior to diagnosis
  3. There are insufficient criteria for a diagnosis of irritable bowel syndrome
For further information, read the article Diagnosis and treatment of constipation: a clinical update based on the Rome IV criteria (available from the ScienceDirect website)[3].

References

1. Management of lower bowel dysfunction, including DRE and DRF. RCN guidance for nurses. [11 September 2019; cited 20 December 201(] Available from: https://www.rcn.org.uk/-/media/royal-college-of-nursing/documents/publications/2019/september/007-522.pdf/
2. Basson MD. Constipation. Medscape. [Updated 4 July 2019; cited 20 December 2019] Available from:https://emedicine.medscape.com/article/184704-overview
3. Sobrado CW, Corrêa Neto JF, Ambar Pintoa R, Faraco Sobrado L, Nahas SG, Cecconello I. Diagnosis and treatment of constipation: a clinical update based on the Rome IV criteria. J Coloproctology. 2018;38;2;137-144. [Cited 24 August 2018] Available from: https://doi.org/10.1016/j.jcol.2018.02.003
© Association for Continence Advice. CC BY-NC 4.0
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Understanding Continence Promotion: Effective Management of Bladder and Bowel Dysfunction in Adults

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