VIDEO: Diagnostic process for patients presenting with constipation-related symptoms

Editor’s note: This is an automatically generated transcript, which has been slightly edited for clarity. Please notify editor@healio.com if there are concerns regarding accuracy of the transcription.

So in general, we evaluate patients by first going through their history in great detail. Finding out how long they've have constipation-related symptoms is extremely important. The longer the duration — and oftentimes it'll go back to childhood — but looking for triggers or events that may have precipitated their constipation could be extremely important. If someone presents with constipation, it could mean completely different things to different people.

A study done in Canada over a decade ago asked the general population what they meant by constipation, and they found that infrequent stools was actually a minority of patients. It was predominantly straining, bloating, cramping, cramping pain, incomplete evacuation and then infrequent stools were the most commonly related symptoms.

So really you need to probe into finding why, what they feel and what those symptoms are, and then find out what their predominant symptoms are. Because sometimes your treatments may be geared towards that. For example, patients that may have pelvic floor dysfunction or rectal evacuation syndrome may have more straining. Sometimes they'll have odd positioning in order to initiate a bowel movement.

So really the history's going to be important. Discussing family history, because oftentimes, you'll see that IBS and constipation can be commonly within families. Also talking about the pattern of bowel movements is extremely important. When do they have a bowel movement? Do they leave sufficient time to have a bowel movement? What's the positioning that they have on the toilet when they have a bowel movement?

So when you think about the modern-day toilet, it's probably too high, right? Most of mankind didn't have a toilet that was in a sitting position. It was more of a squatting position, and that squatting position is probably better for us to initiate evacuation, improving the anal-rectal angle, which is oh-so-important to keep us continent, but can in patients where it paradoxically contracts, inhibit constipation.

So I'll tend to ask them about their positioning, the timing, are they leaving sufficient time, and then trying to get them to utilize other factors. So typically in the morning is when you'll have these high-amplitude propagating contractions that can initiate a bowel movement, particularly after a meal. So having some food in the morning, maybe some caffeine if they drink coffee or other caffeinated drinks, and then spending a little time in order to have a bowel movement. Generally telling them to wait until they have their urge to go to the bathroom, so not sit on the toilet and try to strain. And then we also see that the pattern sometimes will vary in people.

So a lot of people with severe constipation, they tend to have bowel movements later in the day. So inquiring about when that occurs, and sometimes that whole event will occur later in the evening or the late afternoon, and so that can be helpful to know. Not only to help them initiate bowel movements, but as we talk about treatments, that can help guide to when you should be initiating treatment, what time of the day you should be giving people treatments for their constipation.

So of course, we do want to do a full physical exam, and I would be remiss if I didn't talk about the rectal exam. And we all, I think, everybody has heard how important it is and what we need to do for a rectal exam. That includes assessing the ability for the puborectalis and the anal sphincter to relax.

One of the things we also do is put one hand on the abdominal wall to assess that they're able to contract the abdominal wall while they're initiating their bowel movement, because of course, that's what increases the intraabdominal pressure and the pressure released in the rectum and that helps push stool through. So they have to be able to do that. That's one major component and they have to be able to relax the puborectalis and the anal sphincter.

So if you don't feel that both of those working at the right time and efficiently, then that can be a strong sign that they have a rectal evacuation syndrome or paradoxical pelvic floor contraction, and that may be give you a clue that they could go through pelvic feedback for pelvic floor therapy. We could also send patients for anal-rectal motility and balloon expulsion, which is a very good way of assessing pelvic floor dysfunction, but that's not always widely available. So when it's not available or when the exam is inconclusive, then you know, you can consider anal-rectal motility, but if your exam is conclusive and it's not available, then we could just go on to biofeedback.