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Constipation is a common lower gastrointestinal tract condition that can lead

to hospital admission for many sufferers. It is particularly common in younger children and older adults, although it does cross all genders and ages.

With 25% of the population experiencing some symptoms within their lifetime (Belsey et al, 2010; Tack et al, 2011), it is a problem that deserves more attention. Hospital episode statistics data from 2009/10 showed almost 64,000 inpatient admissions in the UK caused by constipation (Health and Social Care Information Centre [HSCIC, 2010)

How can community nurses manage chronic constipation?

— 73% of these were emergency admissions rather than elective waiting list episodes and the average length of stay was 5.6 days. The total of 147,000 occupied bed days directly related to constipation equates to a substantial financial burden on the NHS, which, it could be argued, is largely preventable.

WHAT IS CONSTIPATION?

Defining constipation is a challenge as there is no universal agreement on what the term means. It is typically defined as an individual experiencing less than three bowel movements a week, however, patients often describes a wider variety of symptoms (Jamshed et al, 2011). The experience of constipation is subjective and individual perceptions of the condition vary (Woodward, 2012).

However, a broad definition that goes someway to bridging the gap between traditional medical views of the condition and the reality of patient experience would include unsatisfactory defaecation characterised by infrequent stools and/or difficult stool passage (Brandt et al, 2005; Gallegos-Orozco et al, 2012).

It is widely acknowledged that people who experience chronic constipation in any form find that it has a substantial negative effect on the social, economic, functional and

Sharon Holroyd, lead clinical nurse specialist, Continence Service, St John’s Health Centre, Halifax

Constipation is a widespread problem although its subjective nature can mean that diagnosis and treatment can be difficult as there is often a mismatch between patients’ and clinicians’ view of the condition. Constipation is widely believed to include unsatisfactory defecation, infrequent stools and/or difficult stool passage. Thorough patient assessment and promotion of continence issues are imperative to improving services for people with constipation. This article highlights how breaking social taboos around bladder and bowel issues, helping people to acknowledge bowel issues, and referring them to the appropriate specialist nurse-led services will all help to provide a more accurate and timely diagnosis of constipation.

KEYWORDS:Continence Chronic constipation Bowel issues Diagnosis

Sharon Holroyd

THE SCIENCE — COMMON BOWEL SYMPTOMSSymptoms of bowel dysfunction are varied, but common problems

include:Difficulty having bowel movements or less than three bowel movements per week may indicate constipation, as does straining on the toilet or not feeling ‘empty’Passing ‘watery’ or very loose stools over three times a dayAbdominal pain (located in the lower left stomach) and changes in bowel habits, such as constipation or diarrhoea as well as mild fever, nausea and vomiting are symptoms of diverticular diseaseDiarrhoea, weight loss and abdominal pain are symptoms of Crohn’s diseaseBloody or mucus-filled diarrhoea as well as a constant urge to go to the toilet are symptoms of ulcerative colitisLeaking faeces without being aware of it is a sign of faecal incontinence.

Source: Bladder and Bowel Foundation: www.bladderandbowelfoundation.org

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76 JCN 2015, Vol 29, No 5

emotional aspects of their life (Koch and Hudson, 2000; Cheng et al, 2003). In some cases the impact can be comparable to conditions such as osteoarthritis, rheumatoid arthritis and diabetes (Belsey et al, 2010).

Other commentators such as Marples (2011) have suggested that constipation should be considered a symptom rather than a disease, as there are many causes of constipation and often it is a consequence of other conditions, medications or lifestyle choices rather than a disease process in itself.

Self-managementWhatever the definition of constipation, it is clear that it represents a real burden to the health economy, particularly as it is estimated that official figures only detail a small proportion of the true incidence, with many sufferers managing their own symptoms — this is evident in the millions spent in the UK every year on over-the-counter laxatives (Higgins and Johanson, 2004; Potter and Wagg, 2005).

Many people are too embarrassed to seek medical help for their condition and try to self-manage (Pare et al, 2001) — even those who do look for medical assistance often report dissatisfaction with the treatment (Tack et al, 2009/2011; Johanson and Kralstein, 2007).

the delayed movement of bowel contents through the intestine. The efficiency of bowel motility is reduced and often accompanied by increased resistance of bowel contents in transit (Bharucha, 2007). People with slow transit constipation have difficulty with the physical act of defaecation.

