Toiletting issues with dysautonomia

Bladder problems: 

I practice double voiding (have for many years) to keep voluntary control of my bladder.  My ability is slowly declining, very noticeably the last couple of weeks.  I am so grateful that I was in good shape before all this started, that may have bought me some time 

when I have impactions (about once ever two months), it is caused by several things, and can be helped along: 

• do not eat more than my stomach and digestive tract can process 
• without proper saliva nothing is predigested slowing the process down and making for more solid feces than someone with normal saliva which breaks food down before getting to the stomach, this is why raw vegetables and fruit are not a good idea, nor amounts over a few ounces 
• my anal sphincter cannot open to allow the solids to pass out (damaged nerves), so only liquids or very soft feces are able to pass, and when the pressure builds to a certain point, it will vacate my body with no regard for where I am, a transit bus, a meeting, cooking in the kitchen, and there is no way to make it to a bathroom, worse still is that this gives barely any relief, that will come later, and often involves bleeding and tearing, and enormous pain
• being stationary does nothing to promote moving intestinal contents through the bowels and collects up in corners and loops to form impactions, must keep moving especially stretching out and walking to help it along - motivation is always a problem
• if you start to have edema (swelling of belly, ankles or around the eyes - stop taking in fluids, we cannot sweat it out, cry it out or manufacture saliva, so without proper bladder strength we retain 'all' of it - just sip to keep mouth moist, nothing else - drinking more water can hurt you
• when it comes to fluids people with PAF and SDS have little in common with PD+, most doctors don't seem to realize that - and they urge more fluids, I'd refuse an IV also (my choice) if having full blown edema.
• raising oil/fat content in foods (on a regular basis) does help to make feces slip more easily through the tract - again this is not the same in PD+ - I like olive oil and greasy french fries (patat), greasier the better 
• our body temp is lower (more often than not) than normal people and docs often think we don't run a fever when in fact we actually do, my usual body temp is 35.5, by the time our skin is clammy we are seriously life threateningly ill 
• the digestive tract is regulated by the autonomic nervous system, without extra help (meds and the stuff I've listed) it will not function well enough to sustain us

URINARY INCONTINENCE

I was asked by Aletta to write up a little something about incontinence.  I’m 27 years old and yes, I’ve been incontinent and have experiences with some treatments including bladder training, Kegel exercises, medication, and a medical device called Interstim Neurostimulator.  I’m not a medical practitioner so I don’t want to go into long discussion about the medical part of incontinence.  If you want more info on the definition, types and treatments of incontinence, you should check out the Canadian Continence Foundation see resources or it's counterpart in your country. 

DEFINITION OF URINARY INCONTINENCE 
Urinary incontinence is the involuntary loss of urine.  This is a very common complaint affecting 1.5 million Canadians of various ages.  It’s not a part of getting older but a condition that affects many people and causes some to be embarrassed about approaching their health care providers, and sometimes be afraid to leave their homes due to the possibility of having an embarrassing accident. 

CAUSES OF URINARY INCONTINENCE 
Urinary incontinence can be caused by a variety of things including: prostate problems, hormonal changes, birth defects, injuries to muscles or nerves, side effects of surgery, weakening of pelvic floor muscles due to child birth or other causes, various medical conditions such as multiple sclerosis and other neurological conditions, and other things such as interstitial cystitis, urinary tract infections, etc. 

TREATMENTS OF URINARY INCONTINENCE 
The treatments of incontinence vary and may depend on the cause.  For the most part, urinary incontinence can be successfully treated with diet changes, bladder training and pelvic floor exercises or Kegel exercises.  However, there are some cases where these techniques don’t improve the situation and more invasive treatments such as medication or surgery are needed. 

