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How are your bowel motions? The question nurses need to ask

Patients may be embarrassed to talk about it, but bowel problems affect quality of life and help is available

Patients may be embarrassed to talk about it, but bowel problems affect quality of life and help is available

  • Up to one in seven adults and one in three children are thought to be affected by constipation
  • It can cause anxiety and depression and affect school or work performance, as individuals may be reluctant to go out or ignore the urge to go to the toilet in public places
  • Advice on how to help patients, how to broach the subject, and options for addressing the problem, including diet, exercise, toileting routines and laxatives
Picture: iStock

Bowel care is of great importance for a patients quality of life, yet many people are too embarrassed to discuss the

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Patients may be embarrassed to talk about it, but bowel problems affect quality of life and help is available

  • Up to one in seven adults and one in three children are thought to be affected by constipation
  • It can cause anxiety and depression and affect school or work performance, as individuals may be reluctant to go out or ignore the urge to go to the toilet in public places
  • Advice on how to help patients, how to broach the subject, and options for addressing the problem, including diet, exercise, toileting routines and laxatives
Picture: iStock

Bowel care is of great importance for a patient’s quality of life, yet many people are too embarrassed to discuss the subject.

It’s a conversation that arguably needs to be had whatever the clinical setting: £168 million was spent by NHS England on treating constipation in 2018-19, the equivalent of funding 7,304 newly qualified nurses for a year.

Here, we look at the causes, prevention and treatment of constipation, and advice on potentially difficult conversations with patients about their bowel habits.

Some definitions of constipation

According to the National Institute for Health and Care Excellence (NICE), constipation is defecation that is unsatisfactory because of infrequent stools, difficulty passing them or a sensation of incomplete emptying. Stools may be dry, hard or lumpy, abnormally large or small.

In reality, constipation is often defined as passage of stools less frequently than the person's normal pattern, according to NICE’s clinical knowledge summary on the topic, revised in May 2020.

Jennie Burch: ‘We all look at constipation
in a slightly different way’

Jennie Burch, head of gastrointestinal nurse education at St Mark's Hospital, part of London North West Healthcare NHS Trust, says the issue is not always clear cut.

‘We all look at constipation in a slightly different way,’ she says.

For some patients, it can be that they haven’t been that day. For the lay person it probably means passing small hard pellets, having to strain or the feeling that they need a laxative to help them.’

Remember what’s normal, says Ms Burch. ‘Having a bowel movement shouldn’t hurt and there shouldn’t be blood,’ she says.

But how often someone usually goes is very individual anything between three times a day and three times a week is considered normal.’

Also be aware that constipation may arise as the result of a change in someone’s circumstances, she says. ‘If someone breaks a leg and can’t move around as much, if their usual medication alters, they give up smoking or coffee, or they are trying to lose weight any of those things can have an impact,’ says Ms Burch.

Causes and risk factors

For some people, constipation can be lifelong, for example, if caused by a neurological problem.

It may also be a short-term reaction to a minor change in diet, including irregular mealtimes, or to dehydration or reduced activity.

‘You go might go holiday and be eating different food,’ says Ms Burch.

According to NICE, particular risk factors include:

  • A low-fibre diet or low calorie intake.
  • Difficulty accessing a toilet or limited privacy when using the toilet.
  • Changes in normal routine or lifestyle.
  • Lack of exercise or reduced mobility.
  • Ignoring the urge to go to the toilet.

There may also be psychological risk factors, such as anxiety and depression, eating disorders or a history of sexual abuse.

Digestive disorders charity Guts UK suggests that emotional upsets can also be a cause.

Constipation may be a side effect of some medications, including opiates, antidepressants, antiepileptic drugs, antihistamines, iron supplements and diuretics.

Other causes include endocrine and metabolic diseases, including diabetes, myopathic conditions and neurological conditions, including Parkinson’s disease, multiple sclerosis and spinal cord injuries.

It can also be caused by structural abnormalities, including haemorrhoids, colonic strictures, inflammatory bowel disease and postnatal damage, and irritable bowel syndrome.

How common is constipation?

A 2020 report by the Bowel Interest Group (BIG), which aims to educate health professionals on the diagnosis and treatment of bowel conditions, estimates that up to one in seven adults and one in three children are affected by constipation.

In 2018-2019, hospital admissions in England for constipation totalled 76,929 people, equivalent to 211 people a day.

In that time frame, NHS England spent £168 million on treating the condition, including the cost of emergency admissions and £87 million on laxative prescriptions.