Generally, this type of constipation has no obvious or identifiable anatomical or physiological cause and the sufferers are often otherwise healthy (Marples, 2011). It is more common in women, but crosses all ages and genders (Kyle, 2011; Marples, 2011).

Slow transit constipation may go undiagnosed for a long time, in part due to individuals managing the symptoms themselves with over-the-counter medications (Burke, 2010). People often complain of nausea, bloating, cramps and faecal straining or incontinence. They are often too embarrassed to ask for help and their symptoms can cause them to take time off work, having a significant impact on social and economic status (Tod et al, 2007; Neri et al, 2014; Sanchez and Bercik, 2011).

DEFAECATION DISORDERS

Also known as outlet constipation or pelvic floor dysfunction, these disorders are characterised by an inability to coordinate the muscles of the pelvic floor during defaecation. In such cases, the stool reaches the rectum but cannot be expelled. Patients describe excessive or prolonged straining, soft stools that are difficult to pass and rectal

CAUSES/TYPES OF CONSTIPATION

Constipation can be acute or chronic. Chronic constipation is generally defined as an episode where the symptoms last for longer than three months (Gray, 2011).

Research organisation the Rome Foundation has issued criteria to assist clinicians in the classification of functional gastrointestinal disorders, the most recent of which is termed Rome III (Rome Foundation, 2006). The classification refers to chronic constipation as exhibiting two or more of the symptoms listed in Table 1 — it also differentiates constipation from irritable bowel syndrome (IBS).

Constipation may also be secondary to an underlying pathology such as Parkinson’s disease, multiple sclerosis (MS) and IBS, or as a side-effect of medication. A well-known example of the latter is constipation as a result of opioid medication used after orthopaedic surgery. A thorough investigation that excludes any underlying pathology will determine a diagnosis of functional constipation (Woodward, 2012).

Normal transit constipationThis refers to the patient’s perception of being constipated despite normal stool movement through the bowel (Jamshed et al, 2011). Individuals often report abdominal pain and bloating, however, these symptoms will generally respond to pharmacological treatment including laxatives and fibre supplementation.

Slow transit constipationAs the name suggests, this refers to

Red Flag Rectal bleeding

Rectal bleeding can be caused simply by swollen blood vessels or small tears in the tissue of the anus (bright red blood), but can be more serious and should never be ignored. If the blood is darker in colour (melaena — black or plum-coloured blood), it may come from the digestive system and is potentially more serious. Although rectal bleeding can signify early bowel cancer, there are many other symptoms that need to be verified and the patient should always seek medical advice.

Source: www.nhs.uk/conditions/rectal-bleeding

Table 1: Summary of the Rome III classification

Criteria must be fulfilled for at least the last three months with symptom onset at least six months before diagnosisPresence of two or more of the following symptoms: Lumpy/hard stools in at least a quarter of all bowel movements Straining during at least a quarter of all defaecations Sensation of incomplete emptying in at least a quarter of all defaecations Sensation of anorectal obstruction/blockage in at least a quarter of all defaecations Manual manoeuvres to facilitate at least a quarter of all defaecations (digital stimulation, evacuation,

pelvic floor support).

Loose stools rarely present without use of laxatives

Insufficient criteria for irritable bowel syndrome (IBS)

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macrogol 3350, sodium hydrogen carbonate,sodium chloride, potassium chloride

letsyou be youConstipation relief for everyday people.

