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Primary treatment of
constipation
• Explanation of symptoms and education
• Ensure adequate fluid intake (1500 mls)
• Adequate, but not excessive, fibre intake
(suggested 30gm fibre per day). This should
be in a mixture of formats rather than just
adding cereal fibre to the diet
• Increase daily exercise if possible
(massage??)
Retraining for chronic
constipation - 1
• Educate the patient about normal bowel
activity
• Stop all laxatives
• Eat breakfast and take a warm drink
• Capitalise on the gastro-colic response by
attempting to use the toilet approximately
20-30 minutes after breakfast
• Sit on toilet with feet raised on a footstool
Retraining for chronic
constipation - 2
• Use abdominal muscles to expel stool, but
do not hold breath and strain
• Review medications and change those
likely to cause constipation if possible
• Glycerin suppositories may help for 1-2
weeks to get a regular bowel habit
established, but always review this after 2
weeks.
Biofeedback for constipation
• Show patient paradoxical EAS contraction
(EMG): learn to relax
• Rectal sensation training
• Abdominal EMG: pushing correctly?
• No evidence that biofeedback better than
verbal training in adults or children
• May help “sell” the exercises to sceptical
patients?
Rational use of laxatives
• Most become less effective with time
• Some cause abdominal discomfort and
bloating
• Response seems very individual
• Very limited evidence base
• Rectal vs. oral?
• What to try first
– Symptoms, past history, what else??
Laxatives: non-impacted
• Address diet, fluid, toilet, exercise, habit
• Evacuation difficulty – suppository or micro
enema
• Hard stool – bulk laxative
• Symptoms persist – add stimulant
• Symptoms persist – try osmotic agent
(Emmanuel 2002)
Impaction
• Exclude organic disease
• Non-ambulant: enemas
• Ambulant: osmotic eg magnesium
sulphate or macrogols
(Emmanuel 2002)
When to use manual
evacuation?
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Faecal impaction / loading
Incomplete defaecation
Inability to defaecate
Other bowel emptying failed
Neurogenic bowel dysfunction
Spinal Cord Injury
Anal electrical stimulation
• Suggested should improve muscle
function
• Strong enough current @ 35Hz :
involuntary muscle contraction
• Used especially when voluntary
contraction very weak
Anal electrical stimulation: RCT
• Biofeedback waiting list
• Recruited, NO ASSESSMENT OR
ADVICE OR EXERCISES
• Randomised (blinded) to 35Hz or 1Hz
• 8 weeks use at home
• Manometry, diary, symptom questionnaire
before & after
• Patients’ evaluation after
Results
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90 patients randomised
43 sham (1Hz), 47 active (35 Hz)
70 completed
No differences active & sham detected
Median rating +2 (-5 to +5 scale)
Median satisfaction 5.5/10
Sensitisation may be more important than
strenthening??
• (Norton et al 2006, DCR Feb)
Summary
• Biofeedback is a tool to help patients learn
about bowel function and how to control it
• Patient teaching and education may be the
most important part
• Biofeedback useful with some patients
• But you CAN run a good service without
fancy equipment