Poo Management
In the last few posts, we’ve spoken about the state of our poo, what it can tell us about our health and causes of constipation. This week we’ll look at the management of constipation.
Can constipation be managed at home?
While simple or occasional constipation can be managed at home, certain bowel problems should always be discussed with a doctor without delay. Examples of so called ‘alarm’ symptoms warranting a timely visit to a doctor include acute or recent constipation, rectal loss of blood, presence of mucous, weight loss, fever and rectal pain.
Do I HAVE to talk to my doctor about my constipation?
Some people feel embarrassed discussing certain problems with their doctor. Studies show that only one third of people with symptomatic haemorrhoids (experiencing bleeding, severe protrusion etc) see their doctor. Yep that’s right folks, only one out of three people with symptomatic haemorrhoids actually visit their doctor.
Doctors are trained to handle embarrassing things in a confidential and respectful way. There is nothing to fear and no reason to feel embarrassed. You can talk to your doctor about anything and you should always talk to your doctor promptly if you experience any of the alarm symptoms discussed above.
What will your doctor do?
Your doctor will take a medical history (asking questions about medication use, diet, lifestyle and exercise) and perform a physical examination (usually of the abdomen, pelvis and rectum) to help determine if any further action is required. In the absence of ‘alarm’ symptoms, it’s possible that no investigations will be required. Occasionally, a number of simple investigations may be requested. Sometimes, additional more complex investigations may be ordered to help try to identify the cause(s) of the constipation. A cause may not always be found.
What sort of investigations are ordered?
A number of investigations may be ordered. Simple investigations involve collection of blood samples for routine testing. A thyroid function (blood) test, for example, checks thyroid hormone levels, as constipation may present as a symptom of an underactive thyroid gland. Other common investigations include sigmoidoscopy (insertion of a lighted, flexible tube into the anus, while under anaesthetic, to examine the rectum and lower (sigmoid) colon) or colonoscopy (insertion of a flexible, camera-equipped tube into the anus, while under anaesthetic, for examination of the rectum and entire colon). Tests can also investigate transit time (the time taken for food to move through the intestines), assess functioning and coordination of the muscles used to move the bowels, as well as diagnose a prolapse.
How is constipation managed?
Treatment for constipation depends on the underlying cause. Long standing constipation may require removal of the impacted faeces (faeces can dry out and get stuck in the bowel) using stool softeners, medication (laxatives) or occasionally enemas.
When an underlying cause for constipation is not found, non-drug treatments are initially recommended which focus on making lifestyle and dietary changes. Medication (laxatives) may be added if changes in lifestyle and diet do not relieve the problem. Diet and lifestyle changes are always continued even if medications are added.
What sort of diet and lifestyle changes are recommended?
Recommendations may include:
- Ensuring adequate dietary fibre intake: 18–30 g daily for adults; fibre intake should be increased gradually to avoid bloating and flatulence; see previous fibre blog post; (foods high in fibre include fruit, vegetables, whole grain bread and cereals, legumes)
- Increasing fluid intake and/or ensuring adequate fluid intake: liquids help to bulk up the faeces and ensure an appropriate consistency for passing through the rectum with ease (diuretic drinks should be limited as these dehydrate or remove fluids from the body; eg: coffee, tea, alcohol)
- Increasing levels of activity/exercise: movement improves motility of the bowel helping to move stool
- Toileting habits: it’s important to respond immediately to the urge to defecate and use the toilet after meals (the reflex for bowel emptying is maximal at this time) this helps minimise formation of drier harder to pass stools
It can take a few days to a few weeks to respond to dietary and lifestyle changes.
What about laxatives?
Several different types of laxatives are available to manage constipation. Doctors decide which laxative(s) to prescribe based on the person’s preferences, the laxative’s mechanism of action, required onset and duration of action. Some trial and error is involved in determining the best laxative and a stepwise approach may be used. A laxative may be replaced by another agent if it’s not well tolerated or effective. Before moving from one type of laxative to another, doctors check that people are still following any lifestyle modifications recommended for them and that they are taking their laxatives as prescribed. A combination of laxatives with different mechanisms of action may be prescribed rather than a large dose of one laxative.
Can you discuss the different types of laxatives?
Laxatives are categorised based on their mechanism of action. Bulking agents are often trailed first. When bulking agents are not effective or not suitable, they are stopped and osmotic laxatives are trialled, followed by stimulant laxatives. Some laxatives are more appropriate for certain types of patients (eg bulking agents are less effective in people with poor mobility and/or chronic constipation, while osmotic laxatives are better for these groups).
Common laxative types are summarised in the table below.
Table: Summary of Common Types of Laxatives
Type of laxative
How it works
Time for effect
Common side effects
Bulking Agents
(oral)
Eg psyllium husks, bran (oral)
Increase moisture content of stool, increasing faecal volume which stimulates colonic activity leading to improved transit & ease of passing
Initial effect usually within 24 hours.
Therapy may be required for several days for full effect
- Flatulence
- Bloating
- Abdominal discomfort
Osmotic Laxatives
(oral & rectal)
Eg glycerol, lactulose, sorbitol, macrogol 3350, magnesium salts
Move water into the colon, or keep water in the colon, which expands and softens the stool
Usually work within 2 to 48 hours (2 days).
Effect is more rapid when taken on an empty stomach.
- Nausea,
- Abdominal cramping
- Gas
Stimulant laxatives
(oral & rectal formulations)
Eg senna bisacodyl, sodium picosulfate
Stimulate intestinal motility moving stool along
Usually work within 6 to 12 hours.
- Abdominal cramps
- People abusing stimulant laxatives may have difficulty resuming a normal bowel pattern when stopping use
Stool softeners
(oral)
Eg docusate
Docusate softens stool by helping to mix water into faeces.
Usually work within 1 to 3 days.
- Stomach pain
- Diarrhoea
- Cramping
- Throat irritation
Lubricants
(oral & rectal formulations)
Eg paraffin emulsion, glycerol suppository
Liquid paraffin lubricates fecal material which facilitate its passage.
Variable: 2-3 days for oral paraffin emulsion; 5 -30 minutes for glycerol suppository.
- Prolonged use of paraffin may cause malabsorption of fat soluble vitamins & should only be used for specific patients
Any final words?
Always seek medical advice promptly regarding any ‘alarm’ symptoms and/or ongoing problems with constipation that do not respond to lifestyle and dietary changes and/or over the counter short term use of laxatives. It’s important to understand that long term use of laxatives, unless medically prescribed, is not an appropriate management strategy for constipation. Long term use of certain laxatives can lead to new medical problems. For example, excessive use of osmotic laxatives may lead to fluid and electrolyte disturbances. Lastly, the advice in this blog post relates to management of constipation in adults and does not apply to children or pregnant women.
Further Reading
Blog post – Dietary Fibre
Blog post – All About Poo
Blog post – Spotlight on Constipation