Presentation: MOVICOL Sachet of white powder which dissolves in about 125ml water to make a lemon/lime flavoured drink. Each sachet contains: 13.125g macrogol 3350, 178.5mg sodium hydrogen carbonate, 350.7mg sodium chloride and 46.6mg potassium chloride. MOVICOL Plain Sachet of white powder which dissolves in about 125ml water. Each sachet contains: 13.125g macrogol 3350, 178.6mg sodium hydrogen carbonate, 350.8mg sodium chloride and 50.2mg potassium chloride. Does not contain flavourings or sweeteners. MOVICOLChocolate Sachet of white to light brown powder which dissolves in about 125mlwater to make a chocolate flavoured drink. Each sachet contains: 13.125gmacrogol 3350, 178.5mg sodium hydrogen carbonate, 350.7mg sodium chlorideand 31.7mg potassium chloride. MOVICOL Liquid A clear concentrated liquid, whichis diluted in water to make an orange flavoured drink. Each 25ml of MOVICOL Liquid is diluted in 100ml of water before use and contains the following active ingredients: 13.125g macrogol (polyethylene glycol) 3350, 178.5mg sodium hydrogen carbonate, 350.7mg sodium chloride and 46.6mg potassium chloride. MOVICOL-Half Sachet of white powder which dissolves in about 62.5ml of waterto make a lemon and lime flavoured drink. Each sachet contains: 6.563g macrogol3350, 89.3mg sodium hydrogen carbonate, 175.4mg sodium chloride and 23.3mgpotassium chloride MOVICOL Paediatric Plain Sachet of white powder, which dissolves in about 62.5ml of water. Each sachet contains: 6.563g macrogol 3350, 89.3mg sodium hydrogen carbonate, 175.4mg sodium chloride and 25.1mg potassium chloride. Does not contain flavourings or sweeteners. MOVICOLPaediatric Chocolate Sachet of white to light brown powder, which dissolves in about 62.5ml of water to make a chocolate flavoured drink. Each sachet contains: 6.563g macrogol 3350, 89.3mg sodium hydrogen carbonate, 175.4mg sodium chloride and 15.9mg potassium chloride. Uses: MOVICOL, MOVICOL Plain, MOVICOL Chocolate and MOVICOL-Half: Treatment of chronic constipation and faecal impaction in adults, adolescents and the elderly. MOVICOL Liquid: Treatment of chronic constipation. MOVICOL Paediatric Plain and MOVICOL Paediatric Chocolate: Treatment of chronic constipation in children aged 2-11 years. For the treatment of faecal impaction in children from the age of 5 years. Dosage and administration: MOVICOL, MOVICOL Plain and MOVICOL Chocolate ChronicConstipation: Adults, adolescents and the elderly: 1-3 sachets daily in divided doses, according to individual response. For extended use: adjust dose down to 1 or 2 sachets. Children (below 12 years): not recommended. Alternative MOVICOL products are available for children. Extended use may be necessary in patients with severe chronic or resistant constipation, secondary to multiple sclerosis or Parkinson’s Disease, or induced by regular constipating medicine, in particular opioids and antimuscarinics. A course of MOVICOL, MOVICOL Plain or MOVICOL Chocolate treatment does not normally exceed 2 weeks, but can be repeated if required. Faecal Impaction: Adults, adolescents and the elderly: 8 sachets per day.

A course of treatment for faecal impaction does not normally exceed 3 days. The8 sachets should be taken over 6 hours (2 sachets per hour maximum in cardiovascular impairment). The 8 sachets may be dissolved in 1 litre of water. Children (below 12 years): Not recommended. Alternative MOVICOL products are available for children. MOVICOL Liquid Chronic Constipation: Adults, adolescents and the elderly: 25 ml diluted in 100 ml of water 1-3 times daily in divided doses, according to individual response. For extended use, the dose can be adjusted down to 1 or 2 doses per day, each consisting of 25 ml diluted in 100 ml of water. Extended use may be necessary in patients with severe chronic or resistant constipation, secondary to multiple sclerosis or Parkinson’s Disease, or induced by regular constipating medicine, in particular opioids and antimuscarinics. A course of MOVICOL Liquid treatment does not normally exceed 2 weeks, but can be repeated if required. MOVICOL Liquid is not recommended for faecal impaction MOVICOL-Half Chronic Constipation: Adults, adolescents and the elderly: 2-6 sachets daily in divided doses, according to individual response. For extended use: adjust dose down to 2 or 4 sachets.Children (below 12 years): Not recommended. Alternative MOVICOL products are available for children. Extended use may be necessary in patients with severe chronic or resistant constipation, secondary to multiple sclerosis or Parkinson’s Disease, or induced by regular constipating medicine, in particular opioids and antimuscarinics. A course of MOVICOL-Half treatment does not normally exceed 2 weeks, but can be repeated if required. Faecal Impaction:Adults, adolescents and the elderly: 16 sachets per day. A course of treatment for faecal impaction does not normally exceed 3 days. The 16 sachets should be taken over 6 hours (4 sachets per hour maximum in cardiovascular impairment). The 16 sachets may be dissolved in 1 litre of water. Children (below 12 years): Not recommended. Alternative MOVICOL products are available for children. MOVICOLPaediatric Plain and MOVICOL Paediatric Chocolate Chronic Constipation: The usual starting dose is 1 sachet daily for children aged 2-6 years, and 2 sachets daily for children aged 7-11 years. The dose should be adjusted up or down as required to produce regular soft stools. If the dose needs increasing this is best done every second day. The maximum dose needed does not normally exceed 4 sachets a day. Treatment of children with chronic constipation needs to be for a prolonged period (at least 6-12 months). Faecal Impaction: Escalating dose regimen starting with 4 sachets per day for children aged 5-11 years. Refer to Summary of Product Characteristics (SmPC) for full dosing recommendations. Not recommended in children with cardiovascular impairment or renal insufficiency. Doses for prevention of re-impaction should be as for patients with chronic constipation. For patients of 12 years and older it is recommended that MOVICOL is used. Contraindications:Intestinal perforation or obstruction due to structural or functional disorders of the gut wall, ileus and severe inflammatory conditions of the intestinal tract, such as Crohn’s disease, ulcerative colitis and toxic megacolon. Hypersensitivity to

