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Constipation can oftentimes be difficult to discuss, even with a health professional. It is a defecation disorder that can significantly impact daily life and should not be neglected. Normal bowel movements occur up to 3 times per day or 1 to every 3 days. If your bowel movements occur less than twice per week, continue reading.

What is Constipation?

Constipation is defined by the International Urogynecological association as “a complaint that bowel movements are infrequent and / or incomplete and/or there is a need for frequent straining or manual assistance to defecate”. Infrequent bowel movements occur twice per week, the rectum does not feel empty after opening the bowels. The final criterium is excess effort or manual assistance to assist with evacuation.

Classification

  1. Straining during more than ¼ (25%) of defecations
  2. Lumpy or hard stools (Bristol Stool Form Scale 1-2) more than ¼ (25%) of defecations
  3. Sensation of incomplete evacuation more than ¼ (25%) of defecations
  4. Sensation of anorectal obstruction/blockage more than ¼ (25%) of defecations
  5. Manual manoeuvres to facilitate more than ¼ (25%) of defecations (e.g., digital evacuation, support of the pelvic floor)
  6. Fewer than three soft bowel movements per week
  7. Loose stools are rarely present without the use of laxatives
  8. Insufficient criteria for irritable bowel syndrome

Constipation is defined as 2 or more of the above.

Causes

  • Cancer or cancer related causes
  • Hormonal changes
  • Metabolic disorders
  • Gastrointestinal disorders
  • Neurological conditions
  • Psychological conditions
  • Pregnancy
  • Age
  • Medications
  • Other factors such a sexual trauma, privacy and time

Engaging with a General Practitioner will guide the treatment pathway and rule out alternative diagnoses. This will involve an anorectal exam whereby your Physician will visually and digitally assess the rectum for masses, strictures, blockages and tone. This may be accompanied by an X-ray. Your Physician will review your medication list for any possible contributing pharmacological agents that can be altered to another type, dosage or key ingredient.

Management

Unfortunately, there is not a lot of evidential support for lifestyle intervention regarding constipation however it is the least invasive and requires little effort to implement changes. Being aware of the signals to pass a bowel movement is a great starting point, this will usually occur after a meal and if ignored, can reduce normal rectal signalling overtime.

Increasing fluid and fibre intake are commonly recommended for the management of constipation. Water intake for healthy adults should be 1.5-2 litres. Evidence shows that increasing water consumption above this recommended amount will not reduce constipation however drinking less than 500ml will reduce bowel movement frequency. Studies have validated increases in both fluid intake frequency and fibre ingestion as a combined therapy. In the pregnant population, increasing fluid intake has demonstrated positive effect on pregnancy related constipation.

Recommended fibre intake is between 20-35 grams for healthy adults. Fibre can be found in fruits, vegetables, nuts, legumes, breads, pastas and cereals. Alternatively, fibre supplementation, laxatives, caffeine and exercise can aid constipation. Laxatives and other fibre supplements when used in excess can cause diarrhoea and abdominal discomfort.

Toileting Posture and Position

Ensuring correct posture and position when opening the bowels is vital to reduce strain on the pelvic floor, reduce dyssynergic motor control and allow for complete emptying. When opening the bowels:

  1. Lean forward with your trunk
  2. Rest the elbows onto the knees
  3. Ensure the knees are above the level of the hip
  4. Use a stool or toilet roles to elevate the feet – DO NOT go onto the tip toes

Breathe, brace and bulge technique:

  1. Breathe into the belly and relax the shoulder and upper body, this is also called diaphragmatic breath.
  2. Brace the stomach by trying to widen the waist. With your hands on your waist, try and move your ribs down and out. As if you are pretending to blow up a balloon without breathing out.
  3. Bulge your stomach outwardly
  4. Maintain the breath, and push into the belly and waist a little more to bring the bowel movement into the rectum
  5. Once you have passed the bowel movement, contract/ lift the pelvic floor to ensure complete closure. Imagine picking up a blueberry with your back passage.

Ensure that you are not holding the breath when toileting, bearing down or straining to pass a bowel movement. See diagram below for guidance.