How to effectively combat chronic constipation? Advice from specialists

in collaboration with

Pauline Guillouche (gastroenterologist)

After reviewing 134 studies published between 1^er January 2014 and 1^er February 2024, experts from the American Society of Colorectal Surgeons (ASCRS) developed a series of 13 recommendations to improve the management of chronic constipation.

Follow hygiene and dietary rules as a first step

“Chronic constipation is defined as having fewer than three bowel movements per week. defines Dr. Pauline Guillouche, gastroenterologist and hepatologist in Nantes. A transit disorder that affects 3 to 5% of the population.

Unsurprisingly, the first recommendation is to adopt hygiene and dietary rules.Initial management of patients with constipation symptomatic treatment involves dietary modifications and ensuring adequate fluid intake and fiber supplementation” write the authors.

Information confirmed by Dr Pauline Guillouche: “The patient must actually, as a first step, put in place hygiene and dietary rules such as eating well to hydratewith 1.5 to 2 L of drink per day (excluding sodas and fruit juices) and eating enough fibersby consuming vegetables, legumes and fruits, on a daily basis“. In addition, you can use a small step stool, to place in front of you to raise your feet and facilitate the expulsion of stools.

Consult a doctor to discuss it

If despite these rules, constipation persists, it is necessary to consult a doctor.A directed history and physical examination should be performed” recall American experts.

They also specify that “of the laxatives Osmotic drugs are an appropriate first-line medical treatment for managing chronic constipation.“and that”Stimulant laxatives, such as bisacodyl, may be considered for rescue therapy or as second-line therapy, if necessary.”.

Dr. Guillouche supports these recommendations.If despite taking hygienic and dietary measures, the situation does not improve, it is important to consult a doctor. It may be functional constipation, that is to say without an associated cause, but it is up to the treating physician to make the diagnosis” she recalls. “He may also prescribe osmotic laxatives, rather than irritant laxatives, such as Dulcolax, which can cause abdominal pain.“.

Perform anal area washes or rehabilitation

Other recommendations from experts include biofeedback. “Biofeedback treatment is considered a first-line treatment for patients with symptomatic pelvic floor dyssynergia” we can read in the document.

Dr Guillouche explains that this treatment is also carried out in France, generally by specialist physiotherapists. “It is used in cases of ano-rectal muscular problems, with a patient who has difficulty in defecation (i.e. evacuating stools) during terminal constipation”.

Biofeedback treatment involves inserting a probe into the patient’s anal canal, which will record the contractions of the sphincter and muscles. These are displayed on a computer screen and the patient can visualize them, which will help him reestablish the link between the order given by his brain and the relaxation of his sphincter.

Botulinum toxin used in rare cases

Among other recommendations from American experts is the injection of botulinum toxin.Botulinum toxin injection into the puborectalis muscle and external sphincter muscle may be considered in patients with outlet dysfunction, constipation related to non-relaxing puborectalis muscle” underlines the ASCRS.

According to Pauline Guillouche, this indication remains to be demonstrated. “The latest French recommendations do not recommend this practice. If it is carried out, it will be in an expert center, with practitioners trained and specialized in the matter and it will only concern a few patients.“.

In France, the use of enemas is recommended and works well.

What the gastroenterologist prescribes more often to her patients, on the other hand, are enemas.This is called transanal irrigation. These medical devices are prescribed to patients when laxatives have failed. They allow irrigation of the anus with water, in the toilet. The patient must learn to do it with a nurse at first, then do it alone, three times a week. It works well and saves them the pain and discomfort associated with their constipation.” There is also a variation of this technique that uses a cecostomy, which is a tube inserted into the cecum (part of the colon) through the skin.The patient then uses this access route to mobilize his stools, with water irrigation” the doctor specifies.

Finally, the American learned society discusses different situations where surgery will be recommended.In the case of a rectocele, that is to say a prolapse of organs affecting the rectum, a pouch forms and the patient will have difficulty emptying it. This may be an indication for surgery if laxatives do not work and the pouch becomes too large” confirms Pauline Guillouche. But generally speaking, surgical indications are assessed on a case-by-case basis and often come as a last resort, when all other solutions have been exhausted.

Pay attention to warning signs

For the gastroenterologist, the patient must trust his doctor who will refer him to a specialist if necessary.If first-line treatments (laxatives) fail, more in-depth examinations (pelvic MRI, manometry, colonoscopy, etc.) will be carried out to detect a disorder of the ano-rectal sphere. Pauline Guillouche still recalls.

Because some chronic constipation can be caused by another pathology.This may be due to a thyroid pathologyof a Parkinson’s diseasefrom taking medication (antidepressants, etc.) or even from cancer” she explains.

Our expert therefore insists on the warning signs which should prompt you to consult, whether the constipation is old or not.Beware of changes in transit, blood in the stool or on the toilet paper, loss of appetite, weight variations, fatigue, abdominal pain unusual… These are all signs that should prompt you to consult a doctor” she concludes.

Slide: Misconceptions about constipation