macrogol, or any of the excipients. Warnings and precautions for use: Diagnosis of impaction should be confirmed. If patients develop any symptoms indicating shifts of fluids/electrolytes the product should be stopped immediately. When using paediatric forms of MOVICOL to treat faecal impaction, use with caution in patients with impaired gag reflex, reflux oesophagitis or diminished levels of consciousness. MOVICOL Liquid contains benzyl alcohol. Do not exceed the maximum recommended daily dose. Interactions: There is a possibility that the absorption of concomitantly administered medication could be transiently reduced. Pregnancy and lactation: Can be used during pregnancy and lactation. Undesirable effects:Reactions related to the gastrointestinal tract are the most common and include: abdominal pain, abdominal distension, nausea, vomiting, dyspepsia, diarrhoea, flatulence, borborygmi and anal discomfort. Allergic reactions, including anaphylactic reaction, angioedema, dyspnoea and skin reactions can occur. Other effects can include electrolyte disturbances, headache and peripheral oedema. Licensing and legal category: MOVICOL Legal category: P. Cost: 20 sachets £4.90, 30 sachets £7.35, 50 sachets £12.24. MA number: PL 00322/0070. MOVICOL PlainLegal Category: P. Cost: 30 sachets £7.35, 50 sachets £12.24. MA number: PL 20142/0004. MOVICOL Chocolate Legal Category: P. Cost: 30 sachets £7.35. MA number: PL 00322/0086. MOVICOL Liquid Legal Category: P. Cost: 500ml UK £4.90. MA number : PL 20011/0007 MOVICOL-Half Legal Category: P. Cost: 20 sachets £3.21, 30 sachets £4.82. MA number: Number PL 00322/0080. MOVICOL Paediatric Plain Legal Category: POM; Cost: 30 sachets £4.38; MA number: Number PL 20011/0005. MOVICOL Paediatric Chocolate Legal Category: POM; Cost: 30 sachets £4.38; MA number: Number PL 20011/0004 For further information contact:Norgine Pharmaceuticals Limited, Norgine House, Moorhall Road, Harefield, MiddlesexUB9 6NS 01895 826606 E-mail: medinfo@norgine.com MOVICOL® is a registered trademark of the NORGINE® group of companies. Date of preparation/revision: UK/MOV/0715/0087

Adverse events should be reported. Reporting forms and informationcan be found at www.mhra.gov.uk/yellowcard. Adverse events should

also be reported to Medical Information at Norgine Pharmaceuticals Ltdon 01895 826606.

References:1. Attar A et al. Gut 1999;44:226-30.2. Gruss HJ, Ulm G. Eur J Ger 2004;6(3):143-50.3. Thomson MA et al. Arch Dis Child 2007;92:996-1000.