Diet- reducing the amount of caffeine in your diet and ensuring you get lots of water is always good for your bladder.  Caffeine is a diuretic, which means it causes you to excrete a lot of fluid.  I’m sure we all know a few people that seem to pee every 15 minutes after their cup of coffee in the morning but normally they don’t pee so often.  Caffeine sources include coffee, chocolate, some teas and some kinds of pop.  If your bladder is irritated by acid, it might help to decrease acid foods, which are primarily fruits (apples, oranges, lemon, lime, grapefruit, cranberries, grapes… pears, bananas, cantaloupe and blueberries are the less acidic fruits) and some vegetables, mainly tomato products, on top of the caffeine containing products. 

Bladder training- depending on the cause of your incontinence, bladder training might be helpful.  This technique involves timing intervals between urinating.  If you systematically need to urinate ever hour, you might start forcing yourself to wait 5 extra minutes before urinating.  With time, you can lengthen the time between bathroom trips. Other than timing when you go, you can do this when the urge comes by deciding to wait 1 minute from the time you feel you have to go and slowly increasing the time.  In some conditions, this technique would not be recommended such as in cases of interstitial cystitis where holding it can cause extreme pain.  There may be others I’m not aware of, possibly cases where the bladder isn’t emptying properly.  Please talk to your doctor. 

Pelvic floor exercises or Kegel exercises- pelvic floor muscles are the muscles that help control the flow of urine.  It is very common for theses muscles to be weakened for various reasons but most commonly vaginal childbirth.  These exercises are good for everyone and not only can they help with incontinence, but they can improve orgasm as an added bonus or motivating factor.  You do Kegel exercises by tightening the pelvic floor muscles and holding it for a few seconds.  As with everything, practice helps and you try to lengthen the time you can keep the muscles tightened.  Also, one try once a day isn’t enough.  If you can do it for 10 repetitions twice a day or so, that’s good.  You can do these exercises anywhere anytime because if you’re doing them right, no one can tell.  You tighten the muscles as though you are stopping the flow of urine when you’re peeing.  In the past they taught people to try to stop the flow while peeing but in some conditions this is not recommended.  You can try it once to see if you can get the idea what you’re supposed to be tightening but I wouldn’t recommend you always practice these exercises this way.  To know if you’re doing it right, put your hand on your belly and you shouldn’t feel your abdominal muscles tighten.  Men will see their penis move up and down slightly.  For women, it may be helpful to insert one finger in the vagina and you should feel some tightening around it as you contract the pelvic floor muscles.  You don’t necessarily need equipment to do these exercises.  Sometimes equipment is used and can include biofeedback machines where you’re hooked up to a machine and it lets you know if you’re doing it right, or some things are put in the vagina and you stand up and try to hold them in there with your muscles.  These exercises are good for everyone and even if you’re not incontinent, doing them might help prevent you from becoming incontinent, especially with childbirth and changes in hormones around menopause. 

Medications- for medications, I do know Detrol, Detrol LA and Ditropan are used in people who have urge incontinence- where they have frequent and sudden urges to go to the bathroom (overactive bladder).  For some it’s miraculous but it all depends on the cause of the urgency and frequency.  Also, some medications can be used for the side effect of causing some people difficulty in urinating (Elavil, Immipramine, Trazodone (traz not good for men, known to cause incontinence but ok for women).  For people with frequency, it can help them pee at more average intervals. 

Surgery- I’m not familiar with these except one, so I’d rather you look on the continence foundation site under consumer guide (see resources). 

Interstim Neurostimulator- This is a fairly new method of treating incontinence or severe frequency and urgency that has not been successfully treated with non invasive techniques.  By the time you get to this stage, you’ll have done the diet, training, exercise and medication thing.  In Canada you wouldn’t even been considered for the trial for this procedure if you have other options you haven’t tried.  The interstim Neurostimulator is a pace-maker like device that is inserted into one of your butt cheeks and has wires attached that are implanted near the sacral nerves.  This device stimulates the nerves continuously, which for some reason or another that I don’t quite understand decreases urgency, frequency and incontinence.  It has been very successful in several patients.  In Canada, there are only 4 doctors who currently implant this device and they are highly trained.  It is covered by the health plan.  Also, in Canada you must undergo a successful trial (outside device with wire put in by a needle only) to be put on the waiting list.  I personally had a successful trial and have had the implant in me since May 21st 2002.  I’ve not had any incontinence since this procedure and my frequency and urgency symptoms caused by interstitial cystitis have improved greatly.  Unfortunately, this device is fairly new and hasn’t been studied in people with bladder control problems due to neurological problems such as multiple sclerosis. 

