Constipation Algorithm

CONSTIPATION & FAECAL INCONTINENCE ALGORITHM NB: This algorithm summarises the guidelines for management of constipation, especially in the elderly.

STOOL CONSISTENCY?

FAECAL LOADING? with infrequent or unpredictable emptying (or no motion for 3 days, or “overflow”) NB This is a short term regime until regular evacuation is established – commence oral regime concurrently

Too Hard

•Increase diet fibre (fit/mobile patients only) •Increase fluid intake •Increase mobility •Osmotic laxative-lactulose if necessary add •Faecal softener –docosate NB. Use bulk laxatives (eg psyllium) only if fluid intake high – can cause constipation

Too Soft

•Loperamide (titrate dose carefully) if necessary add: •Codeine phosphate

With hard stool or “overflow”

Regular/daily suppository/enema*: •Glycerine suppos ↓ •Bisacodyl suppos (or ‘microlax’) ↓ •Enema (Fleet oil &/or phosphate) *

With soft/ formed stool

Trial of short-term oral senna or bisacodyl

Commence regular oral regime

Factors associated with constipation/faecal incontinence •Sphincter weakness •Anal sensory loss •Immobility •Diet/dehydration •Faecal loading (see management above) •Medication (eg opiate, tricyclic) •Slow colonic transit (eg opiates) •Loss of cognitive awareness •Laxative abuse •Bulk laxatives (can constipate if fluid intake insufficient)

Appropriate history

REFERRAL if required

•Past bowel habit •Awareness of call to stool •Stool consistency •Laxative use/ medication •Mobility •Diet

For enema (or suppository not able to be managed by patient):

Examination •Abdominal exam •Anorectal exam •Digital rectal exam •Cognitive assessment

•Contact GP or a Nurse •Prescribe enema or suppository •Complete the nursing medication sheet to enable follow up. NB. The standard regime & protocol may have to be followed by any attending clinician in the times ahead.