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      Note

      1 * The terms fecal incontinence and anal incontinence are often used interchangeably. However, anal incontinence refers to involuntary passage of either faeces or flatus, whereas fecal incontinence refers to incontinence of stool alone.

CHAPTER 20 Constipation

       Katherine A. Evans1 and Charlene M. Prather2

      ¹ Rotherham NHS Foundation Trust, Rotherham, UK

      ² Gastroenterology, Saint Louis University, St Louis, Missouri, USA

Defining constipation

      Constipation most classically refers to reduced defecation frequency and hard stools. Physicians typically define constipation as fewer than three bowel movements per week. Patients more frequently describe constipation as defecatory difficulty with predominant complaints of straining or hard stools. This holds particularly true in older adults. Understanding the patient’s view of constipation assists in evaluation and treatment.

The normal defecatory process requires sufficient cognition (recognizing the need to defecate), normal colon transit, and normal function of the pelvic floor muscles and anal sphincters. Normal colon transit ranges from 24 to 72 hours. Defecation is most often preceded by high‐amplitude propagated colonic contractions. These colonic contractions occur in response to meals, particularly those with higher concentrations of calories and fat. Colonic motility is also more robust during waking hours and quiescent during sleep. Colonic activity propels stool into the rectum, causing distension and reflex relaxation of the internal anal sphincter; this prompts reflex contraction of the external anal sphincter and pelvic floor muscles. The brain registers the urge to defecate, and at an appropriate time, this may be voluntarily initiated through a set of coordinated actions. Initiation of the defecation process starts with relaxation of the puborectalis muscle, opening of the anorectal angle, and relaxation of the external anal sphincter. This is accompanied by a simultaneous rise in intra‐abdominal pressure assisted by valsalva contraction of the abdominal wall muscles (Figure 20.1). An abnormality affecting any of these areas results in the development of an altered bowel pattern (Table 20.1).

      Constipation may be defined in many different ways. Simply stated, primary constipation refers to constipation without an obvious cause, and secondary constipation results from external aetiologies.

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