MOVICOL®, MOVICOL® Plain, MOVICOL® Chocolate, MOVICOL® Liquid Orange Flavour,MOVICOL®-Half, MOVICOL® Paediatric Plain and MOVICOL® Paediatric Chocolate.Prescribing Information.REFER TO FULL SUMMARY OF PRODUCT CHARACTERISTICS (SMPC) BEFORE PRESCRIBING.

Date of preparation: July 2015.Code: UK/MOV/0715/0092.

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?? JCN 2014, Vol 28, No 5?? JCN 2015, Vol 29, No 2

Answer the following questions about this topic, either to test the

new knowledge you have gained or to form part of your ongoing practice

development portfolio.

1 – What are some of common symptoms of constipation?

2 – Can you identify the different types of constipation?

3 – What constitutes a defaecation disorder?

4 – Why is fluid intake an important factor in constipation?

5 – Can you name some of the main treatments for constipation?

Five-minute test

discomfort. Haemorrhoids and anal fissure can occur due to the prolonged straining and constant increased tone of the pelvic floor.

This type of constipation does not react well to laxative use and sufferers often resort to manual evacuation techniques to empty their bowel (Andrews and Storr, 2011).

Prolonged deliberate avoidance of defaecation can also lead to a chronic defaecation disorder. This may be to avoid pain caused by fissures, behaviourally poor toileting habits, obstetric injury or spinal injuries.

Dyssynergia (disturbance of smooth muscular coordination) occurs when an individual is unable to coordinate the pelvic floor, rectoanal and abdominal muscles to propel stool from the rectum. This lack of coordination leads to excessive straining and an inability or reduced ability to empty the rectum, as well as a loss of desire to defaecate (a natural urge known as the ‘call to stool’) (Kyle, 2011).

Treatment options for this include lifestyle changes such as dietary fibre supplementation, biofeedback therapy, and structured pelvic floor muscle and anal sphincter exercises.

any form of bowel dysfunction using appropriate tools such as the Bristol Stool Chart, diaries that record the type, consistency and frequency of stool, as well as any evidence of straining, and Rome III classification.

A comprehensive history and physical examination should be the first steps to diagnosing and managing constipation (Storr, 2011). The history should include the following elements:

Bowel habitDiary of food, fluid intake and frequency/consistency of stoolMedication (including any over-the-counter products)Other medical conditionsLifestyle and activity (e.g. does the individual exercise; go to work; regularly walk to the shops, etc).

It is important to identify any red flags that may be indicators of cancer (Table 2). A comprehensive history and examination will help the community nurse to establish a diagnosis and an individualised plan for treatment (Ness, 2009; 2013).

Physical examination must include abdominal palpation and rectal examination (NICE 2007; Gray, 2011). However, there is still a reluctance among nurses to perform a digital rectal examination. Ness (2013) suggested that this could be attributed to a fear of legal action or accusations of abuse due to the intimate nature of the examination, therefore a chaperone should be offered not only for the safety and comfort of the patient, but also for that of the nurse.

Many patients also fear this element of the examination and many healthcare professionals believe

PREVALENCE

Some reports suggest that there is a higher prevalence of constipation in females than males (Sanchez and Bercik, 2011), which may be attributed to hormonal changes during the menstrual cycle. Oestrogen in particular helps to maintain the elasticity and strength of the pelvic floor muscles and sudden changes in levels such as those seen in the menstrual cycle, or sudden dramatic decreases like those seen during the menopause, may cause increased appetite and raise stress levels leading to unhealthy eating behaviour such as snacking or choosing foods that adversely affect bowel habit.

As with many medications, those given to treat the menopausal symptoms may also lead to constipation. However, it could also be argued that women seek medical advice more than men, and thus the reporting of bowel issues is more obvious in the female population (Kyle, 2011).

Age is widely recognised as a significant indicator in the prevalence of constipation (Gallegos-Orozco et al, 2012; Woodward, 2012), however, not every older person will suffer with constipation.

There are some studies that suggest a higher prevalence of constipation in different races and socio-economic groups (Peppas et al, 2008; Sun et al, 2011), but little consensus. It is perhaps a more accurate statement to say that age, race and socio-economic status are recognised risk factors but not absolute indicators of constipation prevalence (Belsey et al, 2010).

