Talking to patients about fecal incontinence was the subject of our last blog and here we continue with the related issue of chronic constipation.
Many patients will assume constipation is primarily caused by diet and poor toileting habits. They often need to be educated on the many factors that can be involved, particularly when constipation becomes a chronic condition.
Patients who take the step of discussing their problem with a physician are more likely to be suffering outlet constipation, rather than more general constipation that can involve the GI tract overall, because the condition typically has a greater impact on their daily lives. Outlet constipation means that stool cannot be pushed out of the rectum itself and remains there to become hard, dry and increasingly difficult to pass. That’s why, any dietary and lifestyle changes they may have made have had little impact.
Getting your act together: Muscle coordination in the bathroom
According to experts, more than half of all outlet constipation involves poor control over muscles in the pelvic floor and lower colon. The good news you can share with patients, of course, is that most of these are voluntary muscles that can be consciously controlled. Patients can do much to help heal themselves, and surgery is rarely necessary.
An explanation of specific conditions causing chronic constipation will help:
Pelvic Floor Dyssynergia. Many patients need to be educated about the relationship between the pelvic floor, colon and anus and to understand that their muscles need to work together in a coordinated fashion for proper defecation. While physicians are familiar with the complexities of the levator ani muscle, puborectalis muscle and the inner and outer sphincters, patients simply need to understand that dyssynergia results from an inability to execute the multiple steps of defecation with proper sequence and timing.
In addition, discussing with patients their ability to perceive that stool is in the rectum and ready to be expelled is helpful because this is thought to be a contributing factor to dyssynergia for some people.
Anismus. This is a similar but less involved condition that leaves people unable to relax pelvic muscles when attempting a bowel movement and therefore unable to pass stool.
Weak Pelvic Muscles. Weak pelvic muscles mean that patients cannot adequately squeeze or maintain the sharp angle between the rectum and anus needed to streamline passing stool, yet another cause for the chronic constipation.
We all know that pregnancy, chronic straining, nervous system issues or an injury to the region may result in any of these conditions. But in reality, the cause is often unclear. However, it can be reassuring for patients to know that these muscle issues are very real, and they are not at fault.
Understanding that chronic constipation easily can become cyclical also is helpful. Constant straining to evacuate may result in damage to the colon that includes anal fissures, hemorrhoids, hyper-tightening of the muscles involved in defecation and even rectal prolapse. While these conditions can be the initial cause of constipation, they also will worsen an existing condition, whatever the origin.
As healthcare professionals, we all know that while less common, other issues can be involved in chronic constipation. These include neurological problems, colon or rectal blockage and hormonal issues. Treating these often requires more significant intervention. Look for coverage in subsequent blogs.
Anorectal Manometry is one of the most effective ways to test the functioning muscles and the other anatomy of the pelvic floor and lower GI tract to provide a more accurate assessment of the causes and extent of chronic constipation. In addition, in adults, it can be used as a biofeedback tool to retrain and strengthen the muscles involved in defecation.
Studies have shown that biofeedback-based neuromuscular retraining is effective in improving defecation disorders in three-quarters of patients, while curing one-third of suffers, according to the NHS Information Trust in Great Britain.
Today, with Medspira’s mcompass®, physicians can easily and affordably offer both anorectal manometry testing and biofeedback themselves right in their office. The portable, wireless system can be set up in a standard exam room, enhancing quality-of-care and opening a lucrative new revenue stream.
Offering these procedures takes far less staff time, financial commitment and training than you may think. It’s a great opportunity. Our next blog will explore this in greater detail.