Constipation

What is constipation?

Constipation is a very common medical complaint affecting most people at some time. Around 1 in 10 children will seek medical assistance and around 1 in 5 adults complain of being constipated. Most people regard constipation as when they cannot empty their bowels as easily or frequently as they would like to. For others, it is the passage of hard stools or difficulty with bowel motions. The range of “normal” varies from 3 bowel motions per day to 1 bowel motion every 3 days.

What causes constipation?

Constipation can be functional (no underlying cause) or may be due to an underlying cause (secondary constipation). Symptoms that may indicate a secondary cause include a recent change in bowel habits, rectal bleeding, weight loss, incomplete evacuation, needing to digitate to evacuate (use fingers) or abdominal pain.
Many of the causes relate to lifestyle. These include:

• Low fibre diet
• Inadequate fluid intake
• Sedentary lifestyle / inadequate exercise
• Stress or anxiety
• Poor toileting habits.

Other causes of constipation relate to medical problems and medications:

• Certain drugs and medications such as pain killers
• Neurologic conditions (eg Parkinson’s)
• Underactive thyroid
• Pregnancy.

Underlying conditions leading to constipation include:

• Physical blockage or narrowing of the bowel (mechanical)
• Slow movement of stool (slow transit constipation)
• Problems related to defecation (include obstructive defecation, rectocele, rectal prolapse, pelvic dyssynergia/anismus).

What are the common symptoms of constipation?

The most common complaint is infrequent bowel motions. Other symptoms include:

• excessive straining to pass stool
• passing very hard stools
• a sense of incomplete evacuation of stools
• needing to use fingers to evacuate.

Does diet play a role?

A healthy diet with adequate fibre (or a supplement) and adequate fluid will be all that is required for many patients. Regular exercise and good toileting habits will also contribute. The best time to pass stools is usually early in the morning and after meals when the colon is stimulated with “mass movements”. Some people find lifting the knees above the level of the hips a useful technique to improve the angle for defecation. A small stool or foot-rest can assist.

When do I need to see a doctor?

Symptoms that should prompt a visit to the doctor include a change in bowel habits, abdominal pain/distension, rectal bleeding, weight loss, incomplete evacuation, a lump, needing to use fingers/digitation to evacuate. Also, persistent constipation requiring ongoing laxatives should prompt a visit to the doctor to make sure there is no secondary cause of the constipation.

How is constipation treated?

Most constipation is treated with the simple measures identified above as well as laxatives. There are different types of laxatives including:

• Bulking agents such as fibre supplements
• Stool softeners such as polyethylene glycol (PEG)
• Bowel stimulants such as senna or biscodyl.

Generally, a bulking agent is tried first although is not usually successful by itself for moderate to severe constipation and may worsen the constipation in some patients. A gentle stool softener such as a PEG preparation that is available over-the-counter is a good first line option and can be titrated for effect. Some patients require stimulants as well to improve their symptoms.

What might my surgeon do to treat constipation?

A surgeon is usually required if an underlying condition is discovered that is causing the constipation. The treatment will depend on the problem as follows:

• Blockage/obstruction – surgery may be needed to remove the affected part of the bowel
• Slow transit constipation – most patients can be successfully managed with laxatives. Occasionally, surgery will be needed to remove the sluggish bowel and join the small bowel to the rectum
• Obstructive defecation – usually treated with a combination of diet, laxatives and biofeedback with the help of a physiotherapist. Sometimes a Botox injection may be recommended
• Rectal prolapse – can be treated surgically with either an abdominal or perineal procedure. Your surgeon can outline the relative advantages of each option.
• Rectocele – physiotherapy can help. Some patients may require surgical correction of the rectocele.

What is a colorectal surgeon?

A colorectal surgeon is an expert in the surgical and non-surgical treatment of colon and rectal conditions. In Australia, a colorectal surgeon has completed general surgical training to be a specialist general surgeon (FRACS). A minimum of 2 years of clinical post-fellowship training is then undertaken in high volume accredited institutions through the Colorectal Surgical Society of Australia and New Zealand (CSSANZ). There is also a research requirement and a written examination on colon and rectal conditions. An equivalent domestic or international experience may qualify a surgeon for CSSANZ accreditation.