5
Constipation and evacuation disorders

https://doi.org/10.1016/j.bpg.2009.05.001Get rights and content

Constipation and evacuation difficulty symptoms are common in the general populace. The ROME III criteria define the latter as a subset of the former. Constipation and defaecatory symptoms rarely occur in isolation and can often form part of a global pelvic floor problem, involving bladder voiding difficulties, sexual dysfunction and pain syndromes. While there is often a functional cause for symptoms, there are a number of organic causes particularly in the elderly that should not be missed. Novel physiological and imaging insights are improving our understanding, and potentially treatment, of these symptoms. Conservative therapies focus on a holistic approach in tandem with evolving drug therapies that target intestinal secretion and transit. The role of the biofeedback specialist is continually being re-defined to an all-encompassing one of physiotherapist, behavioural psychologist and moderator for alternative therapies such as rectal irrigation. Sacral neuromodulation for constipation is an emerging minimally invasive surgical option, although the criteria for patient selection are still to be elucidated. Colectomy for functional constipation is associated with a high morbidity, and gut symptoms often persist, suggesting a global GI phenomenon. Surgical correction of rectocele and intussusception for evacuation difficulty will benefit those with anatomical symptoms; for those with predominantly functional features, surgery is best avoided to prevent a vicious cycle of multiple re-operations.

Section snippets

Definition

A simple classification of constipation is the infrequent defaecation; passage of hard stools, which may or may not accompany difficulty in emptying, characterised by the need to strain; the feeling of incomplete emptying and/or digital manoeuvres. The 2006 Rome III collaboration on functional disorders have further defined more formal criteria to be used in defining both functional constipation and functional defaecatory disorders. Functional constipation is defined as a bowel disorder that

Epidemiology

Epidemiologic surveys on constipation and evacuation difficulties show wide variation in incidence and prevalence according to the definition used and population studied. The largest population survey in the literature suggests that one in five middle-aged apparently healthy persons have symptoms of functional constipation, and one in 10 have symptoms of obstructive defaecation [3]. Prevalence increases with age, with up to 20% of those above 65 years of age affected, being three times more

Aetiology

Colonic transit is mediated by the local enteric nervous system, under the influence of the autonomic nervous system, spinally mediated reflexes and central control. This nervous innervation modulates intrinsically generated contractions, which are of two primary types: low-amplitude motor complexes, which represent background colonic activity and are non-propulsive; and high-amplitude propagated contractions, which are propulsive and responsible for defaecation. A reduction of this type of

Questionnaires

To supplement clinical history taking, a number of validated instruments have been developed for patients with constipation, but none quantifies obstructed defaecation into a usable clinical and research tool. Some of the reported scores and questionnaires available for functional constipation include:

  • (1)

    the Wexner constipation score – a weighted questionnaire focussing on constipation and including a little quality-of-life focus [22];

  • (2)

    the Patient Assessment of Constipation Quality of Life

Investigations

Colonoscopy, computed tomography (CT) colonography or contrast-enema radiology are required if there is any suggestion of obstructing or other organic disease. The presence of common abnormalities such as diverticulosis and melanosos coli does not indicate causality.

Anorectal physiology assessment of patients with constipation is usually of little value, unlike the pivotal role in patients with faecal incontinence. The role of physiology was reviewed in the AGA statement of 1998 suggesting that

General measures

The patient's primary complaints should guide the initial therapy. In principle, simple, empiric measures should be undertaken before referral to a specialist centre. By contrast, patients in one of the special groups listed below may need specialist involvement at an early stage. Conservative measures will often include advice on ample fluid intake up to eight medium glasses per day, (maintenance fluids for an average 70-kg man being 3 l). Though the majority of this fluid is absorbed in the

Conclusion

Chronic constipation comprises a spectrum of intestinal and extra-intestinal complaints that whilst highly prevalent in society can be a major nuisance to quality-of-life in some patients. Patients have usually tried a variety of lifestyle alterations and over-the-counter remedies before seeing a specialist. It is important from the outset to clearly identify the patient's cardinal complaints and aspirations from treatment. Broadly classifying pathophysiology into either delayed gut transit,

References (66)

  • W.P. Voskuijl et al.