ASSESSMENT AND DIAGNOSIS

Nurses are in an ideal position to initiate the first assessment of a person’s bowel habit as they come into contact with patients in all settings, both acute and community. The National Institute for Health and Care Excellence (NICE, 2007) has produced evidence-based guidelines suggesting the benefits of a structured approach to assessing

78 JCN 2015, Vol 29, No 5

Table 2: Red flag symptoms that may indicate cancerUnexplained weight loss

Blood in stoolAnaemia

Sudden change in bowel habit lasting weeks

Significant abdominal pain

Family history of bowel cancer or inflammatory bowel disease (IBD)Source: NHS Choices (2010); Tack et al (2011)

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JCN 2015, Vol 29, No 5 79

this is a real factor in high ‘do not attend’ (DNA) rates at specialist bladder and bowel clinics.

The Royal College of Nursing (RCN, 2012) has published many guidelines on digital rectal and manual evacuation to help clarify the procedure, the training required and the required competencies. These guidelines are designed to be used in all areas of health care, whether in the independent, NHS or social care sector and should help to ensure that best practice is adopted (Ness, 2013).

Despite all the guidelines, however, in truth there still appears to be a wide gap in practice, with some practitioners having a real fear of undertaking this valuable clinical skill (Royal College of Physicians, 2010). Physical visual inspection of the perineum, observation of leakage of stool on straining, testing pelvic floor dysfunction and testing anal contractions using the ‘anal wink reflex’ test (a reflexive contraction of the external anal sphincter when the skin around the anus is touched) will complete elements of assessment.

In some cases it may be useful to request blood tests, radiology and endoscopy, although in the absence of red flag symptoms these are not first-line investigations when considering chronic constipation (Jamshed et al, 2011).

MANAGEMENT

Conservative management Conservative management such as lifestyle modifications, exercise and increased fluid intake are preferred initially and can be very effective in treating chronic constipation (Gallegos-Orozco et al, 2012; Portalatin and Winstead 2012; Woodward, 2012).

A review of fluid intake and dietary habits can lead to some subtle changes that relieve symptoms, whereas halting medication used for constipation will also optimise conservative treatments (Emmanuel, 2011), as it will allow alternative treatments time and scope to work effectively.

An understanding of how the gut works and the effect of soluble and insoluble fibre on bowel transit will help to inform patients about prevention and enable achievable goals and cost-effective treatment (Table 3). Soluble fibre dissolves in water to form a gel that can bind to other substances and soaks up water to maintain a soft but ‘formed’ stool. In simple terms, soluble fibre slows the bowel transit time but can lead to constipation if too much is ingested, as the faecal matter remains in the bowel for too long and becomes dehydrated as the bowel reabsorbs water.

Alternatively, insoluble fibres add bulk to the stool allowing a smoother and faster passage through the gut, thus helping to reduce constipation. However, an excess of insoluble fibres can lead to loose watery stools, in turn leading to dehydration. A balance of the different types of fibre is essential to maintaining a healthy functioning bowel.

Nurses are less likely than doctors to use pharmacological options to treat chronic constipation (Milhaylov et al, 2008), preferring lifestyle modifications, exercise and increased fluid intake to relieve symptoms, although the data relating to the benefits of increasing exercise and fluids can be conflicting (Ternent et al, 2007; Wong and Lubowski, 2007; Marples, 2011).

The clinical evidence is inconclusive on the optimum fluid intake, although 1.5–2 litres a day is widely accepted as a healthy average. Similarly, evidence on the most beneficial amount of exercise is conflicting, inconclusive and often anecdotal. The author would advise that some exercise is better than none at all.

Medication Pharmacological preparations are widely available both over the counter and on prescription. However, it is easy to confuse the different types available and the effect they may have on symptoms (Table 4). Patients often take a variety of laxatives over time with little reported relief (Emmanuel, 2004; Storr, 2011). This can lead to a poor patient experience and lack of confidence in the treatment (Mihaylov et al, 2008; Basotti and Blandizzi, 2014).

