Get Back Into the Flow of Things; Physical Therapy for Chronic Constipation in Adults and Children.

Did you know constipation is one of the most common complaints of patients seeing colorectal surgeons? Prevalence of chronic constipation in the united states is 2% - 34%!

NORMAL frequency of bowel movement is 3 times per day to 3 times per week. However, in the case of constipation the frequency of defecation is two times per week or less.

So what causes constipation?

The list can be extensive, but here are a few common medical causes:

-Hypothyroidism (underactive thyroid gland) & hypercalcemia (a condition that calcium is above normal in blood) can cause constipation.

-A Variety of medication like those which prescribed for Parkinson disease & hypertension and depression medication also cause constipation.

Evidences shows that there is an association between constipation and urinary incontinence and also constipation is one of the major contributing factor to pelvic organ prolapse as a result of chronic straining in constipated patients.

Other Causes of Constipation:

1) Pelvic outlet obstruction is a common cause of constipation and is attributed to muscular dysfunction of pelvic floor.

2) Descending perineum syndrome (urinary and genital area bulge down or descend below the bony outlet of the pelvis) is frequently associated with constipation.

3) Rectocele which is a herniation or protrusion of the anterior rectal wall into the vagina is also found in patients with chronic constipation.

4) Rectal prolapse which is a full thickness of the rectal wall protrudes through the anus is also associated with long-standing constipation or chronic straining.

5) SRUS (solitary rectal ulceration syndrome) is a condition described classically as an ulceration of the rectal mucosa that it is presented with symptoms of bleeding, passage of mucosa, straining or a sense of incomplete evacuation.

So how do we treat constipation?

There are several tactics to employ and will depend on the cause. Here is a few of the techniques that we use!

1) Laxative

2) Fiber-rich diet

3) Adequate liquid intake

4) Good toileting habit will be taught by physical therapist

5) Physiotherapy (biofeedback therapy, exercise therapy, electrical stimulation)

We should consider that a fiber-rich diet is effective in patients with delayed bowel transit constipation and those with functional outlet obstruction and in patients with irritable bowel syndrome(IBS) can have difficulty with the increased distention caused by gas production.

A person with constipation needs to learn to be aware of the reflexes that creates an urge to empty the bowel. The urge to empty the bowel usually occurs 10-30 minutes after a meal, which leads to pelvic floor muscle relaxation and defecation. Physical therapist train the patient a proper toileting position, breathing exercises and relaxation techniques to take the advantage of this reflex.

Physical therapist also train constipated patients to facilitate movement of the bowel contents and widening the terminal part of the defecation route to ease stool emptying with helpful instructions and exercises.

Biofeedback therapy may be considered as a first-line of treatment for paradoxical puborectalis contraction in constipated patients and defined as a group of therapeutic procedures that utilizes electronic instruments to accurately measure, process and give feedback to individuals in the form of analog, binary, auditory and or visual feedback signals to help patients develop a greater awareness of voluntary control over pelvic floor muscles.

Constipated patients with biofeedback therapy learn how to relax and prevent straining the pelvic floor muscles while the intra-abdominal pressure increase. It may take months to train pelvic floor muscles for an appropriate relaxation without straining, but success rates ranging from 30% to 100%. The results of treatment are largely patient dependent.

Electrical stimulation might be applied by physical therapist for Sacral nerve stimulation in some patients to improve pelvic etiology constipation.

In serious cases of constipation resection of large bowel might be indicated, which patients will experience liquid or soft stool after this surgery.

Constipation in Children:

In the new born, meconium (a tick, green tar-like substance that lines a baby’s bowel during pregnancy) release with in the first 24 hours after birth, but in a child with lower birth weight having delayed passage of stool is normal.

Bowel actions in children occur up to 6 times daily for the first few weeks of life but decline in frequency and increase in size and weight until by 4 years a child will defecate once daily.

Defecation frequency is highly variable in children as likely as adult to pass stool 3 times daily to 3 times per week.

Many children achieve bowel control around 18 months, but the age at which complete control is evidenced varies widely.

Children can voluntarily suppress the urge to defecate, a behavior that may be due to an impairment of learning, distress, trauma, a disruption of routine, inattention, or cognitive difficulties.

Toilet refusal is often associated with the memory or expectation of pain at defecation causes include having passed a large or hard stool and the presence of an anal fissure (small tear in the lining of the anus) and anal infection, anxiety or irrational fears associated with the toilet.

Signs of stool withholding in a toddler include squatting, crossing of the legs, stiffening of the body, forcefully contracting the gluteal muscles, hiding and holding onto furniture.

Physical therapist addresses constipation in children with training optimal defecation mechanics and toilet habits and also desensitization of toilet phobias and environmental management instructions and also tutoring a patient with proper positioning for toileting.

Biofeedback therapy is also as the treatment of choice for retraining defecation which is done by physical therapists.

We have a team of Physical Therapists here to address pelvic floor disorders which include constipation. If you have any questions regarding your condition and treatment options, we will be happy to help!