Diagnosis and Treatment Options
The first step in getting a diagnosis is making an appointment with your doctor, nurse practitioner or physician’s assistant. Constipation is a symptom and deserves to be evaluated. While you may be embarrassed, it is important to discuss it with your health care provider and get an answer as to the reason for the constipation and what the treatment options might be.
Preparing for Your Visit
There are certain pieces of information that will be helpful to take with you for your visit. These include:
- List of medications you are taking, including over the counter (like antacids, laxatives, aspirin) and herbal.
- Previous surgeries
- Number of pregnancies and childbirth, any delivery problems (tearing or episiotomy)
- List of fluids and amount you drink including water, regular or decaf coffee or tea, citrus juices, sodas or diet, alcohol, use of aspartame (Equal™) and also, chocolate (drinks or candy). Also, include a food diary of foods that you have eaten in the last week.
- Bowel Diary (Bladder diary, if experiencing control problems too)
- Include number of BMs, ease of emptying, feeling of complete emptying, feeling urge, color shape(round or flat and like ribbons, ease of cleaning (how much toilet paper used), any seepage after BM
- Difficulty with hard or lumpy stools, straining or incomplete emptying
- If your health care provider is not experienced in treating constipation (especially after conservative methods), ask for a referral to someone who has expertise in treating constipation, either a gastroenterologist or colorectal surgeon. Don’t be alarmed at a referral to a colorectal surgeon as they only want to do surgery when necessary.
Physical Exam
A physical exam may include the following items, among others:
- Checking your reflexes to look for nerve damage
- Taking a fecal sample to check for any blood in the stool
- Doing a rectal exam to check the pelvic muscles and the anal sphincter for the tone, tenderness, obstruction or blood
- Doing blood work to check thyroid and calcium levels or to rule out any other cause for the constipation
If it has been decided that the conservative treatment (water, fiber, exercise) have not been helpful, further testing may be indicated.
Further Testing
Initially a sigmoidoscopy, colonoscopy or barium X-ray will probably be ordered to rule out cancer. A sigmoidoscopy is a test that allows the physician to look with a lighted tube into the anus, rectum and sigmoid portion of the colon. A colonoscopy is used to look through the entire colon. A barium X-ray fills the colon with a barium paste to find any abnormalities. Your health care provider will instruct you on specific preparations to be taken prior to the exam.
Further colorectal testing may include but not limited to the following:
- Colon Transit Time
- A test that measures mouth to anus transit time. Small gelatin capsules with radiopaque markers are swallowed and an X-ray is taken and the markers that remain in the colon are counted. You may not take any laxatives during this test. Fiber is okay to continue. Your health care provider will give you more specific details as to when the X-ray is to be taken as there are a few different ways this test can be done.
- Anorectal Function Study
- Anorectal manometry is an objective measurement for assessing the pressure in the rectum and anal canal, rectal compliance, sensation and anorectal reflexes.
- Surface EMG Studies
- This study evaluates the pelvic muscle activity during rest, squeeze, and push (as if you are trying to have a BM). This test is done with a small internal sensor or with surface sensors around the anus)
- Defecography
- This X-ray study assesses the anorectal function for rest, squeeze, empty and after emptying. This also will assess the relaxation of the pelvic muscles when emptying and closure. The presence of a prolapse will be confirmed.
Treatment Options
After the tests and a discussion with your health care clinician about treatment options, a decision will be made as to what would be the best option. You need to be an active participant in that discussion and decision making.
Your health care clinician will likely offer several treatment choices. If you have not tried the basic three (fiber, fluid, exercise) this would be the beginning choice. The next may be Kegel exercises. Another treatment that may be suggested is Pelvic Muscle Rehabilitation using biofeedback.
Although surgery is generally not a treatment option for constipation, it is sometimes used to correct a prolapse. Or, if the testing shows that the colon is not functioning (colonic inertia) surgery may be an option.