If you are debating having this procedure done or want to ask questions to other people who had this done, you can go to the message board at "http://www.canadaic.com".  If you want more information you can go to  "http://www.interstim.com" www.interstim.com or you can call the Meditronic company in Canada at 1-800-268-5346.  At this time I would not recommend the American Interstitial Cystitis Network board for this topic as the situation in the USA is completely different than in Canada.  Here in Canada it’s a last resort, it’s performed by highly trained doctors, it’s covered by the universal health plan, it’s implanted for the reason for which it was designed, etc.  The mood on the American site is not very positive and you might not get any favorable responses to your questions. 

HOW DO YOU GET TREATMENT FOR INCONTINENCE? 
First of all, you should talk to your doctor about it or find a medical practitioner that is competent in this area.  You should be properly assessed by a doctor before seeking help as there may be a serious underlying condition causing the incontinence.  In most cases it’s not serious but it’s hard to know what will help if you’re not sure what the cause is. 

There are different medical practitioners in the community that may be of some help including continence nurses (specialized in continence- do a lot of education on your bladder, how it works, what is happening and what you can do about it), urologists (diagnosing the cause of the incontinence and helping with the treatment), family doctor (diagnosing the cause of the incontinence and helping with the treatment), physiotherapists (some are trained in treating incontinence- look in yellow page adds as they will specify), pharmacists and nurses at pharmacies supplying medical products (can sometimes offer videos or pamphlets, give samples of products to try or recommend products for you, or recommend someone who can help you). 
 

RESOURCES

The Canadian Continence Foundation-  "http://www.continence-fdn.ca"   1800-265-9575- offers information (can also purchase books and pamphlets), support and referrals.  Go to “list of health care professionals with a specific interest in urinary incontinence”, there are tons of services and professionals listed there. 
Your local VON (Victorian Order of Nurses) may be able to help you find information or services and support in your area. 

Your local Health Unit might be able to help you find information or services and support in your area.

If you have a specific illness causing you to be incontinent, various organizations might be able to offer information and support for your incontinence (ex: MS society, Muscular Dystrophy Association, Kidney Foundation, etc.) 

If you have Interstitial Cystitis  "http://www.canadaic.com" offers information and peer support (no Canadian organization for this disease exists). 

Books 
I’m sure there are some good books out there on incontinence but I’m not entirely sure what those would be.  I own one but I’m not sure if it’s out of print or not.  Maybe you could find it through a library or through inter library loan. 

“Overcoming Bladder Disorders: Compassionate, Authoritative Medical and Self-Help Solutions for Incontinence, cystitis, Interstitial cystitis, Prostate Problems, Bladder Cancer” by Rebecca Chalker and Kristene E. Whitmore.  Haper Perennial: New York, 1991. ISBN- 0-06-092083-1  Incontinence section talks about self-evaluation checklist, stats, definitions and types of incontinence, physiology, causes, diagnosis, tests, lots of information on treatments (medication, exercises, bladder training, surgical…) 

“Irritable Bladder and Incontinence: A Natural Approach” by Jennifer Hunt. Ulysses Press: California, 1998. ISBN- 1-56975-089-0  This book is easy to understand and talks about symptoms, causes, tests and treatments (only small paragraph on treatments), physical and emotional factors, diet, stress, relaxing… 

The Canadian Continence Foundation also has a list of books.

