Constipation

• Obstructed defecation
• Pelvic floor dyssynergia
• Paradoxical puborectalis syndrome
• Anismus

• 564.0 Constipation
• 564.02 Outlet dysfunction constipation

• K59.0 Constipation
• K59.02 Outlet dysfunction constipation
• R32 Unspecified urinary incontinence

• As of May 2013, the APTA’s Guide to Physical Therapist Practice does not include practice patterns for organ system pathology; therefore, the associated or secondary musculoskeletal, cardiovascular/pulmonary, or potential neuromuscular patterns would be indicated
• Pattern 4C: impaired muscle performance1

Description

• Difficulty passing feces
• Obstructed defecation is also known as anismus, sphincter dyssynergia, and non-relaxing puborectalis
  • Pelvic floor muscles and external anal sphincter inappropriately contract instead of relaxing during defecation

General Considerations

• Constipation is a symptom and is not a disease
• Constipation is the most common digestive complaint
• The chief cause of constipation is inadequate alimentary fiber content

Demographics2

• In the U.S., estimates are between 2% to 34%
  • 16.7% (1 in 6 people)
  • 6% of children
  • 80% of nursing home residents
  • In children: more common in males than females
  • In adults: more common in females than males
  • Very common during pregnancy and postpartum
  • In elders, equally as common in males and females
  • More common in non-whites than whites
• More than 3 million prescriptions per year for laxatives; over $725 million spent on over-the-counter laxatives
• 15% to 38% of patients with constipation have obstructed defecation3

Signs and Symptoms4,5

• ROME-III criteria for constipation: in a patient who does not take laxatives or have IBS (Irritable Bowel Syndrome), patient has at least two of the following in any 12 weeks of the last 6 months
  • Straining more than 25% of BMs (bowel movements)
  • Fewer than three BMs/week
  • Sensation of incomplete evacuation/anorectal blockage more than 25% of BMs
  • Lumpy or hard stool in more than 25% of BMs
  • The necessity of digital manipulation to facilitate evacuation more than 25% of BM

Functional Implications

• Headache
• Decreased energy
• Bad breath
• Difficulty concentrating
• Decreased appetite
• Coating on the tongue
• Abdominal bloating
• Gas/flatulence
• Skin problems
• Depression

Possible Contributing Causes

• Underactive, overactive, or non-functioning pelvic floor muscles
• Medications: multiple medicines can cause constipation
• Hormonal fluctuations: pregnancy, lactation, menopause
• Neurological conditions: Parkinson’s disease, multiple sclerosis
• Diabetes mellitus
• Scleroderma
• Anorexia nervosa
• Thyroid disease
• Hyperparathyroidism
• Hysterectomy
• Dietary: inadequate fiber, fluid, weight loss
• Poor defecation patterns, ignoring urge to defecate
• Travel: change in food, time zones, stress
• Change in routine: exercise, sleep, new job
• Admission to hospital or nursing home
• Decreased activity, bed rest

Differential Diagnosis

• Hirschsprung’s disease: aganglionosis
• Colorectal neoplasm
• Colorectal stricture, scarring
• Diverticular disease
• Irritable bowel syndrome
• Anorectal fissure, hemorrhoids, episiotomy scar
• Pelvic organ prolapse; cystocele, rectocele, descended perineum
• Rectal prolapse
• Referred pain from the gut
• Abdominal pain or tenderness; constant or intermittent, possibly related to ingesting food
• Nausea, vomiting
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