Discuss with your doctor which treatments might work best for you
Pelvic Muscle Rehabilitation
Pelvic muscle rehabilitation is a process that involves many techniques. Your clinician will choose the specific ones right for you. Your active participation is very important to your success. Everything will be explained to you. If you have any questions, you should ask your clinician. Don’t be afraid to ask! If you understand why certain things are chosen, it is easier to follow through with the program. You will have homework to do in between office visits. It is important that you follow your clinician’s instructions.
Sometimes we try too hard, or do more than we have been asked, thinking that will speed regaining control. Generally it takes several visits over 2 - 3 months to regain control
Pelvic Muscle Exercise (PME)
Pelvic Muscle exercises that are specifically used to assist in restoring tone to the pelvic muscles. Most people have heard of Kegel exercises. These were developed by Dr. Arnold Kegel in the late 1940’s to 1950’s. They are voluntary contractions of the pelvic muscles followed by a period of rest and then contract again. The number of repetitions will be decided by your clinician. It is important that when doing these exercises that you only tighten the pelvic muscles and not the belly, buttocks or legs and not hold your breath.
Beyond Kegels™ Exercises
The Beyond Kegel exercises utilize the muscles of the Pelvic Rotator Cuff to return to a balance and tone of the muscles. The exercises use two muscle groups: the Obturator Internus and the Adductors. The Obturator Internus is the hip rotator attached to the Levator Ani; it acts like a pulley to lift the Levator Ani. The Adductors are the large muscles of the thigh attaching to pubic bone; this muscle group acts like fireworks sending electrical signals to the Levator Ani to keep it in tone while the Obturator Internus rests.
Biofeedback
Biofeedback is a process that uses instruments to monitor a patient’s physiologic activity and “feed back” information about it. Using biofeedback in combination with techniques such as exercise and body quieting can help us learn how to control physiologic processes, even those we initially feel are involuntary. The instrument and the display are like mirrors to let you (the patient and clinician) know what is actually going on with the muscle activity, skin temperature, or other physiological process – after all, you can’t change something until you know what needs to be changed!
In biofeedback for pelvic muscle rehabilitation, small internal sensors are used in the anus to pick up the muscle activity and surface sensors are placed on the abdomen to make sure the abdominals are used correctly.
Biofeedback does not cure but teaches control. If you quit practicing your exercises, your symptoms will return.
Biofeedback-assisted PME
Biofeedback instruments are used with exercise to learn control for return to function.
As with the exercises used, quitting the practice of exercises will lead to the symptoms returning.
The benefits of biofeedback-assisted PME are
- No side effects
- Non-invasive (minimally do to small sensors, like a tampon or suppository being used)
- Does NOT limit future options
- Involves active patient participation
- Motivating, you can see progress
Bowel Habit Training
Find a time of day after a meal that is convenient. After eating wait about 20 minutes and go to the bathroom. This is to take advantage of a body’s normal response to food or something warm to drink. This stimulates the contents of the colon to move towards the rectum. Sit on the toilet for 10-15 minutes. When you are sitting put your feet on either a thick phone book or something that will elevate the knees slightly higher than the hips. This is similar to the position taken in the days before toilets were invented and we went behind bushes. When you feel the need to push, do NOT strain! This can lead to stretching of the nerve that sends signals to the pelvic muscles and could lead to bowel control issues. Pretend you are blowing on a pinwheel or blowing bubbles. If you feel no urge to go, just get up and try again another time. It takes some time to work on retraining the bowel. Remember never to ignore the urge!
Physiological Quieting (PQ)
PQ is a process of quieting the autonomic (automatic) nervous system. This system works with the bowel/bladder among other organs. It helps you learn to help quiet the bowel/bladder to decrease the feelings of urgency (not the normal urge to have a BM) and to quiet the resting tone off the pelvic muscles. A CD that contains the exercise is used at night when going to bed. The use of slow, regular breathing all the way down to the belly (diaphragmatic breathing) with thoughts of hands being warm during the day assists in helping to quiet the bowel/bladder within a few weeks.
Final Thought
Whatever treatment you choose, work with your healthcare provider as a team to achieve your personal goals. The process will generally not be as long as you have been experiencing bowel/bladder problems.
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