Constipation Due to Pelvic Organ Prolapse

Constipation at a glance

• Constipation is a condition that can include difficulty in passing stool, pain when doing so, stool that is hard or dry, a feeling that the stool has not passed, and having infrequent bowel movements.
• A woman would see a pelvic floor specialist when the underlying cause of constipation is caused by a pelvic floor condition known as pelvic organ prolapse.
• Other forms of constipation (not related to pelvic floor disfunction) are typically addressed by a gastroenterologist.
• Constipation occurs most often when stool that forms from digested food moves too slowly through the digestive tract, though medications and other conditions can cause it like problems with colon and rectal nerves, pelvic floor muscles and hormone balances.
• Though sometimes described as having three or fewer bowel movements a week, this is not an exact definition since frequency can vary by individual.
• Chronic constipation lasts several weeks or longer and is of greater concern, as it can sometimes impact a normal lifestyle and activities. Chronic constipation can be a symptom of an underlying condition that needs attention and can also lead to other problems such as pelvic floor dysfunction.
• Treatments we can provide range from physical therapy to prescribed medications to surgery that corrects an underlying condition. Patients can also try many treatments on their own including over-the-counter medications and lifestyle changes.

What is constipation?

Constipation is a defecation problem involving difficulty having bowel movements, infrequent bowel movements or both. Symptoms include straining too much in passing stool, a feeling that the stool has not passed, and stool that is lumpy, dry or hard.

Some people are under the impression that they have constipation if they don’t have a daily bowel movement, but this is not true. A rule of thumb on frequency is three or less bowel movements a week constitutes constipation (stool generally becomes harder after three days and more difficult to pass). But even this time frame can vary, and frequency alone doesn’t constitute a problem.

Occasional constipation is normal, and just about everyone experiences it at some time. It results in about 2.5 million doctor visits in the United States every year, according to the American College of Gastroenterology. And women experience the condition 3-5 times more often than men.

It can be bothersome and disrupt one’s lifestyle, but it usually is not cause for concern. Constipation and other bowel problems are often related.

Chronic constipation

As many as 50% of those with chronic constipation also have pelvic floor dysfunction.

About 63 million Americans experience a chronic form of this condition, which is considered having constipation for several weeks or longer. It is also more prevalent in women, and incidents of chronic constipation increase with age.

Chronic constipation generally requires medical attention to relieve symptoms and manage the issue. It’s also a good idea for a doctor to identify the cause, which may indicate a serious underlying condition that needs to be corrected, such as Crohn’s disease.

• Pelvic floor-related constipation in women, caused by pelvic organ prolapse, can be treated by a female pelvic medicine specialist.
• Other forms of constipation related to the digestive tract, including chronic constipation, can be addressed by a gastroenterologist.

Causes of constipation

A person generally has constipation due to stool moving too slowly through the digestive system. This slow transit causes too much water to be absorbed from the stool, making it dry and hard. Dietary changes, being dehydrated and some drugs can cause slow transit.

Some causes of normal constipation that would be addressed by a gastroenterologist include:

• Poor diet choices, such as too much meat, dairy, processed foods, caffeine or alcohol; too little fiber.
• Not enough fluid consumption.
• Not enough exercise.

Chronic constipation is more complicated and has many possible causes.

• Other medical conditions including nerve damage, stroke, pregnancy, diabetes and thyroid disease.
• Structural lesions in the colon, which may be due to colon narrowing or colon cancer, can also cause it.
• Various medications (blood pressure, narcotics for pain, anti-seizure) can also cause the chronic condition, and changing the types of the drugs can be the solution.
• Blockages in the rectum or colon.
• Irritable bowel syndrome, an intestinal problem also causing diarrhea, gas and pain in the belly
• Anxiety and depression.
• Dyssynergic defecation, which is due to lack of coordination of the muscles in the pelvic floor, rectum, anal sphincter and abdomen.
• Rectal prolapse in which part of the rectum drops out of position and protrudes from the anus.
• Other types of pelvic organ prolapse.
• Rectocele, also called posterior prolapse, involves the front wall of the rectum pushing into the vaginal wall, sometimes creating a bulge in the vagina.
• Weak pelvic floor muscles and other pelvic floor disorders.

Diagnosing constipation & when to see a doctor

While constipation is normal and can go away on its own, there are several signs of concern:

• If one gets constipation and has never had it before.
• Blood is in the stool.
• Unexplained weight loss.
• Severe pain with bowel movements.
• Changes in bowel movements that occur quickly.

