Constipation is defined as the decreased frequency of bowel actions and is often associated with excessive straining and pain, due to hard, dry faeces (stool or poo). Failure of relaxation of the anal sphincter during defecation is a common problem in CES. Other relevant factors that can aggravate constipation in CES patients include a poor (low fibre) diet, opiate-containing painkillers and immobility.

Constipation occurs because the faeces dry and harden in the rectum, and this can cause abdominal discomfort, rectal bleeding and 'overflow' incontinence. In those with severe constipation problems with anal fissure, rectal prolapse, intussusception or rectocele can aggravate constipation and it is worthwhile asking your doctor about.

Bulking agents:
When diet is lacking in fibre, supplements (called bulking agents) are recommended. Bulk-forming agents result in large moist stools that stimulate gut action (peristalsis) and make the stool easier to pass. However it is necessary to drink large quantities of fluids with these agents. Many of the bulking agents available contain psyllium, an insoluble form of fibre. However, if gut action is impaired, bulking agents can cause constipation.

Stool softening agents:
Many stool softeners are sugar-based solutions and can be useful when bowel emptying is a problem. Some medicines such as dioctyl sodium or sulfasuccinate also improve gut action (peristalsis).

Colonic stimulants:
Colonic stimulants such as mineral oils may also help when gut action is slow by softening the stool and stimulating gut action. For those with severe constipation due to decreased gut action, more powerful stimulants (eg bisacodyl) can be helpful but they should be used only occasionally. Stimulant laxatives will NOT work if the stools in the rectum are hard and difficult to pass. At this point, either 'manual evacuation' of the stool or rectal stimulation is required (see below).

Manual evacuation:
Manual evacuation is the removal from the back passage of hard stool by a gloved finger by a patient or carer. Regular manual evacuation of stool is not harmful and it's definitely better to avoid constipation from not emptying the back passage regularly.

In women, an alternative method to check whether the rectum is full is to put your thumb in the lower vagina and feel the stool through the rectal wall. It is also possible to empty the bowel by pressure through the vaginal wall. It is also possible to empty the bowel by putting pressure on the skin at the lower back, just above the anus.

Tears (fissures) of the anus can occur because the faeces may be too dry and hard – keeping the stools soft can prevent this. Because sensation in the anal area is decreased in CES, it is important to check your anus regularly for tears using a mirror. Wash the anal area regularly.

Rectal stimulation:
Rectal stimulation helps to empty the bowels. A glycerine suppository placed into the rectum using a gloved finger will help to lubricate the anus and can actually stimulate the bowel to empty. Some patients also find 'mini' enemas useful, but others will find them difficult to retain.

Bowel washout regimes:
An enema may assist in clearing the rectum and, if given in the morning, may reduce the risk of faecal incontinence occurring at some other time during the day. The response to rectal washouts is variable and depends on the type of enema used.

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