CPD

CONTINUING PROFESSIONAL DEVELOPMENT

Prevention and management of constipation in adults NS788 Collins BR, O’Brien L (2015) Prevention and management of constipation in adults. Nursing Standard. 29, 32, 49-58. Date of submission: September 2 2014; date of acceptance: January 20 2015.

Abstract

Aims and intended learning outcomes

Keywords

The aim of this article is to assist readers to understand the factors that contribute to constipation in adults and inform them of the most up-to-date treatment options available. After reading this article and completing the time out activities you should be able to: Describe the signs and symptoms of constipation in adults. Outline the factors that contribute to the development of constipation and discuss the strategies used to prevent this condition. Assess a patient presenting with constipation. Describe the different types of laxatives available to treat adults with constipation and their mode of action. Understand the use of irrigation in the management of constipation. Explain the use of biofeedback therapy in treating adults with constipation.

Constipation, gastrointestinal, irritable bowel syndrome, laxatives, probiotics, rectal irrigation, suppositories

Introduction

Constipation is a common, often chronic, condition that is a health concern for providers of care. The condition can be distressing and although seldom life-threatening can lead to patient discomfort and debilitating effects on patients’ quality of life. Initial management of chronic constipation should include lifestyle changes and increased fibre and fluids. More active interventions include the use of laxatives and other medications, irrigation and biofeedback therapy. Some patients may require surgery. This article provides an overview of the strategies used to prevent constipation in adults as well as the possible treatment options available.

Authors Brigitte Rosemarie Collins Lead nurse, St Mark’s Hospital, Harrow, England. Lorraine O’Brien Clinical nurse specialist, St Mark’s Hospital, Harrow, England. Correspondence to: [email protected]

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Constipation is a common gastrointestinal disorder often characterised by difficult and/or incomplete evacuation of faeces. The exact definition of constipation may be interpreted differently by health professionals and patients (Leung et al 2011). Constipation differs from one person to another with varying bowel habits and symptoms, and this makes any single definition a challenge to use in clinical practice (Kyle 2007). An international panel of experts proposed the Rome III criteria (Box 1), which uses a combination of symptoms to define constipation (Rome Foundation 2006). Constipation prevalence rates in the UK vary between studies and population groups. The prevalence of constipation in the UK, defined by Rome II criteria, has been estimated at 8.2% (Thompson et al 2002). Almost 40% of pregnant women experience constipation april 8 :: vol 29 no 32 :: 2015 49

CPD bowel management (Jewell and Young 2001). The incidence of constipation increases with age, and 50% of older adults in the community and 74% of those living in nursing homes are affected by constipation (Rao and Go 2010). However, it is thought that the true incidence of constipation when patients self-report is much higher than is shown in research and in the Rome II criteria (Higgins and Johanson 2004, Johanson and Kralstein 2007). Complications of chronic constipation and straining include pain, discomfort, rectal bleeding, anal fissure, haemorrhoids and faecal impaction (NHS Choices 2014a). Complete time out activity 1

Causes of constipation

1 In your own words describe what is meant by slow and normal transit constipation. Consider how you would explain rectal evacuation disorder to a patient in your clinical area and make brief notes on this. 2 Discuss with your colleagues and local dietitian what dietary advice is available for adults with constipation.

Constipation is a common condition that affects people of all ages. There is no definition by mass of stool, and it is generally diagnosed on the basis of an infrequent stool that is hard in nature and difficult to pass. Most cases are not caused by a specific condition, and the exact cause may be difficult to identify. Contributing factors include secretor and motor dysfunctions of the gastrointestinal tract, lack of central and/or peripheral control of the gastrointestinal function, as well as environmental, genetic and comorbidity factors (Dinning et al 2009). Constipation can be divided into functional disorders, either slow or normal transit constipation (describing the timing of the passage of stool through the gastrointestinal tract), and rectal evacuation disorders, including structural abnormalities or lack of co-ordination during defecation (Thoua and Emmanuel 2006). There are also secondary causes resulting from other conditions (Table 1). Complete time out activity 2