If a woman experiences these issues, it is important to seek medical support. A physician will first discuss the patient’s medical history and symptoms, also addressing any possible underlying conditions and medications. The doctor will conduct a rectal examination and may perform a blood test to evaluate for certain conditions. X-rays may also be taken.

Testing for causes of constipation

Other tests may be necessary including the following.

• A marker study evaluates how food moves through the colon, and involves a pill taken that contains markers (sometimes a wireless recording device) that show on X-rays, which will be taken over a few days.
• A barium enema X-ray highlights the colon and rectal areas by inserting the barium dye into the rectum after the patient has cleaned out the bowels by drinking a liquid the night before. The physician evaluates the area by reading the X-ray. A barium X-ray can also be taken during defecation.
• Anal sphincter muscle evaluation, also called anorectal manometry, checks the coordination of the muscles when the patient moves her bowels. A small balloon at the end of a thin tube inserted into the rectum is inflated and then removed from the rectum. An additional test can be done at the same time that clocks the time it takes for the patient to expel a small, water-filled balloon.
• A sigmoidoscopy is a procedure to examine the rectum and lower colon (sigmoid colon) using a lighted, flexible tube with a camera that gives the physician a clear view.
• A colonoscopy is similar to the sigmoidoscopy but examines the rectum and the entire colon, which is the final part of the digestive tract.

Home remedies for constipation

The providers at CU Urogynecology first recommend that women experiencing chronic constipation try to solve the problem on their own. This can involve lifestyle changes such as improving one’s diet, drinking more water and getting regular exercise.

Enemas can help one with impacted stool. Over-the-counter (OTC) medications like laxatives can also help. But women shouldn’t take them for more than two weeks without consulting a physician, as laxatives can lead to a dependency on them for bowel movements.

There are several different kinds of laxatives that work in different ways. These include osmotics (Phillip’s Milk of Magnesia, Miralax and others) that increase fluid from the intestines, fiber supplements, stimulants, stool softeners and suppositories.

Bowel training can also help, which is trying to get in the habit of having a bowel movement at the same time each day usually soon after eating, helping stool move through the colon. Changing medications or supplements can help, and women should speak to their doctor for recommendations on this.

Medical interventions for serious constipation

Constipation medications

Physicians may prescribe medications that are more powerful than OTC medications. For instance, medications such as lubiprostone and linaclotide help increase the fluid volume in the intestines, which makes stool softer and bowel movements more frequent while reducing any abdominal pain.

Prucalopride can help move stool, and is often prescribed when the cause of chronic constipation isn’t known. Medications called PAMORAs (peripherally acting mu-opioid receptor antagonists) are used when opioid medications taken for pain result in chronic constipation.

Electromyographic biofeedback

A specialized physical therapist can use electromyographic (EMG) biofeedback to help a woman train her bowels to relax and tighten at the right time during bowel movements, easing passage of stool. A tube inserted in the rectum and sensors are placed on internal or external surfaces to measure muscle tension while the patient is instructed to relax and tighten pelvic floor muscles.

This device measures and reports on muscle activity, helping the patient better understand and eventually control the subtle interactions through behavioral training.

Sacral nerve stimulation

Sacral nerve stimulation sends electrical impulses to the nerves that control the bowel and rectum. This can help the patient get better control over bowel movements. We use the InterStim neurostimulator to treat constipation, as well as bladder incontinence.

Pelvic floor physical therapy

Pelvic organ prolapse can be caused or made worse by ineffective ways of moving the bowels. A pelvic floor physical therapist can help a woman change these habits. The therapist will use various techniques to help a woman learn how to relax her pelvic floor while allowing her abdominal muscles to gently force stool completely out of the bowels.

The therapist will help educate the individual on pelvic floor dysfunction and dyssynergia, which is lack of pelvic floor muscle coordination. This therapy will also involve analyzing the patient’s bowel movement habits, diet and other possible contributing factors.

Surgery

Some patients may have a rectocele that we can surgically repair. Rectocele prolapse happens when the tissue that separates the vagina from the rectum weakens, usually causing the rectum’s front wall to protrude into the vagina. Colporrhaphy is a minimally invasive surgery to strengthen and repair the vaginal wall after a prolapse. It can also treat rectal prolapse, which is very similar.

Rectal prolapse, which can cause constipation, may also require surgical correction. This condition is when the walls of the rectum have dropped out of position (prolapsed) so they protrude out of the rectum and are visible.

An anal stricture, or anal stenosis, is the narrowing of the anal canal that takes stool out of the body. This is caused by scar tissue. Surgery can correct this if the stricture is severe or does not respond to other treatments. Our surgeon may make small incisions in the scar tissue or remove scar tissue.