Laxatives vary in their effect, with some exerting a ‘softening’ influence on bowel function, while others act as a purge (see Table 4 for specific details of different products/actions). It is important to understand how a laxative is designed to work and to offer the correct choice dependent on the symptoms, i.e. does the bowel need to slow down or speed up? Laxatives are most effective when taken according to

Table 3: Soluble versus insoluble fibre

Soluble fibre Insoluble fibre

Passion fruit AvocadoFruits with skin and pips

Cabbage

Brussel sprouts Grapefruit Vegetables with skin Onions

Figs Prunes Wheat Tomatoes

Oranges Bran Rye Carrots

Sweet potato Oatmeal Rice Cucumbers

Asparagus Rye bread Nuts Green beans

Broccoli Whole wheat bread Whole golden linseeds Dark leafy vegetables

Pear Barley Whole grains Raisins

Peach Pasta Barley Grapes

Apricot Beans Couscous Root vegetable skins

Nectarine Lentils Brown rice Fruit skin / peel

Aubergine Flax seed Bulgar wheat

Mango Oats Courgettes

Carrot Seeds Celery

Ground golden linseed Broccoli

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the patient’s presenting symptoms, without conflicting agents and as per manufacturer’s instructions.

In the author’s experience, single doses rarely solve the problem and dosage needs to be considered along with lifestyle/dietary changes. Anecdotally, many patients try a medication expecting a quick result and often struggle to regulate their bowel habit, misinterpreting diarrhoea, overflow and constipation.

Biofeedback Biofeedback is a technique of neuromuscular re-education. An anorectal probe is inserted to measure bowel function and identify abnormal responses. This is a painless procedure that when used correctly and in conjunction with other lifestyle/behavioural changes can help to modify or change bowel habit.

Biofeedback is usually offered by specialist nurses or physiotherapists and aims to improve bowel function by combining behaviour and exercise, correcting unsynchronised contractions of the pelvic floor and external anal sphincter during defaecation (Wald et al, 2007; Marples, 2011).

Transanal irrigation Transanal irrigation has emerged as a useful and effective treatment for constipation in some patients. There are a variety of commercial systems available (Peristeen®, Coloplast; Qufora®, MacGregor Healthcare; Aquaflush®, Oakmed; IryPump®; B. Braun) — these comprise a single-use cone or catheter which is inserted rectally and has a pump system to irrigate the lower bowel and rectum, from every day to several times a week.

The aim of irrigation is to empty the rectum, sigmoid and descending colon of faecal matter, allowing the patient to exercise more control and be able to predict bowel movements. The clinical evidence suggests that emptying as high as the sigmoid colon can prevent impaction and constipation in the long term (Christensen and Krogh, 2010).

Transanal irrigation is considered to be minimally invasive and has a proven benefit in people with neurogenic bowel disorders related to spinal cord injury and multiple sclerosis (Emmanuel, 2010; 2011). These systems all require training and ongoing support from a specialist continence nurse, however (Woodward, 2012; Christensen and Krogh 2010), and can be expensive initially depending on the delivery system. Future prescriptions are less

Table 4: Different types of laxatives and side-effects

Type Action Active ingredient (products) Side effects

Bulk-forming laxative

Increase the amount of fibre and water absorption in gut, increase transit time

May take several days to work and reliant on adequate fluid intake

Bran Polycarbophil Methylcellulose (Celevac®, Amdipharm UK) Carboxymethylcellulose Ispaghula husk (Fybogel®, Reckitt Benckiser

Healthcare; Regulan®, Procter & Gamble) Sterculia (Normacol®, Norgine)

Bloating, flatulence

Stimulant laxatives

Increase motility and secretions of gut

Increase frequency Improve stool consistency

Anthraquinone Senna ( Senokot®, Reckitt Benckiser Healthcare) Bisacodyl (Dulcolax®; Boehringer Ingelheim;

Correctol®; Bayer Group Sodium picosulphate (Dulcolax® Pico Liquid;

Boehringer Ingelheim) Castor oil Glycerine suppositories Sodium docusate (Dioctyl®; UCB Pharma;

Norgalax®; Norgine)

Electrolyte disturbance, abdominal cramps

Osmotic laxatives Attract water into stool using osmosis Require adequate fluid intake

Macrogols or polyethylene glycol (Movicol®; Norgine)

Lactulose Magnesium salts Rectal phosphates Sodium citrate (Micralax®, UCB Pharma) Magnesium salts Phosphate enema