 INTRODUCTION -  CLINICAL -  DIFFERENTIALS -  WORKUP -  TREATMENT -  FOLLOW-UP

Authored by Dave Holson, MD, MPH, Clinical Assistant Professor, Department of Emergency Medicine, Columbia University

Coauthored by Neill Oster, MD, Assistant Site Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine, Elmhurst Hospital Center

Dave Holson, MD, MPH, is a member of the following medical societies: Society for Academic Emergency Medicine

Edited by William Chiang, MD, Assistant Director, Assistant Professor of Clinical Surgery/Emergency Medicine, Department of Emergency Medicine, Bellevue Hospital Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eugene Hardin, MD, Chair, Department of Emergency Medicine, Martin Luther King Jr/Charles R Drew Medical Center; Medical Director, Hubert H Humphrey Comprehensive Health Center; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Barry Brenner, MD, PhD, Chairman, Department of Emergency of Medicine, Professor, Departments of Emergency Medicine and Internal Medicine, University of Arkansas for Medical Sciences

Background: Constipation is a symptom rather than a disease and is the most common digestive complaint in the United States. A standard set of criteria has been suggested that includes at least 2 of the following symptoms present for at least 3 months:

Hard stools 
• Straining at defecation
• Sensation of incomplete evacuation at least 25% of the time
• Two or fewer bowel movements per week
• Pathophysiology: Constipation results from a colonic or anorectal functional disorder.


Frequency: 
In the US: More than 4 million people have frequent constipation, a prevalence of about 2%. Constipation accounts for an estimated 2.5 million physician visits per year. 

Mortality/Morbidity: Most patients with constipation can be treated medically, resulting in complete success or improvement. However, a small percentage of patients are quite debilitated as a result of constipation. Some patients with functional constipation (ie, colonic inertia) require total abdominal colectomy with ileorectal anastomosis. 

Race: Constipation appears to affect people of color 1.3 times more frequently than whites. 

Sex: Male-to-female ratio is approximately 1:3. 

Age: Constipation can occur in all ages, from newborns to elderly persons. An age-related increase in the incidence of constipation exists, with 30-40% of adults older than 65 years citing constipation as a problem.

CLINICAL 

History: 

History provides the most useful information about the etiology of constipation. Understanding the type and degree of disability caused by the symptoms is important. Disability may include the following: 

• Length of time attempting rectal evacuation
• Number of bowel movements per week
• Presence of chronic straining and/or hard stools
• The patient may be totally asymptomatic or complain of the following:
• Abdominal bloating
• Pain on defecation
• Rectal bleeding
• Spurious diarrhea
• Low back pain

The following also suggest that the patient may have difficult rectal evacuation: 

• Feeling of incomplete evacuation
• Digital extraction
• Tenesmus
• Enema retention

Physical: 

General physical examination often is of no benefit in determining etiology or deciding on treatment. The following are exceptional findings: 

A localized mass on abdominal examination 

Local anorectal lesions, which can cause or contribute to constipation (eg, anal fissures, fistulground: Constipation is a symptom rather than a disease and is the most common digestive complaint in the United States. A standard set of criteria has been suggested that includes at least 2 of the following symptoms present for at least 3 months: 

• Hard stools
• Straining at defecation
• Sensation of incomplete evacuation at least 25% of the time
• Two or fewer bowel movements per week (ed. seriously, people have more than two per week?)

Pathophysiology: Constipation results from a colonic or anorectal functional disorder. 

Frequency: In the US: More than 4 million people have frequent constipation, a prevalence of about 2%. Constipation accounts for an estimated 2.5 million physician visits per year. 

Mortality/Morbidity: Most patients with constipation can be treated medically, resulting in complete success or improvement. However, a small percentage of patients are quite debilitated as a result of constipation. Some patients with functional constipation (ie, colonic inertia) require total abdominal colecto hemorrhoids, strictures, and tumors 

