Continence Coach: Chronic Constipation Relief for Older Patients

     Chronic constipation is quite common across the American population and responsible for 2.5 million physician office visits annually.¹ Older people generally are more concerned with their bowel health than younger folks; they may be preoccupied by the myth of needing a daily bowel movement. The fact is that older individuals are more likely to routinely experience problems with constipation — researchers have found that 33% of the elderly suffer from chronic constipation.² Women are two to three times more likely to experience constipation than men.³

     Although constipation typically is defined by infrequent bowel movements (fewer than three a week) and/or evacuation of hard, even painful stool, it is slow transit that often receives greatest attention as symptoms are addressed. An even more common but less frequently addressed factor is the lack of coordination and general weakness of pelvic floor muscles that can make evacuation a problem. The sphincters (circular muscles around rectum) and the puborectalis muscles must relax to have a bowel movement and stay contracted to prevent one. When functioning normally, this balance is controlled by the pressure from accumulating stool in the rectum, which is sensed by nerves in the body and the brain’s decision to respond (or not) to this sensation. Unless the underlying pelvic floor dysfunction is fully addressed, efforts aimed at reducing transit time will not remedy the problem of evacuation caused by lack of coordination of pelvic floor muscles and general muscle weakness. In most cases, both slow transit and problems with evacuation must be addressed for enduring success.

     Anatomic abnormalities such as rectal prolapse are the result of pelvic floor muscle weakness and exacerbate the problem of outlet obstruction. If prolapse in the form of a rectocele (anterior vaginal wall collapse) or enterocele (vaginal ceiling collapse) is present, it must be addressed surgically or with a pessary; a colonoscopy can ensure rectal blockage is not caused by colon or rectal cancer. Repeated straining to have a bowel movement worsens the degree of prolapsed organs.

     A complete patient assessment can identify other causal factors. Slowed bowel action is a frequent side effect of pain medication used, for example, for chronic inflammation (eg, osteoarthritis).⁴ Even temporary pain medication following surgery can cause sudden changes in bowel regimen, triggering chronic constipation. A history of sexual abuse can contribute to chronic constipation later in life.⁵ Thus, knowing the patient’s full history is essential to determining the steps to take in treatment and whether ultimately referral to a specialist such as a colon and rectal surgeon is necessary. Readers may wish to become familiar with a new validated instrument developed at the University of California, San Francisco, for assessing the severity of constipation.⁶

     Physical therapy can be helpful.⁷ Getting patients moving and performing abdominal contraction exercises assists peristalsis (movement of feces through the bowel). A personalized abdominal strengthening program is also crucial because the abdominal wall must first contract to allow relaxation of the muscles supporting the anal sphincter muscles to complete stool evacuation. Additional techniques for strengthening pelvic floor muscles include electrical stimulation to the muscles, pelvic floor weights for strengthening, and a personal exercise program to strengthen the pelvic floor. These techniques can be adapted to the limitations of an elderly patient.

     Conservative remedies to address transit work well in most cases and include increasing dietary fiber and even fiber supplements, especially insoluble fiber that adds bulk and weight to the stool; increasing physical activity and exercise to improve peristalsis; increasing fluid intake; and adding a mild non-prescription laxative (eg, MiraLAX®, Merck and Company, Inc., Whitehouse Station, NJ) to help make the stool more spongy.

     It is essential for nurses — both in primary care and in specialties such as continence — to deepen their understanding of chronic constipation. Taking time to fully assess causal factors and symptoms is key to successfully remedying chronic constipation. In the majority of cases, simple advice and intervention work.

The National Association For Continence is a national, private, non-profit organization dedicated to improving the quality of life of people with incontinence. The NAFC’s purpose is to be the leading source for public education and advocacy about the causes, prevention, diagnosis, treatments, and management alternatives for incontinence.

This article was not subject to the Ostomy Wound Management peer-review process.

1. Varma MG. Bowel Health: Managing Chronic Constipation. Presentation at A Woman's Guide to Pelvic and Bladder Health Program. San Francisco, CA. October 3, 2009.

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5. Leroi AM, Bernier C, Watier A, et al. Prevalence of sexual abuse among patients with functional disorders of the lower gastrointestinal tract. Int J Colorect Dis. 1995;10(4):200–206.

6. Varma MG, Wang JY, Berian JR, Patterson TR, McCrea GL, Hart SL. The constipation severity instrument: a validated measure. Dis Colon Rectum. 2008;58(2):162–172.

7. Wisinski C. Neurological disorders get help from physical therapy. Quality Care. 2003;4.