chronic constipation

by Diane K. Newman, RNC, MSN, CRNP, FAAN

What is constipation?

Constipation is usually defined as the infrequent and difficult passage of stool with fewer than three bowel movements per week. If more than three days pass without a bowel movement, the intestinal contents, stool, may harden or may be pellet-like.

A person may have difficulty or even pain during elimination and use excessive straining to pass the stool. Older adults are 5 times more likely than younger adults to report problems with constipation. Many times older persons become overly concerned with having a daily bowel movement and constipation may be imaginary. If the person also has urinary incontinence, once constipation is resolved, improvement in the "accident" (episodes of urinary incontinence) rate is seen. Constipation is a symptom, not a disease, but prolonged constipation can lead to urinary retention and urinary incontinence.

Laxatives

Many persons have misconceptions concerning normal bowel habits. They feel that a bowel movement is necessary every day. You need to understand that bowel patterns vary and that having a bowel movement every other day or every third day may be normal. Also, individuals feel that wastes in the bowel are absorbed and can shorten their lives. Therefore, they take large amounts and many different types of laxatives to have daily bowel movements and to get rid of "harmful wastes." Heavy dependence on laxatives can become habit-forming. Routine use of laxatives interferes with your bowels so that over time the bowels forget how to operate on their own. Plenty of other problems come with habitual use of laxatives. Mineral oil coats the intestines, which blocks absorption of vitamins A,D,E, and K, and may also interact with other drugs you are taking. Milk of Magnesia pushes stool through your intestines so fast that nutrients are not completely absorbed. Habitual use of enemas leads to loss of normal bowel function.

Causes of Constipation:

Unbalanced Diet: A diet high in animal fats and refined sugars tends to be low in fiber. High-fiber diets result in larger stools, more frequent bowel movements and less constipation.
Poor Fluid Intake: Water and other fluids add bulk to stools, making bowel movements softer, more frequent, and easier to pass.
Laxative Abuse: Individuals who habitually take laxatives become dependent upon them and may require increasing dosages until the intestine becomes accustomed to the laxatives and does not respond to them properly.
Travel: When traveling, individuals often experience constipation, especially during long distance trips and trips to other countries. This may be due to changes in drinking water, schedule, diet and lifestyle alteration.
Hemorrhoids: Hemorrhoids are swollen veins in the anus or rectum. They can be internal, inside the rectum, or external, outside the anal opening. These conditions cause pain, itching, and discomfort when passing stool and cause spasms of the anal sphincter, which can delay bowel movements. Drinking plenty of fluids and increasing dietary fiber can help hemorrhoids during flare ups as can Witch Hazel compresses.
Medications: Most of the medications commonly prescribed for older adults cause constipation. This is especially true with pain medications, antidepressants, antacids that contain aluminum, iron supplements, and tranquilizers.
Diseases: Diseases such as multiples sclerosis, Parkinson's, stroke, or spinal cord injury that affects nerves leading to the intestines or rectum and anus can cause constipation.
Pregnancy: Women who are pregnant often have problems with constipation. The reason may be due to increased pressure from the baby on the intestines or hormonal changes.
Lack of Exercise: A decreases in ambulation or prolonged bed rest due to an accident or illness may contribute to constipation.
Restricting Fluids: Cutting down or limiting fluid intake can cause constipation.

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Children and Constipation

Constipation is a problem in children and is usually due to poor bowel habits. Studies show that many who suffer from constipation as children continue to have the problem as adults. Constipation in children may be due to the fact that they may hold their stools because of inconvenient toilets, difficulties at school, or emotional stress from a family crisis. Constipation in children may lead to fecal impaction.

References

Behm, R.M. (1985) A Special Recipe to Banish Constipation. Geriatric Nursing. 6(4):216-217.

Badiali, D., Corazziari, E., Habib, FI., Tomei, E., et. al. (1995) Effect of Wheat bran in treatment of chronic nonorganic constipation - A double-blinded controlled trial. Digestive Diseases and Sciences. 40(2): 349-356.

Benton, JM., O'Harra, PA., Chen, H., Harper, DW., Johnston, SF., (1997) Changing bowel hygiene practice successfully: A program to reduce laxative use in a chronic care hospital. Geriatric Nursing. 18(1)12-17.

Beverley, L, Travis, I. (1992) Constipation - Proposed Natural Laxative Mixtures. Journal of Gerontological Nursing. 18(10):5-12.

Chassagne, P., Landrin, I., Neveu, C., Czernichow, P., et.al. (1999) Fecal Incontinence in the institutionalized elderly: incidence, risk factors, and prognosis. The American Journal of Medicine. Feb 106:185-190.

Chiang L., Ouslander J., Schnelle J., Reuben, D. (2000) Dually incontinent nursing home residents: Clinical characteristics and treatment differences. J Am Geriatr Soc. 48(6): 673-676.

Doughty, D. (1996) Physiologic Approach to Bowel Training. JWOCN. 23(1): 46-56.

Howard, LV., West D, Ossip Klein DJ. Chronic constipation management for institutionalized older adults. Geriatric Nursing. 21(2): 78-82.

Jackson S., Weber A., Hull AT., Mitchinson A., Walters M. (1997) Fecal Incontinence in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol. 89(3): 423-427.

Jensen, L. (1997) Fecal Incontinence: Evaluation and Treatment. JWOCN. Sept 24(5):277-282.

Jensen, LL. (2000) Assessing and treating patients with complex fecal incontinence. OstomyWound Management. December 46(12): 56-60.

Johanson, JF., (1998) Geographic distribution of constipation in the United States. American Journal of Gastroenterology. 93(2): 188-191.

Ko, CY., Tong, J., Lehman, RE, et. al. (1997) Biofeedback is effective therapy for fecal incontinence and constipation. Arch Surg. 132:829-834.

Kumar, D., Bartolo, DCC., Devroede, G., Kamm, MA., Keighley, MRB., et. al. (1992) Symposium on constipation. International Journal of Colorectal Disease. 7:47-67.

Nelson R., Norton N., Cautley E., Furner S. Community-based prevalence of anal incontinence. JAMA. 1995; 274(7): 559-561.

Patamkar, SK, Ferrara, A., Levy, JR, Williamson, PR, Perozo, SE, (1997) Biofeedback in colorectal practice: a multicenter statewide, three-year experience. Diseases Colon Rectum. 1997;40:827-831.

Poulton, B., Thomas, S. (1999) The Nursing Coat of Constipation. Primary Health Care. November, 9(9):17-20.

Smith DA, Newman DK. (1989) The bran solution. Contemporary Long Term Care. 12:66.

Venn MR, Taft L, Carpentier B, Applebaugh G. (1992) The influence of timing and suppository use on efficiency and effectiveness of bowel training after stroke. Rehabilitation Nursing. May-June 17(3): 116-120.

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Posted February 2003
Updated July 2009

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