• Endocrinopathic and metabolic - Hypercalcemia, hypokalemia, hypothyroidism, diabetes mellitus, and pregnancy
• Neurologic - Stroke, Hirschsprung disease, Parkinson disease, multiple sclerosis, spinal cord lesion, Chagas disease, and familial dysautonomia
• Connective-tissue disorders - Scleroderma, amyloidosis, and mixed connective-tissue disease
• Drugs
• Antidepressants (cyclic antidepressants, monoamine oxidase inhibitors [MAOIs]) Metals (iron, bismuth) Anticholinergics (benztropine, trihexyphenidyl) Opioids (codeine, morphine) Antacids (aluminium, calcium compounds) Calcium channel blockers (verapamil) Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or diclofenac Sympathomimetics (pseudoephedrine) Cholestyramine and stimulant laxatives (long-term use)
• Psychologic - Depression
• Functional constipation
• Simple constipation - Repressed defecatory urge
• Irritable bowel syndrome
• Constipation with colonic dilatation - Idiopathic megacolon or megarectum
• Constipation without colonic dilatation - Idiopathic slow transit constipation
• Chronic intestinal obstruction
• Rectal outlet obstruction - Anismus, solitary rectal ulcer, intussusception
• Weak pelvic floor - Descending perineum, rectocele
• Ineffective straining

Bowel Obstruction, Large 
Other Problems to be Considered: 

• Diabetes mellitus Hyperparathyroidism Hypothyroidism Lead poisoning Neuropathy Parkinson disease Scleroderma

Lab Studies: 

• Serum chemistry may exclude any metabolic causes of constipation, such as hypokalemia and hypercalcemia.
• Complete blood count (CBC) may reveal any anemia that might be associated with rectal bleeding (gross or occult).
• Thyroid function tests may be helpful with patients suspected of having hypothyroidism.

Imaging Studies: 

• Plain film of the abdomen (upright and flat) - This study underscores the amount of stool present in a patient’s colon. Differentiation of fecal impaction, bowel obstruction, and fecalith is possible.
• Diagnosis of fecaliths is important because of the dreaded complication of stercoral ulcers, which can lead to colonic perforation.
• Diabetic gastropathy, as well as fecal impaction, may be seen in patients with diabetic neuropathy.
• Residual barium (from barium enemas) can be visualized.
• Scleroderma and other connective-tissue diseases may be complicated by motor disturbances that mimic colonic obstruction on plain film.
• Myxedema ileus is a consequence of hypothyroidism.

Other Tests: 

• An extensive workup of the constipated patient is performed on an outpatient basis and usually occurs after approximately 3-6 months of failed medical management.
• These tests are either anatomic (eg, Gastrografin enema, proctosigmoidoscopy, colonoscopy) or physiologic (eg, colonic transit study, defecography, manometry, electromyography).

Procedures: 

• Anoscopy: Routinely perform anoscopy on all constipated patients to visualize anal fissures, ulcers, hemorrhoids, and local anorectal malignancy.
• Digital disimpaction: A well-lubricated gloved finger might be required in patients with lower anorectal impactions.
• Warm water enemas: These usually are unpopular among the nursing staff and probably are not necessary within the ED.

Emergency Department Care: 

Most patients have chronic constipation, which does not lend itself to a specific etiology at time of presentation. 

• A comprehensive history should readily identify the most common causes of fecal impaction including (1) postoperative constipation, (2) prolonged bed rest, (3) residual barium from barium enemas, or (4) medication-related constipation (eg, opioids, anticholinergics).
• In elderly bedridden patients, it is important to exclude severe dehydration and electrolyte abnormalities.
• Exclude any life-threatening complication of constipation (eg, volvulus) and remember that the patient might present with intestinal perforation after tap water enemas performed at home.
• Specifically focus therapeutic interventions on facilitating rectal evacuation rather than increasing bowel movement.
• Consultations:
• Consult a general surgeon if you suspect intestinal obstruction or volvulus.

The mainstay of treatment is a high-fiber diet. Bulking agents usually are the next line of treatment. Enemas can be used to assist in complete stool evacuation. Avoid irritant or peristaltic stimulants (eg, senna). Chronic use has been reported to induce damage to the myenteric plexus, which may eventually impair bowel motility. 

