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The Bowel Interest Group has highlighted the huge costs to the NHS of treating constipation. This article outlines key points for nurses about managing the condition
The Bowel Interest Group recently published a report on the cost of constipation to the NHS, highlighting the scale of chronic constipation cases in the UK and the urgent need to implement solutions to alleviate the problem. This article outlines the key findings from the report that are relevant to nurses including communication, managing high-risk patients, laxative use and dedicated services.
Citation: Igbedioh C (2021) Constipation: how can nurses help to reduce the scale of the problem? Nursing Times [online]; 117: 5, 53-54.
Author: Carlene Igbedioh is integrated continence advanced nurse practitioner, St Thomas’ Hospital, London.
- This article has been double-blind peer reviewed
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The Bowel Interest Group (BIG) focuses on raising awareness of bowel conditions, which can be given insufficient attention due to the taboo around this aspect of health. Its report on the cost of constipation to the NHS, which highlighted the scale of chronic constipation in the UK and the urgent need to implement solutions to ease this problem, found that the cost of avoidable emergency admissions to hospital due to constipation is rising year on year in most regions of England and that, in 2018-19, NHS England spent £168m on treating constipation (BIG, 2020). This article outlines the report’s key findings, which nurses can use to inform their daily practice and improve constipation care.
There is a perception among patients and health professionals that constipation is a common, minor condition that can be managed easily. However, according to the BIG (2020) report, almost 77,000 people in England were admitted to hospital with constipation in 2018-19 – equivalent to 211 people a day. Of those, around three-quarters were unplanned emergency admissions. This begs the question: why does the condition become so severe before patients seek help? Misconceptions about constipation, along with embarrassment, mean many patients do not seek early treatment so symptoms get much worse. Apart from the physical discomfort caused by this delay, some patients experience anxiety and depression due to the impact on their daily lives.
Part of the challenge of reducing avoidable hospital admissions is to improve understanding about constipation and dispel myths; almost a fifth of patients are embarrassed about talking to their GP about constipation and a fifth would try to solve the problem themselves without speaking to anyone about it (BIG, 2020). Part of the issue is that patients may not be aware of what constitutes healthy bowel movements; 11% could not identify or did not know the symptoms of constipation – which are outlined in Box 1 – while almost one in five thought passing stools less than once a day is a symptom (BIG, 2020).
Box 1. Constipation symptoms
- Opening the bowels <3 times a week
- Needing to strain to open bowels on more than a quarter of occasions
- Passing a hard or pellet-like stool on more than a quarter of occasions
- Experiencing a sense of incomplete emptying after a bowel opening
- Needing to use manual manoeuvres to achieve bowel emptying
A proactive approach may help to identify the issue or encourage patient awareness of their bowel health. For example, nurses can integrate a few simple questions into routine health checks to gauge whether patients are experiencing any discomfort related to their bowels. These include:
- How long do you spend on the toilet?
- Do you ever need to strain on the toilet?
- Do you get any leakage from your bowel? (Soiling is often a feature of constipation)
- How frequent are your bowel movements?
- Do your bowels prevent you from enjoying any part of your life?
This is particularly beneficial for patients known to be at higher risk of developing constipation symptoms.
Causes and high-risk patients
Most patients experience ‘functional constipation’, in which they have constipation symptoms but no other underlying health problems. For those with some existing health conditions, constipation may be a secondary impact that further complicates their overall condition. This type of constipation is referred to as ‘neurogenic’ – a lack of nervous control prevents the bowel from functioning properly.
Neurogenic constipation is common in patients with spina bifida, multiple sclerosis, Parkinson’s disease, spinal cord injuries or those who have had a stroke. Up to 63% of patients with neurogenic bowel dysfunction spend more than one hour on each episode of defecation (Christensen et al, 2006). Their limited mobility means they will need additional support to reach a toilet when needed.
Comorbidities and lack of movement also make older patients more susceptible to constipation. Despite the disproportionate number of such people in this group – around a quarter of men and a third of women aged ≥65 years experience constipation – it is a myth that it is an inevitable part of ageing. Lifestyle factors, such as a low-fibre diet or reduced fluids, may cause constipation, and dehydration has been identified as a problem among older patients and care home residents (Thomas, 2020).
Certain drugs may cause constipation so pre-emptively prescribing laxatives may help to address symptoms in their early stages. Older people may be especially embarrassed to discuss their symptoms, so a proactive approach, as described above, is beneficial.
Women are twice as likely as men to have constipation, due to the effects of pregnancy and pregnancy-related pelvic floor disorders, among other causes, and 60% of constipation-related hospital admissions are in females (BIG, 2020). However, this may also be a reflection of the willingness of women to seek healthcare.
Laxative use and other treatments
Laxatives are often considered a short-term easy fix, but constipation has several causes and these must be assessed before prescribing treatment. Sedentary lifestyles, processed foods and poor diets may be the root of the problem, and environmental stressors may cause some patients to resist the urge to defecate, which can aggravate symptoms. A regular, unhurried toilet routine is vital to good bowel health. Opiates, antihistamines and antidepressants also list constipation among their side-effects.
Apart from lifestyle changes and laxatives, there is a lack of guidance for health professionals on how to progress constipation treatment. This means patients may use laxatives for a long time without seeing full recovery from the symptoms. BIG has produced a treatment pyramid (Fig 1) to show a range of therapeutic alternatives when laxatives no longer work. It also gives recommended durations for trialling each therapy so patients receive the right treatment as soon as possible.
After initial approaches, the pyramid – based on the National Institute of Health and Care Excellence’s clinical knowledge summary – leads to minimally invasive treatments, such as transanal irrigation and, if this proves ineffective, more-invasive options such as colonic irrigation. Once all treatment options have been exhausted, a permanent stoma may be needed.
One of the issues highlighted by the report is the level of variation across the country, with some regions performing much better than others. On average, the rate of hospital admission in England is 134 per 100,000 of the population. Humber, Coast and Vale records the highest rate, with 209.6 per 100,000 while, at the lower end, Bristol, North Somerset and South Gloucestershire has a rate of 82.8 per 100,000. Not surprisingly, areas with a higher spend on laxatives tend to see higher rates of admission.
To see a national improvement in constipation management, treatment pathways must be improved across the board and individual trusts are already providing best-practice examples. For example, some have developed bowel management pathways, so patients can be referred from emergency departments to specialist clinics dealing with constipation.
As the NHS reviews its service provision during and after the coronavirus pandemic, there is an opportunity to improve care across many therapeutic areas. Left untreated for too long, constipation can cause chronic pain as well as additional complications, such as urinary tract infections, haemorrhoids, anal fissures or rectal prolapse. It can also have a serious impact on quality of life and lead to feelings of embarrassment or anxiety. All of these secondary factors add to the pressure on nursing staff across healthcare services. Better management of chronic constipation can help to alleviate some of this pressure and, crucially, reduce the number of avoidable emergency admissions.
- The cost of avoidable emergency hospital admissions due to constipation is rising year on year in most regions in England
- It is common for the condition to become severe before patients seek help
- Good proactive communication with patients can help identify problems early on
- Laxatives are often considered a short-term easy fix, and the underlying causes of constipation are not addressed
- Better treatment pathways are needed to reduce national variation
Bowel Interest Group (2020) Cost of Constipation Report. BIG.
Christensen P et al (2006) A randomized, controlled trial of transanal irrigation versus conservative bowel management in spinal cord-injured patients. Gastroenterology; 131: 3, 738–747.
Thomas M (2020) Why is dehydration a problem in older patients and care home residents?
Nursing Times [online]; 116: 8, 45-48.