BOX 1 Diagnostic criteria for functional constipation 1. Must include two or more of the following for the previous three months:  Straining during at least 25% of defecations.  Lumpy or hard stools in at least 25% of defecations.  Sensation of incomplete evacuation in at least 25% of defecations.  Sensation of anorectal obstruction and/or blockage in at least 25% of defecations.  Manual manoeuvres to facilitate at least 25% of defecations.  Fewer than three defecations a week. 2. Loose stools are rarely present without the use of laxatives. 3. Insufficient criteria for irritable bowel syndrome. 4. Symptoms should have started at least six months before diagnosis. (Rome Foundation 2006)

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Prevention Although constipation is common, there are simple lifestyle changes that can help to prevent it. Eating a healthy, well balanced diet, including fibre, can improve the function of the bowel. A Western diet is associated with reduced dietary fibre (Portalatin and Winstead 2012). The average intake of dietary fibre in the UK is 14g per day; however, the recommended daily intake is at least 18g (NHS Choices 2013). Dietary fibre is soluble or insoluble: sources of soluble fibre are oat bran, beans, barley, vegetables and fruit, and sources of insoluble fibre are wholewheat bread, beans, cereals and skins of vegetables and fruits (NHS Choices 2013). It is recommended that dietary fibre is increased slowly, to aid tolerance, since a sudden increase may cause abdominal bloating and flatulence (NHS Choices 2013). Immobility as a result of illness or lack of exercise because of lifestyle choices can increase the risk of constipation. Taking daily, light exercise and being active can reduce this risk (NHS Choices 2014b). It is important to respond to the urge to have a bowel movement and make time to relax and complete evacuation. Persistent suppression of the urge to open the bowels can lead to constipation (Kunimoto et al 1998). Establishing a regular toilet habit is important and providing privacy and a clean environment, and allowing sufficient time can help to facilitate this (Khaikin and Wexner 2006). An adequate intake of fluids, up to 1.5-2.0L per day, is recommended (World Gastroenterology Organisation Global Guidelines 2010). However, there is no evidence that increasing fluids in the absence of dehydration will prevent constipation (Gavura 2011).

Assessment Assessment of the patient with constipation includes a thorough history and physical examination, along with appropriate investigations. The tests performed can be directed by the clinical findings and should be used to confirm the diagnosis as well as assess the severity of the problem. The Bristol Stool Form Scale (Figure 1) is a useful visual aid to classify different stool consistencies, and this helps to assess how long the stool has been in the bowel (Bladder and Bowel Foundation 2013). Accurate patient assessment is crucial in providing effective individualised treatment, and an extensive assessment is required to establish a differential diagnosis (Ness 2009). It is essential to include risk assessment to identify

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high-risk individuals (Royal College of Nursing (RCN) 2012). The risk factors associated with constipation are medical conditions, medication, toileting facilities, mobility, nutritional intake and fluid intake (Kyle 2007). Red flag symptoms that may indicate colorectal cancer should also be considered (Box 2). Questionnaires may guide the patient to think about their bowel problem and how it can affect quality of life. One such example is the Patient Assessment of Constipation Quality of Life (PAC-QOL) (Marquis et al 2005). It is useful to have a structure or guidance for commencing assessment, which may include the following: The patient’s main bowel problem at the present time and when it started. Were there any precipitating factors? Is there an urge for a bowel movement? How often does the patient have a bowel movement? What is the consistency of stool? Is there a history of blood or mucus in the stool? Does the patient need to strain and how much time is spent on the toilet?

Does the patient feel evacuation is incomplete? Does the patient use laxatives, suppositories or enemas? How much and how often? What result does the patient get? Assessment of diet can include: finding out if the patient is eating regularly, the type of fibre content and how much? Is a special diet being followed? How does the bowel problem affect everyday life, relationships and/or emotions? It is also important to obtain a history of laxative use (prescribed and over the counter), any medication that may contribute to constipation and any surgical procedures.

Digital rectal examination

Digital rectal examination should be undertaken only by appropriately trained practitioners and may be used in conjunction with a nursing assessment to (RCN 2012): Establish the presence of faecal matter in the rectum, as well as amount and consistency. Establish the state of the rectum before giving any rectal medication.