Drug Category: Bulk forming agents -- Used to increase fecal mass, which stimulates peristalsis. Drug Name Psyllium (Metamucil, Fiberall) -- Promotes bowel evacuation by forming a viscous liquid and promoting peristalsis. Adult Dose 1 tsp PO qd/tid with 8 oz of liquid Pediatric Dose 6-12 years: Administer half of adult dose with 8 oz of liquid Contraindications Documented hypersensitivity; fecal impaction; intestinal obstruction; colonic atony; undiagnosed abdominal pain Interactions May decrease absorption and effects of salicylates, nitrofurantoin, tetracyclines, and diuretics Pregnancy B - Usually safe but benefits must outweigh the risks. Precautions Caution in intestinal adhesions, ulcers, or stenosis 

Drug Name Methylcellulose (Citrucel) -- Promotes bowel evacuation by forming a viscous liquid and promoting peristalsis. Adult Dose 1 tbsp PO qd/tid with 8 oz of liquid Pediatric Dose 6-12 years: Administer half of adult dose with 8 oz of liquid Contraindications Documented hypersensitivity; fecal impaction; colonic atony; intestinal obstruction; undiagnosed abdominal pain Interactions May decrease absorption and effects of salicylates, nitrofurantoin, tetracyclines, and diuretics Pregnancy C - Safety for use during pregnancy has not been established. Precautions Caution in intestinal adhesions, ulcers, or stenosis 

Drug Category: Emollients or softeners -- Lower surface tension of stool and allow mixing of aqueous and fatty substances, thereby softening stool. Drug Name Docusate (Colace, Surfak) -- Allows the incorporation of water and fat into stool causing softening of stool. Adult Dose 100 mg PO qd/bid Pediatric Dose <3 years: 10-40 mg/d PO qd or divided bid/qid >3-6 years: 20-60 mg/d PO qd or divided bid/qid 6-12 years: 40-150 mg/d PO qd or divided bid/qid >12 years: Administer as in adults Contraindications Documented hypersensitivity; nausea; vomiting; acute abdominal pain Interactions Decreases effects of warfarin and increases effects of phenolphthalein Pregnancy A - Safe in pregnancy Precautions Prolonged use of medication may result in electrolyte imbalance 

Drug Category: Emollient stool softeners in combination with stimulants -- Emollient stool softeners cause stool to soften. Stimulants increase peristaltic activity in the GI. Drug Name Docusate sodium and casanthranol combination (Peri-Colace, Diocto C, Silace-C) -- Docusate sodium allows incorporation of water and fat into stool causing stool to soften. Casanthranol is an anthraquinone stimulant hydrolyzed by colonic bacteria into active compound. Usually produce action 8-12 h after administration. Adult Dose 1-4 cap or tab PO qd Alternatively, 5-60 mL PO qd if syrup or emulsion given Pediatric Dose <6 years: Not recommended >6 years: Administer as in adults Contraindications Documented hypersensitivity; nausea, vomiting, GI bleeding, appendicitis, GI bleeding, congestive heart failure, fecal impaction, appendicitis, nausea, vomiting, or acute abdominal pain Interactions Decreases effects of warfarin and increases effects of phenolphthalein Pregnancy C - Safety for use during pregnancy has not been established. Precautions Excessive use may lead to electrolyte imbalance, osteomalacia, steatorrhea, and cathartic colon 

Drug Category: Osmotic laxatives -- Act by retaining fluid in the bowel, osmosis, or altering the pattern of water distribution in feces. Drug Name Magnesium hydroxide (Phillips' Milk of Magnesia) -- Causes osmotic retention of fluid, which distends colon and increases peristaltic activity. This in turn promotes emptying of the bowel. Adult Dose 5-15 mL PO q6h prn Pediatric Dose 2.5-5 mL PO prn up to qid Contraindications Documented hypersensitivity; colostomy; ileostomy; renal failure; fecal impaction; appendicitis Interactions Decreases effects of tetracyclines, digoxin, indomethacin, and iron salts Pregnancy A - Safe in pregnancy Precautions Caution in severe renal impairment 

