Conservative and behavioural management of constipation

Abstract

This article deals with psychological contributions, such as stool withholding or responses to abuse experiences, to the aetiology of evacuation disorders (with a focus on dyssynergic defecation), and with education and behavioural approaches to treatment.

American Gastroenterological Association Technical Review on Constipation

“…Disordered defecation may be conceptualized as maladaptive learning of sphincter contraction, perhaps initiated by avoidance of pain or trauma 65 or even neglecting the call to defecate. Symptoms may date to childhood; indeed, one-third of children with childhood constipation continue to have severe symptoms beyond puberty.…”

The Physiology of Human Defecation

“…Other associated findings were the presence of a rectal/abdominal mass and a history of earlier painful defecation [21,24,25]. There is evidence that constipation and painful defecation not only precede toileting refusal [26], but also help in maintaining this behavior [27,28], which manifests as ''retentive posturing'' where toddlers hold an erect posture and forcefully contract their gluteal and pelvic floor musculature [24] until the defecatory urge disappears due to rectal accommodation. It is hypothesized that stool in the rectum gradually hardens and becomes more difficult to evacuate causing a vicious cycle that can ultimately lead to chronic rectal distension [29].…”

Diagnosis and Treatment of Pelvic Floor Disorders: What's New and What to Do

“…2 However, alternative etiologies and pathophysiologic mechanisms have been suggested, including rectal hyposensitivity, 3 perineal laxity manifested by excessive perineal descent, 4 and delayed colonic transit. 5,6 Rectal hyposensitivity and delayed transit may be consequences rather than causes of obstructed defecation because they improve after successful biofeedback treatment.…”

“…Partial division of the puborectalis and myectomy produced sustained improvements in constipation, but a few patients developed fecal incontinence after division of the puborectalis. The authors do not regard myectomy or partial division of the puborectalis as a viable alternative to behavioral or medical treatment of disordered defecation because it is believed to be a behavioral disorder 2 —there is no neurologic or structural lesion—and surgical treatments for behavioral disorders entail an unacceptable risk of morbidity. Small uncontrolled studies suggest that sacral nerve stimulation (SNS) may also improve symptoms in some patients with chronic constipation and disordered defecation.…”