TABLE 1 Causatory factors for constipation Functional

Gynaecological

Lifestyle

Idiopathic constipation (no obvious cause). Pelvic floor dyssynergia. Irritable bowel syndrome. Slow transit constipation.

Pelvic floor relaxation. Rectocele.

Inadequate fluid intake. Inadequate dietary fibre intake. Lack of exercise. Suppression of defecation (voluntary).

Medication

Endocrine or metabolic

Neurological

Antacids. Anticholinergics. Anticonvulsants. Antidepressants. Antiemetics. Antihypertensives. Antiparkinsonian drugs. Antipsychotics. Calcium supplements. Cytotoxic therapy. Diuretics. Iron supplements. Laxatives (chronic usage). Opiates. Non-opiate analgesia.

Diabetes mellitus. Hypercalcaemia. Hypothyroidism. Hypokalaemia. Panhypopituitarism. Uraemia. Porphyria. Amyloidosis. Hypermagnesia. Lead poisoning.

Cerebrovascular accident. Hirschsprung’s disease. Multiple sclerosis. Parkinson’s disease. Spinal cord injury.

Psychological

Physiological

Primary diseases of the colon

Depression. Eating disorders, anorexia, bulimia. Stress-related dementia, learning disability.

Pregnancy. Old age.

Anal fissure stricture (tumour, ischaemia, diverticular disease). Mega colon, mega rectum, pseudo-obstruction.

(World Gastroenterology Organisation Global Guidelines 2010)

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CPD bowel management Determine the need for digital removal of faeces. Evaluate bowel contents before administering suppositories, enemas or rectal irrigation and bowel emptiness following their use.

FIGURE 1 Bristol Stool Form Scale

Without a proficient assessment and digital rectal examination, the treatment and management of the patient are likely to be inadequate. Complete time out activity 3

Medical management Acute constipation is common in primary care (World Gastroenterology Organisation Global Guidelines 2010). Initial intervention should include advice on diet, fluids and physical activity. No single treatment is appropriate for all individuals since there are many contributing factors and causes of constipation and patients respond differently to various treatments. Some patients will require a combination of treatments, which should be assessed regularly with changes instigated if they fail to be effective. The management of patients with chronic constipation involves clearing any faecal impaction and applying a stepped approach to the use of laxatives and, depending on the response to treatment, adjusting the dose and frequency as necessary, combining laxatives and consideration of individual preferences (Paré et al 2007). Complete time out activity 4

Laxatives

(Reproduced by kind permission of Dr KW Heaton, Reader in Medicine at the University of Bristol. ©2000 by Norgine Pharmaceuticals Limited.)

BOX 2 Red flag symptoms for colorectal cancer  Bleeding from the rectum or blood in stools.  A change in normal bowel habit to diarrhoea or looser stools, which is persistent and unexplained.  A rectal and/or anal lump or abdominal lump.  A feeling of needing to strain in the rectum.  Unexplained weight loss, fever or nocturnal symptoms.  Iron deficiency anaemia.  Feeling tired or breathless.  Pain in abdomen or rectum.  Bowel obstruction. (Cancer Research UK 2014)

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Evidence for the use of laxatives is limited since many laxatives have been in use for a long time, clinical trials at the time were less vigorous, and there is a scarcity of new studies (National Institute for Health and Care Excellence (NICE) 2015a). There are five groups of laxatives: bulk-forming, stimulants, faecal softeners, osmotic and bowel-cleansing preparations (British National Formulary (BNF) 2014). If laxatives are indicated, the patient should be prescribed a bulk-forming laxative first. If stools remain hard, an osmotic laxative should be used or given in addition to a bulk-forming laxative (NICE 2015a). Macrogols are the osmotic laxative of choice, changing to lactulose if macrogols are not effective or tolerated (NICE 2015a). If the stools are soft but are still difficult to pass or incomplete, a stimulant laxative should be added (NICE 2015a).