Can be poorly tolerated, bloating, flatulence

Faecal softeners Allow water into stool mass Lubricate and emulsify faeces

Sodium docusate Aachis oil Liquid paraffin

Irritation, impact on dignity

Prokinetic (promotility) agents

Increases colonic contractions thereby increasing transit

Prucalopride (Resolor®; Shire Pharmaceuticals) Linaclotide (Constella®, Almirall)

Nausea, vomiting, abdominal pain,

Chloride channel activator

Increases fluid secretion in intestine Decreases transit time

Lubiprostone (Sucampo®, Pharma Europe) Nausea, headache, diarrhoea

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costly as only the consumables need to be frequently replaced. Compared to the cost of someone taking long-term medication — which might involve repeated tests, consultations and hospital admissions — transanal irrigation can be far better value for money (Christensen et al, 2009).

Surgery Surgery is considered a last resort for sufferers of chronic constipation and only when all other treatment options have been tried. Surgical options include: Prolapse repair Sphincter replacement Sacro-neuromodulation: electrical

stimulation therapy typically involving the implantation of a subcutaneous programmable stimulator

Antegrade continent enema formation: surgical procedure used to create a continent pathway proximal to the anus that facilitates faecal evacuation using enemas

Colectomy and raising of a colostomy (in severe intractable cases).

QUALITY OF LIFE

Continence is a skill learnt in childhood through toilet training (Holroyd, 2015), with defaecation in particular being regarded as a private part of life (Woodward, 2012). The Department of Health (DH, 2010) has identified the importance of privacy and dignity in relation to bowel and bladder care.

Constipation is a subject that is often laughed about, however, many people are embarrassed to use public facilities, with hospitals in particular lacking privacy and easy access to toilet facilities, thus contributing to the incidence of constipation (Tariq, 2007).

Any deviation from so-called ‘normal’ toilet patterns can have a significant and distressing effect on people’s physical, psychological and social wellbeing (Belsey et al, 2010; Lukacz et al, 2011). It is common for people with incontinence to report feelings of isolation, anxiety, depression and embarrassment (Wan and Wang, 2014).

ECONOMICS OF CONSTIPATION

The actual cost of constipation is difficult to define as many sufferers do not seek professional help and manage their symptoms with over-the-counter remedies, such as such as Dulcolax® (Boehringer Ingelheim) and Senokot® (Reckitt Benckiser Healthcare).

Similarly, many cost-comparative studies have focused on the prescribing costs of laxatives and do not include other considerations such as loss of work/school days and reduced productivity (Lacy et al, 2012; Neri et al, 2014; Sanchez and Bercik, 2011).

One Europe-wide study (Müller-Lissner et al, 2012) reported that almost one-third of people with constipation were unhappy with their laxative treatment and the majority would have liked to look at alternative treatment options, suggesting that millions is being wasted on inappropriate or unsatisfactory treatments.

With the life expectancy continuing to rise as people’s general health improves, it is safe to assume — if current management approaches continue unchallenged — that the burden on the health economy of chronic constipation will increase.

In the author’s opinion, a reasonable strategy would be an emphasis on early identification with potential referral to specialist continence services where nurses could offer effective lifestyle and dietary advice rather than simply reaching for medication. However, this would rely on a certain amount of self-confidence and patients being confident enough to identify and report the issue rather than attempting self-diagnosis and management.

Education on normal bowel health and function aimed at the general public would also help to break the taboo of discussing bowel issues and might encourage other healthcare professionals to view bowel function as an essential rather than a basic requirement. This could only improve

the long-term experience of patients experiencing chronic constipation.

CONCLUSION

Constipation is a common problem worldwide. The treatment is challenging as diagnosis and definition varies between clinicians and sufferers. As discussed in this article, many over-the-counter and prescribed laxatives have proven ineffective or unsatisfactory for many patients, often resulting in long-term use of several medications and a detrimental effect on the person’s social and emotional wellbeing.

Thorough patient assessment and promotion of continence issues are vital if services are to improve, with an emphasis on all clinicians recognising continence issues as essential to any patient’s overall health (Holroyd, 2015).

Breaking the social taboo that surrounds bladder and bowel issues and referring to appropriate specialist nurse-led services will lead to more accurate and timely diagnosis of constipation (Orrell et al, 2013). Similarly, empowering patients with appropriate information about treatment options will improve their quality of life and reduce the financial burden of constipation for health economies. JCN

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