A randomized trial of biofeedback for PFD in the elderly showed improvement in physiologic measures and in bowel function after eight sessions in 1 month.
Rarely indicated, subtotal colectomy with ileorectal anastomosis is the treatment of choice for refractory slow transit constipation in cases when PFD is excluded. Complications include diarrhea, incontinence, and bowel obstruction.
Results of segmental colonic resections for constipation are disappointing compared to ileorectal anastomosis. Surgical indications for PFD are poorly defined, and surgery should be considered only if functional significance can be determined. However, these anatomical abnormalities have been widely thought to be secondary to PFD since the relationship of these findings and CC symptoms is weak.
Moreover, long-term outcomes of patients that seemed to be adequate candidates for the stapled transanal resection procedure have not been promising. Alternative therapies to manage CC included sacral nerve stimulation and botulinum toxin injection therapy for PFD. Sacral nerve stimulation has been shown to be helpful in some small trials and may be useful for patients with combined urinary dysfunction.
Botulinum toxin therapy cannot be recommended based on the available data. Adjunctive therapy may be necessary for psychopathology associated with CC, and maintaining adequate caloric intake is essential. Evidence does not support the popular notion that toxins from constipation harm the body or that irrigation is needed. There is no obvious significance of an elongated colon dolichocolon , and surgical shortening does not lead to reliable clinical improvement. Although mineral oil, colchicine, and misoprostol , may improve constipation, these agents have potential side effects and complications that likely outweigh any potential benefits.
Their use in the elderly has not been explored and not recommended. Alteration of the bacterial milieu in the colon has been associated with slow transit constipation. A careful history, medication assessment, and physical examination are helpful in obtaining relevant clues that aid direct management. Physiologic categorization of the cause leading to patient presentation improves management outcomes, and it is important to consider that many causes can be present in one patient, and many factors influence the clinical presentation of an older patient.
Fiber supplementation and osmotic laxatives are an effective first line of therapy for many patients. A consistent history or inadequate response to standard initial therapy should prompt an assessment for PFD. If identified, and the patient is a reasonable treatment candidate, pelvic floor rehabilitation biofeedback is the treatment of choice. Surgery is rarely indicated in CC. National Center for Biotechnology Information , U. Journal List Clin Interv Aging v. Clin Interv Aging. Published online Jun 2.
Author information Copyright and License information Disclaimer. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. This article has been cited by other articles in PMC. Keywords: pelvic floor dysfunction, constipation, elderly.
Introduction Constipation is a common functional gastrointestinal GI disorder. Pelvic floor function Disorders of the pelvic floor manifesting with both constipation and disorders of incontinence are prevalent in the elderly population. Open in a separate window. Figure 1. Anatomy of pelvic floor. Pathophysiology The two major etiologies of constipation are PFD and slow colonic transit.
Aging process and the enteric nervous system The elderly population is impacted by age-related cellular dysfunction that affects plasticity, compliance, altered macroscopic structural changes ie, diverticulosis , and altered control of the pelvic floor. Table 1 Proposed physiologic colonic changes in the elderly.
Pelvic floor dysfunction Defecation occurs through a neurologically mediated series of coordinated muscle movements of the pelvic floor and anal sphincters Figure 2.
Figure 2. Dynamics of defecation. Colonic transit Delayed colonic transit has been described as a cause of constipation in the elderly. Psychosocial and behavioral factors Constipation is associated with significant psychological impairment. Clinical presentation The clinical presentation of a patient suffering from constipation is heterogenous. Diagnostic approach Patients typically present to their primary care physician for the initial evaluation and management of constipation. Figure 3.
Anorectal examination. Metabolic and structural evaluation Although important, particularly for individuals on multiple medications with various comorbid conditions, routine lab tests such as a complete blood count, electrolytes, calcium levels, and thyroid function studies rarely identify the cause of CC. Pelvic floor evaluation Assessment of the pelvic floor function is essential to determine if PFD is the underlying cause of constipation.
Table 3 Diagnostic findings in patients with defecatory disorders. Colonic transit Colon transit studies objectively determine the rate of stool movement through the colon, although clinically it is rarely indicated.
Treatment Selection of treatment in CC depends on the underlying physiologic cause. Table 4 Clinical factors that impact bowel function in the elderly. Table 5 Summary of commonly used laxative agents. Bulking agents Fiber supplementation is a reasonable first step in the management of CC. Laxatives Available laxatives in the marketplace include osmotic and stimulant laxatives Table 5. Stool softeners, suppositories, and enemas Stool softeners, which enhances softer stool consistency, are overall of limited efficacy.
Prokinetics Prokinetic agents exert their action through the 5- hydroxytryptamine type 4 receptor of the enteric nervous system, stimulating secretion and motility. Secretagogues Lubiprostone is a bicyclic fatty acid that activates type 2 chloride channels on the apical membrane of the enterocytes, which results in the chloride secretion with water and sodium diffusion. Pelvic floor rehabilitation biofeedback Pelvic floor rehabilitation or biofeedback is the treatment of choice for PFD. Surgery Rarely indicated, subtotal colectomy with ileorectal anastomosis is the treatment of choice for refractory slow transit constipation in cases when PFD is excluded.
Other therapies Alternative therapies to manage CC included sacral nerve stimulation and botulinum toxin injection therapy for PFD. Additional comments Adjunctive therapy may be necessary for psychopathology associated with CC, and maintaining adequate caloric intake is essential.
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Summary CC in the elderly is common, and it has a significant impact on quality of life and the use of health care resources. Footnotes Disclosure The authors report no conflicts of interest in this work. References 1. Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol. American Gastroenterological Association technical review on constipation.
Cumulative incidence of chronic constipation: a population-based study — Aliment Pharmacol Ther. Constipation in an elderly community: a study of prevalence and potential risk factors. A multinational survey of prevalence and patterns of laxative use among adults with self-defined constipation. Longstreth GF. Functional bowel disorders: functional constipation. In: Drossman DA, editor. The Functional Gastrointestinal Disorders.
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Learning Together in the Early Years: Exploring Relational Pedagogy
Physician visits in the United States for constipation: to Dig Dis Sci. Health-related quality of life in young adults with symptoms of constipation continuing from childhood into adulthood. Health Qual Life Outcomes.
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