Bulk-forming laxatives The action of fibre

supplements is similar to dietary fibre in that they increase the bulk of the stool. Fibre supplements are formed of natural plant extracts such as ispaghula husks or sterculia. One to two sachets of the preparations are taken daily, after meals with water. Potential

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side effects include abdominal bloating and increased flatulence. Tolerance can be aided by increasing the dose slowly (Portalatin and Winstead 2012). Older or debilitated patients with intestinal narrowing or decreased motility should be supervised when taking these preparations (BNF 2014). Methylcellulose is a synthetic fibre, which acts as a faecal softener as well as a bulking agent (BNF 2014).

Stimulant laxatives Stimulant laxatives such as

senna and bisacodyl act by increasing peristalsis, stimulating sensory nerve endings and possibly interfering with electrolyte fluidity to inhibit water absorption (Emmanuel 2011, Toner and Claros 2012). This type of laxative often acts rapidly and is particularly useful in a single dose for temporary constipation, producing a normal soft-formed stool (Portalatin and Winstead 2012). There is limited evidence from clinical trials supporting the use of stimulant laxatives with recommended approaches to treatment being primarily by expert opinion (NICE 2015a). In particular there is a lack of evidence for use of stimulants in adults with chronic constipation, and clinicians are careful not to recommend unlimited stimulants (Emmanuel 2011, Portalatin and Winstead 2012), since long-term use may contribute to development of electrolyte imbalance (Folden 2002). Potter and Wagg (2005) point out that long-term use of stimulants can lead to tolerance and decreased efficacy. Even in situations where the symptoms of constipation are similar, there can be a discernible variability in response to medications (Eltringham and Yiannakou 2003).

Faecal softeners Faecal softeners such as docusate sodium have stimulant and softening actions (BNF 2014), and prevent hardening of the faeces by adding water to the stool to lubricate and make it easier to pass (Portalatin and Winstead 2012). The active ingredient in most faecal softeners is docusate, although preparations such as arachis oil and paraffin do not contain docusate. Preparations containing docusate are used more to prevent constipation than to treat it. Emmanuel (2011) suggests that faecal softeners are often used as an adjuvant to bulk-forming or stimulant laxatives or as an alternative if bulk-forming laxatives do not work or are contraindicated, and they are usually well tolerated although with moderate effectiveness. Faecal softeners are often recommended for individuals who should avoid straining while defecating, including those: NURSING STANDARD

Who are recovering from abdominal, pelvic or rectal surgery, childbirth, or myocardial infarction. With severe high blood pressure or abdominal hernias. With painful haemorrhoids and/or anal fissures.

Osmotic laxatives Osmotic laxatives increase the amount of water in the bowel either by drawing fluid from the body into the bowel or by retaining the fluid they were taken with. This group of laxatives is associated with side effects, including abdominal bloating, nausea, electrolyte imbalance and colic (BNF 2014). Magnesium sulfate (Epsom salts, dose 5-10g) is a potent laxative that can generate a large volume of liquid stool and abdominal distension (DiPalma et al 1996). There are no placebo-controlled trials of magnesium salts in chronic constipation (Emmanuel 2011). Magnesium laxatives are not recommended in patients with renal insufficiency or cardiac dysfunction (Portalatin and Winstead 2012). Lactulose is a semi-synthetic disaccharide that is not absorbed from the gastrointestinal tract. Gas and bloating are common with its use because it is fermented by colonic bacteria. The dose is 15-30mL, once or twice per day, with results occurring after 24-72 hours (BNF 2014). Macrogols are inert polymers of ethylene glycol that sequester fluid in the bowel. The dose is one to three sachets per day taken with 125mL water, but liquid concentrations are available, with 25mL to be diluted in 100mL of water. Common side effects include abdominal bloating, cramps and diarrhoea. Several studies have shown improvement in stool consistency and stool frequency compared with placebo (Corazziari et al 2000, DiPalma et al 2000, Cleveland et al 2001). A Cochrane review of ten randomised controlled trials found that polyethylene glycols are better than lactulose in outcomes comparing stool frequency, form of stool and relief of abdominal pain (Lee-Robichaud et al 2010). Other medications used in constipation

Prucalopride is recommended for women with chronic constipation who have used two laxatives for at least six months with no satisfactory improvement in symptoms (NICE 2010). Prucalopride primarily stimulates colonic motility (NICE 2010), and it is recommended that 2mg is taken by adults up to 65 years and 1mg by adults over the age of 65. In a large clinical trial, 12 weeks of treatment with prucalopride 2mg

3 Review the history and assessment documentation of three adult patients recently referred with constipation. Look for evidence of a systematic assessment that results in a clear management pathway. 4 Explain the difference between stimulant laxatives and osmotic laxatives. Give two examples of each.