Drug Name Sodium phosphate (Fleet enema) -- Through osmotic effects, these agents draw water from the intestine into the lumen of the gut, producing distention and promoting bowel emptying. Adult Dose 1 adult (4.5 fl oz) enema PR Pediatric Dose 1 pediatric (2.25 fl oz) enema PR Contraindications Documented hypersensitivity; hypernatremia; hyperphosphatemia; renal failure; hypocalcemia; fecal impaction Interactions Do not administer aluminum, magnesium antacids, or sucralfate Pregnancy A - Safe in pregnancy Precautions Hypocalcemia, hyperphosphatemia, hypernatremia, and acidosis in patients with renal difficulties; caution in congestive heart failure and cirrhosis 

Drug Name Polyethylene glycol solution (Miralax) -- For treatment of occasional constipation. In theory, less risk of dehydration or electrolyte imbalance with isotonic polyethylene glycol compared with hypertonic sugar solutions. Laxative effect generated because polyethylene glycol is not absorbed and continues to hold water by osmotic action through small bowel and colon, resulting in mechanical cleansing. Supplied with measuring cap marked to contain 17 g of laxative powder when filled to indicated line. May require 2-4 d (48-96 h) to produce bowel movement. Adult Dose 17 g/d in 8 oz of water Pediatric Dose Not established Contraindications Documented hypersensitivity; colitis, megacolon, bowel perforation, gastric retention, or GI obstruction Interactions Reduces effectiveness and absorption of oral medications Pregnancy C - Safety for use during pregnancy has not been established. Precautions Caution in ulcerative colitis and hot loop polypectomy; not for use >2 wk 

Drug Name Lactulose (Cephulac, Cholac, Constilac) -- Produces an osmotic effect in the colon, resulting in distention and promoting peristalsis. Action may take up to 48 h. Adult Dose 15-30 mL PO qd/bid Pediatric Dose <1 year: 2.5 mL PO bid 1-5 years: 5 mL PO bid 6-12 years: 10 mL PO bid Contraindications Documented hypersensitivity; galactosemia; intestinal obstruction Interactions Decreases effects of neomycin, laxatives, and antacids Pregnancy B - Usually safe but benefits must outweigh the risks. Precautions Adverse effects include flatulence, cramps, and abdominal discomfort; caution in diabetes mellitus; monitor for electrolyte imbalance

Further Inpatient Care: 

Patients with the following warrant admission and surgical evaluation: 

• Obstructive symptoms
• Nonrectal impactions
• Fever and dehydration
• Further Outpatient Care:

Further outpatient care should include contact with the primary care physician to ensure follow-up. 

• Referral to a gastroenterologist is warranted for patients with the following:
• Constipation of recent onset
• Chronic constipation associated with weight loss, anemia, or change in stool consistency
• Refractory constipation
• Constipation requiring chronic laxative use

In/Out Patient Meds: 

Bulk-forming agent: Psyllium (eg, Metamucil) increases frequency and softens stool consistency.

Emollient: Docusate sodium (eg, Colace) improves hard bowel movements.

Lukewarm tap water enema: This treatment facilitates rapid relief of symptoms and may help regulate further bowel movements.

Deterrence/Prevention: 

Adequate fluid intake (ie, eight 8-oz glasses of water per day)

Regular exercise

High-fiber diet

Avoidance or decreased use of constipating medications

Regular bowel habits with attempted bowel movements at the same time daily may help symptoms, especially after meals when the gastrocolic reflex is strongest.

Complications: 

• Anal fissures
• Fecal impaction
• Bowel obstruction
• Fecal incontinence
• Stercoral ulceration
• Megacolon
• Volvulus
• Rectal prolapse
• Urinary retention
• Syncope

Prognosis: 

• Most active patients do well with medical management.
• Constipation is an ongoing problem for patients who are bedridden or otherwise debilitated.
• Colectomy usually is reserved for patients with slow transit constipation who fail to respond to 6 months of medical management with good patient compliance.

Patient Education: 

• Listening to patients' concepts of normal bowel activity is important.
• Instituting a behavior modification program allows patients to become more aware of and responsive to normal urges to defecate.
• Emphasize the importance of a high-fiber diet.
• Emphasize adequate fluid intake.
• Emphasize regular exercise.