    New insight into rectal function in pediatric defecation disorders: disturbed rectal compliance is an essential mechanism in pediatric constipation

    J Pediatr

    (2006)
  • R. Spiller

    Serotonin and GI clinical disorders

    Neuropharmacology

    (2008)
  • S.S. Rao et al.

    Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation

    Clin Gastroenterol Hepatol

    (2007)
  • J.M. Vanderwinden et al.

    Nitric oxide synthase distribution in the enteric nervous system of Hirschsprung's disease

    Gastroenterology

    (1993)
  • J.E.J. Doty

    Bowel dysfunction in pelvic floor dysfunction

    (2006)
  • D.C. Nyam et al.

    Long-term results of surgery for chronic constipation

    Dis Colon Rectum

    (1997)
  • D.A. Drossman et al.

    Sexual and physical abuse and gastrointestinal illness. Review and recommendations

    Ann Intern Med

    (1995)
  • A.M. Leroi et al.

    Prevalence of sexual abuse among patients with functional disorders of the lower gastrointestinal tract

    Int J Colorectal Dis

    (1995)
  • G. Bassotti et al.

    The role of glial cells and apoptosis of enteric neurones in the neuropathology of intractable slow transit constipation

    Gut

    (2006)
  • W.E. Whitehead et al.

    Functional disorders of the anus and rectum

    Gut

    (1999)
  • R.C. Evans et al.

    The normal range and a simple diagram for recording whole gut transit time

    Int J Colorectal Dis

    (1992)
  • N.A. Rotholtz et al.

    Anal manometric predictors of significant rectocele in constipated patients

    Tech Coloproctol

    (2002)
  • M.A. Gladman et al.

    Rectal hyposensitivity: a disorder of the rectal wall or the afferent pathway? An assessment using the barostat

    Am J Gastroenterol

    (2005)
  • A.G. Klauser et al.

    Behavioral modification of colonic function. Can constipation be learned?

    Dig Dis Sci

    (1990)
  • D.R. Chatoor et al.

    Functional symptoms and their psychological correlates in patients with a rectocele and evacuation difficulties

    Gut

    (2007)
  • M. Pescatori et al.

    A prospective evaluation of occult disorders in obstructed defecation using the ‘iceberg diagram’

    Colorectal Dis

    (2007)
  • F. Agachan et al.

    A constipation scoring system to simplify evaluation and management of constipated patients

    Dis Colon Rectum

    (1996)
  • P. Marquis et al.

    Development and validation of the patient assessment of constipation quality of life questionnaire

    Scand J Gastroenterol

    (2005)
  • A.O. Chan et al.

    Validated questionnaire on diagnosis and symptom severity for functional constipation in the Chinese population

    Aliment Pharmacol Ther

    (2005)
  • A. Renzi et al.

    Stapled transanal rectal resection to treat obstructed defecation caused by rectal intussusception and rectocele

    Int J Colorectal Dis

    (2006)
  • A. Longo

    Obstructed defecation because of rectal pathologies. Novel surgical treatment: stapled transanal rectal resection (STARR)

  • M.G. Varma et al.

    The constipation severity instrument: a validated measure

    Dis Colon Rectum

    (2008)
  • M. Angrist et al.

    A gene for Hirschsprung disease (megacolon) in the pericentromeric region of human chromosome 10

    Nat Genet

    (1993)
  • Cited by (68)

    • A Longitudinal Study of Predictors of Constipation Severity in Oncology Outpatients With Unrelieved Pain

      2020, Journal of Pain and Symptom Management
      Citation Excerpt :

      In addition, one-third of our patients reported hard stools (Fig. 2b), another indicator of constipation.44,45 As highlighted in the definition,1–3 constipation should be characterized by the number of BMs per day and various stool characteristics. Given the relatively large number of potential predictors identified in the exploratory analyses, it is notable that only three clinical characteristics and one symptom were associated with interindividual variability in constipation severity.

    • Clinical, radiological and physiological assessment of anorectal function

      2017, Surgery (United Kingdom)
      Citation Excerpt :

      Constipation and related functional bowel disorders have been formally defined by the ROME III collaboration.3 They affect up to 25% of the population and comprise a symptom complex associated with infrequent defaecation, hard stools, difficulty in emptying, straining and a feeling of incomplete evacuation.4 A recent study suggested that 1 in 8 tertiary level students have an adverse quality of life as a result of bowel dysfunction.5

    View all citing articles on Scopus
    View full text