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CPD bowel management

5 Discuss the

indications for using (a) suppositories and (b) enemas to treat adults with constipation.

6 Find out about three different irrigation systems used to treat constipation. Make brief notes on how each system works and list the differences between each system.

and 4mg/day resulted in a greater proportion of patients reaching more than three spontaneous complete bowel movements than with placebo (Camilleri et al 2008). Bowel habit and associated symptoms, patient satisfaction with bowel habit and treatment, and quality of life were significantly improved in patients with severe chronic constipation, including in those who did not experience adequate relief with previous therapies. Camilleri et al (2008) showed that improvement was maintained during treatment for up to 24 months. Linaclotide is a medication licensed for the treatment of moderate-to-severe symptoms of irritable bowel syndrome with constipation in adults. Taken once daily, linaclotide is associated with decreased visceral pain, increased intestinal fluid secretion and accelerated intestinal transit (NICE 2013). An improvement in spontaneous bowel movements in patients taking linaclotide versus those taking placebo was found in two trials (Rao et al 2012, Quigley et al 2013). Lubiprostone is recommended for chronic constipation if two categories of laxatives have failed to be effective in the past six months (NICE 2014). Lubiprostone activates chloride channels in gastrointestinal epithelial cells, relieving symptoms of chronic constipation by improving intestinal secretion (NICE 2014). The dose is 24mg twice daily (NICE 2014). Complete time out activity 5

tubes to ensure that there is no trauma to the rectal mucosa (Portalatin and Winstead 2012). Complete time out activity 6

Rectal suppositories and enemas

The Peristeen irrigation system works by the patient inserting a catheter into the rectum and inflating a balloon while sitting on the toilet. This has been found to be effective for evacuation difficulty in people with spinal cord injury, who use on average 400mL, and up to 1L, of water (Christensen et al 2006).

Rectal suppositories and enemas can assist in the short-term relief of constipation if the patient has difficulty evacuating a bowel movement despite an urge to defecate. Glycerol (glycerin) suppositories act as a rectal stimulant (BNF 2014), mildly stimulating the rectal mucosa. They can be used as a first-line treatment, with bisacodyl suppositories or micro-enemas containing sodium citrate as an alternative if glycerol suppositories alone are not effective. Bisacodyl suppositories and micro-enemas exert a stimulating action in the rectum (Portalatin and Winstead 2012). Phosphate enemas are hypertonic solutions that cause stimulation and irritation of the rectal mucosa, resulting in a bowel movement. They should be used with caution in older patients and those with electrolyte imbalance, congestive heart failure or uncontrolled hypertension. Adequate fluids should be maintained. Phosphate enemas are contraindicated in acute gastrointestinal conditions including obstruction and inflammatory bowel disease (BNF 2014). Care should be taken on insertion of enema

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Rectal irrigation When the patient with constipation has not responded to conservative treatment measures and symptoms have not improved adequately, rectal or transanal irrigation is available to assist in evacuation of faeces. Irrigation helps to empty the lower bowel (the rectosigmoid area) by introducing water via the anus, which can accelerate transit time through the colon and prevent constipation (Bazzocchi et al 2006). Irrigation enables the bowel to be emptied regularly, and as a result a bowel routine can often be re-established by choosing the time and place of evacuation (Emmanuel et al 2013). There are several types of irrigation systems available and a few examples are discussed in this article; however, this is not an exhaustive list. It is important to point out that the system should be chosen based on individual assessment and reflect the patient’s mobility, dexterity and any other conditions that may affect its use. The evidence base for adults using irrigation to manage constipation is sparse, with much of the research referring to neurogenic bowel dysfunction.

