1. Bowel Workshop Alison Bardsley – Continence Advisor and Continence Service Manager, Oxon. Clinical Director – Continence UK Supported by an educational grant from

2. Function of the Large Bowel Storage of food prior to elimination Absorption of remaining water, electrolytes and some vitamins Synthesis of Vitamin K and some Vitamin B by colonic bacteria Secretion of mucus to lubricate the faeces Elimination of food residual

3. How to Know when it’s time to ‘go’ Faeces move from sigmoid colon into the rectum Full rectum Adopt correct posture Raise intra-abdominal pressure Internal and external anal sphincters relax Rectum contracts to expel stool Should pass soft formed stool with minimal effort Sphincter “snaps shut” after completion

4. THE IDEAL BOWEL MOVEMENT The feeling you want to go is definite but not irresistible Once you sit on the toilet there is no delay No conscious effort or straining The stool glides out smoothly & comfortably Followed by a pleasant feeling of relief

5. Have a Look Change in ‘normal’ bowel habit persistent for 6 weeks Undiagnosed rectal bleeding Undiagnosed rectal pain Blood/slime in stool Accompanying abdominal pain/vomiting Anorexia and weight loss Suspected infected stool *Refer to national colorectal cancer screening guidelines

6. BRISTOL STOOL FORM SCALE* Type 1:Hard lumps like nuts Type 2:Lumpy sausage Type 3:Sausage with cracked surface Type 4:Sausage with smooth surface Type 5:Soft blobs with well-defined margins Type 6:Fluffy with ragged edges Type 7: Watery, no solid pieces * Reproduced by kind permission of Dr Ken Heaton, Bristol University. 9

7. Risk factors for Constipation Medical condition Medication Toileting facilities Mobility Nutritional intake Fluid Intake

8. Diet l Fibre softens stools and speeds transit l Caffeine stimulates the gut l Artificial sweeteners can cause diarrhoea l Advice on fibre moderation if stool loose or increase if hard l Gradual caffeine reduction l Look for sensitivities in diet

9. Dietary Fibre: 18-30g per day Fluid Intake: 1.5 to 2 litres per day Fruit and vegetables: 5 portions per day Introduce fibre gradually if in doubt, liaise with dietician for specialist advice Fibre don’t over do it

10. Insoluble & Soluble Fibre Insoluble - bulking (laxative) agents help prevent constipation –Examples: Oats, fruit, vegetables and pulses Soluble – help reduce blood cholesterol levels & can help control blood sugar levels –Examples: Wholegrain cereals and wholemeal bread

11. What about laxatives? Choice of agent will depend on Presenting symptoms Nature of complaint Efficacy Side –effects Speed of action Patient acceptability Compliance Cost

12. Types of laxatives Bulk forming – Fybogel®, Celvevac® Normacol®, Regulan® Relieve constipation by increasing faecal mass which stimulates peristalsis Usually work within 24 -36 hours

13. Stimulant Laxatives Senna, Bisacodyl, co-danthramer, co- danthrasate, dioctyl, docusol Stimulate an increase in colonic motility (peristalsis) and mucus secretion Rapid acting 8-12 hours

14. Faecal Softener Liquid paraffin, arachis oil Lubricate and soften faeces to promote a bowel movement by lowering surface tension of colonic contents and allowing fat and fluid to penetrate.

15. Osmotic/iso-osmotic Laxatives Lactulose and Magnesium salts – Osmotic Act by drawing fluid from the body into the bowel by osmosis MOVICOL® - iso-osmotic MOVICOL increases stool water content and directly triggers colonic propulsive activity and defaecation. 4 in 1 mode of action: Bulks, softens, stimulates and lubricates.

16. Enemas & Suppositories Phosphate, Sodium citrate, Bisacodyl, Glycerine Uses: Acute or severe constipation Retention or evacuation Stimulation or lubricant

17. NEUROLOGICAL DISEASE Most patients will have a degree of dysfunction or suffer from constipation Caused by:- –Loss of mobility –Constipating medication –Obstetric trauma –Anal sphincter mechanism impairment –Dysphagia –Cognitive problems –Inadequate care & facilities –Lack of understanding of care needs

18. AUTONOMIC DYSREFLEXIA Unique to spinal injury above T6 SYMPTOMS  Headaches  Severe hypertension  Flushing above the lesion  Sweating below the lesion  Blotching of the skin  Nasal congestion  Bradycardia / tachycardia  Palpitations  Dilation of the pupils

19. SYMPTOMS  Headaches.  Severe hypertention  Flushing above the lesion  Sweating below the lesion  Blotching of the skin  Nasal congestion  Bradycardia / tachycardia  Palpitations  Dilation of the pupils

20. TREATMENT Acute medical emergency Remove the offending stimulus eg pr Elevate patients head Inspect skin & toe nails Medicate with nifedipine

21. Sensation Tone Outcome Medication Presence Effect & Evaluation Removal Stimulation Indications for Digital Rectal Examination

22. Indications to perform a Manual Removal of Faeces F ailure of other bowel techniques L oading or impaction I ncomplete defaecation I nability to defaecate N eurogenic cause of bowel dysfunction S pinal Injury patients

23. Consent and legal issues Lawful Consent Consent should be given by someone with the mental ability to do so sufficient information should be given to the patient Consent must be freely given Considerations – Adults unable to give consent Children

24. Conclusion Health care practitioners play a key role An holistic assessment is essential Establish the underlying cause and thus plan treatment accordingly Patient/general public education on prevention of constipation.

25. Any questions? Norgine Pharmaceuticals Ltd. for providing an educational grant to support this workshop. Contact details: alison.bardsley@continence-uk.com With thanks to…