Peristeen irrigation system

Qufora mini irrigation system

The Qufora mini irrigation system is a compact rectal irrigation system (Figure 2). It is a handheld device that can be used with one hand. It holds up to 100mL of fluid, most commonly tap water, is ideally suited for emptying the rectum and is similar to using an enema. The Qufora mini irrigation system was found to be acceptable, comfortable and helpful by the majority of patients in an audit, with two thirds wishing to continue using it regularly or some of the time (Collins and Norton 2013).

Qufora cone toilet system

The Qufora cone toilet system is a rectal irrigation system used while sitting on the toilet (Figure 3). A water bag is filled with lukewarm

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Biofeedback therapy Biofeedback therapy incorporates an instrument-based learning process to reinforce normal defecation and correct inco-ordination of abdominal, rectal, puborectalis and anal sphincter muscles to achieve complete evacuation (Rao 2011). The aim of biofeedback therapy is for the patient to improve and take control of his or her bowel function. A study by Rao et al 2010 showed that biofeedback was superior to standard therapy in patients with dyssynergic defecation (failure of normal relaxation of the pelvic floor muscles during attempted defecation). At St Mark’s Hospital in Harrow, biofeedback incorporates symptom assessment, education, bowel and muscle retraining, behavioural therapy and psychological support using a complex package of care. Biofeedback therapy is provided as an outpatient service and patients are seen by the same therapist for up to four or five sessions at intervals of four to six weeks. The initial appointment is for about 60 minutes, with subsequent follow-up appointments of 30 to 40 minutes. It is important to respond to an urge to defecate. Developing a toileting routine, preferably in the morning or after meals, taking time and ensuring privacy will assist normal bowel function. This complies with peristalsis, which propels the contents of the bowel through the colon and is increased in the mornings, getting out of bed, washing, dressing and after meals and is referred to as the gastro-colic response (Sherwood 2008). Patients are taught evacuation positioning and the evacuation method referred to as the brace-pump technique. The optimal position is to sit on the toilet leaning forward with forearms resting on thighs, shoulders relaxed

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Percutaneous tibial nerve stimulation Percutaneous tibial nerve stimulation delivers a low-frequency electrical current via a needle electrode inserted at the ankle adjacent to the posterior tibial nerve (Allison 2011).

FIGURE 2 Qufora mini irrigation system MACGREGOR HEALTHCARE LTD

The Qufora balloon catheter system is an irrigation system where a balloon is inflated in the rectum so the patient does not have to support it while instilling the water. There is a safety valve to reduce the risk of over-inflation of the balloon. The system has a control unit with a dial that is turned clockwise in four easy steps (Figure 4).

FIGURE 3 Qufora cone toilet system MACGREGOR HEALTHCARE LTD

Qufora balloon catheter system

and feet placed onto a small foot stool. This is a natural position to adopt to open the bowels. The patient should not strain and instead should inhale and breathe out normally, while avoiding holding the breath. Initially the patient should brace the abdomen by widening the waist, then engage the abdominal oblique muscles, pushing downwards and backwards into the rectum, pause for one second, and push again and repeat this pump action, keeping the abdomen braced throughout (Horton 2004).

FIGURE 4 Qufora balloon catheter system MACGREGOR HEALTHCARE LTD

water and a cone is inserted into the rectum. Squeezing the hand pump makes water run into the rectum. Removal of the cone allows water and faeces to flow into the toilet. A non-return valve in the pump prevents contaminated water from running back into the system.

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CPD bowel management The afferent fibres of this nerve transmit impulses to the sacral nerve plexus, providing neuromodulation of the rectum and anal sphincters (Allison 2011). Percutaneous tibial nerve stimulation has potential as an affordable and minimally invasive treatment for slow transit constipation, as demonstrated by Collins et al (2012). This pilot study of 18 patients showed a statistically significant decrease in constipation and improvement in the patients’ assessment of constipation and quality of life; physical and psychosocial comfort were also improved. However, this is the first study of this treatment and involves small numbers, and further research is required before it can be recommended as a treatment for constipation. Complete time out activity 7

Surgical management

7 Surgery may be a treatment option for some patients with constipation. Discuss with a colleague working on a surgical ward the different surgical procedures that could be considered.

Some patients with chronic constipation do not respond to treatment and may be considered for surgery as a last resort. This could involve a total colectomy with ileorectal anastomosis, sigmoid colectomy, left hemicolectomy or an ileostomy. A systematic review of abdominal surgery for chronic idiopathic constipation showed an increase in bowel movements and a reduction in laxative use (Arebi et al 2011). There were surgical complications of ileus, infection, and anastomotic leakage (Arebi et al 2011). However, patient satisfaction and quality of life scores were high. Patients with constipation often have additional symptoms of abdominal pain and bloating; however, the studies in the review did not record the outcomes for these symptoms. An alternative treatment, sacral nerve stimulation, has shown an improvement in stool frequency and successful evacuation with a reduction of abdominal pain and bloating. This improvement occurred in patients with slow transit and normal transit constipation (Kamm et al 2010). In a review of ten studies in adults, in patients who proceeded to permanent sacral nerve stimulation, up to 87% (39 of 45) showed improvement at a median follow up of 28 months (Thomas et al 2013). The authors recommended that larger studies should be undertaken with longer follow up and comparisons with surgical therapies.

Complementary therapies Complementary therapies for constipation include probiotics, hypnosis, acupuncture and reflexology.

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Probiotics

Probiotics in the form of capsules or yoghurt drinks have been suggested as an alternative treatment for constipation. They are thought to act by suppressing growth of pathogenic bacteria, blocking epithelial attachment by pathogens, enhancing mucosal function and modulating immune response (Sartor 2005). Probiotics are live micro-organisms which, when administered in adequate amounts, confer a health benefit on the host (Isolauri et al 2004). Commonly used strains of bacteria are Bifidobacteria and Lactobacilli. Evidence to support the use of probiotics is sparse since probiotics are regulated as foods and do not undergo the rigorous testing and approval required for medicines (NHS Choices 2014c).

Hypnosis

Hypnosis is an intervention that assists a patient to achieve a trancelike state that resembles an altered state of consciousness. This results in an increased responsiveness to suggestion. It is recommended for people with refractory irritable bowel syndrome of which one of the symptoms is constipation (NICE 2015b). Houghton et al (2002) studied the effect of emotions on visceral sensitivity in 20 patients receiving hypnosis and concluded that emotions are linked to visceral hypersensitivity and perceptions of symptoms. This suggests that a patient’s state of mind can have a direct effect on gut function and indicates that patients should receive psychological as well as physical assessment. One important aim of this therapy is teaching self-hypnosis to patients to enable them to take control of their bowel function (Gonsalkorale 2006).

Acupuncture

Acupuncture is a traditional Chinese method used to relieve pain or alter the function of a body system by inserting thin needles into the skin at specific sites on the body along a series of meridians. It is being used more frequently to treat a wide range of health conditions and is thought to be of benefit in relieving symptoms of constipation. Electro-acupuncture has been found to be of benefit to female patients with constipation (Chen et al 2013). However, there is a need for further research.

Reflexology

Reflexology is a non-intrusive complementary therapy that is based on the theory that different points on the feet correspond with different areas of the body. Reflex points in

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the feet are massaged in a specific way that has a functional effect on distant parts of the body. A study found that there was no improvement in symptoms such as abdominal pain, bloating and constipation in patients with irritable bowel syndrome who underwent reflexology treatment (Tovey 2002). A pilot study of the effectiveness of treating 19 women with constipation using reflexology showed that there was some improvement in patients’ symptoms (Woodward et al 2010). However, numbers were small in this study and randomised controlled trials are required.

Conclusion Nurses in community and hospital settings have a unique role in the prevention and management of constipation in adults (Ness

2009). A thorough assessment of patients’ medical histories, physical examination and appropriate tests will confirm the diagnosis. Simple interventions such as adequate fibre intake, adequate fluid intake, regular meals and bowel routine can be implemented initially. However, some patients will require more active intervention, including medical and or surgical management. Some commonly used agents lack evidence to support their use (Portalatin and Winstead 2012), and therefore it is important that nurses are knowledgeable about the various treatment options available so that they can inform and advise patients, offer individualised care and monitor the effectiveness of any interventions administered NS Complete time out activity 8

8 Now that you have completed the article, you might like to write a reflective account. Guidelines to help you are on page 62.

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