More common in older people

Constipation tends to be more likely with increasing age, with almost three-quarters of older nursing home residents being given laxatives for bowel regulation, says the BIG.

In patients aged 65 and older, approximately 26% of men and 34% of women complain of constipation, which may be due to a number of factors such as medication, co-morbidities, and a decrease in physical activity and fluid intake, according to BIG.

It’s usually temporary

Women are much more likely to experience constipation; its incidence is two to three times higher in women than in men.

Some women notice that their bowels are more sluggish at certain times of their menstrual cycle, while pelvic floor weakness can allow the bowel to bulge abnormally during attempted rectal emptying. Constipation is also common during pregnancy, affecting around 40% of women, and for up to six weeks after giving birth.

Overwhelmingly, constipation is temporary, with only around 3% of adults experiencing persistent constipation over 20 years, according to Guts UK.

Effect on daily life and well-being

According to the BIG report, there is a significant impact on quality of life for those with constipation, with 40% experiencing anxiety disorder and 38% having depression. Performance at school or work is also affected, say 69%.

Constipation makes it hard for people to travel freely, and socialise, because of the necessity to identify every accessible toilet. Individuals with constipation may also lose a lot of their personal time, perhaps through time spent on the toilet trying to open their bowel, or the time spent worrying about it,’ says the BIG report.

Ms Burch says: ‘People worry about it a lot. While normal is usually defined as a bowel movement three times a day to three times a week, some in the older generation were taught that if they didn’t go every day there was something wrong, and that view can be passed down the generations.

Picture: iStock

Many patients believe that constipation can cause a poisoning of the system, but there is no evidence that bacteria or toxins leak from the bowel into other parts of the body as a result, says Guts UK.

Similarly, there is also no evidence that long-term constipation increases the risks of getting bowel cancer another common cause for anxiety among patients.

Too busy to spend five minutes on the toilet

Prevention is always better than cure, says Ms Burch.

‘For some, it can be as simple as making time to have a bowel motion in peace, without someone knocking on the door, or feeling embarrassed because you don’t want to go at work or school,’ she says.

For women especially, finding time after they have had children can be problematic. ‘They’re so busy they don’t seem to have time to spend five minutes on the toilet,’ says Ms Burch, who advises patients not to ignore the urge and to prioritise time to go to the toilet.

Toileting routines recommended by NICE

NICE recommends several helpful toileting routines, including:

  • Visiting the toilet in a regular and unhurried way, giving time to ensure defecation is complete.
  • Responding immediately to the sensation of needing to defecate.
  • Ensuring that those with limited mobility are helped with access to the toilet and given privacy.
  • Providing supported seating for those who are unsteady on the toilet.

For nurses, being aware of a patient’s risk factors, such as pregnancy, recent surgery or taking painkillers, is also key. ‘Address the problem at an early stage, if you anticipate there might be one,’ advises Ms Burch. ‘If they are prescribed an analgesic or any drug that constipates, ask about regularity of bowel motions and consider the impact the drug may have for them.’

Instead of a laxative, some people may benefit from advice on modifying their diet, taking in extra fluids and being more active. ‘Having an extra piece of fruit, brown bread instead of white and going for a walk every day might just stop them needing medication,’ says Ms Burch.

Take a good history before prescribing laxatives

Laxative use should be tailored to the patient’s symptoms and type of constipation, advises the RCN in its guidance on bowel care.

Types include:

  • Bulk-forming agents, available in powder, granule or tablet form, which can help retain water in the stool, facilitating peristalsis and increasing bulk. They may take up to 72 hours to work. It is essential to maintain a fluid intake, or symptoms of constipation may worsen, advises the RCN. Bear in mind they can exacerbate cramping, bloating and flatulence.
  • Stimulants, which work by stimulating enteric nerve endings directly and inhibiting water absorption, helping induce a bowel movement within eight to 12 hours. They should not be used if there is a risk of intestinal obstruction, says the RCN.
  • Osmotic laxatives, which work by increasing fluid content of the stool, helping to soften it. They may take up to 48 hours to act and should be given with plenty of water.
  • Faecal softeners, including glycerol suppositories and enemas containing arachis oil, which increase the amount of water into the stool, making it softer and facilitating transit.

‘Before prescribing, it’s important to take a really good history,’ says Ms Burch. ‘And patients need full advice, such as keeping up their fluid intake, explaining that otherwise the medication may make them feel worse.’

How to help patients overcome embarrassment

A survey of 2,352 patients carried out by YouGov in 2016 showed that almost one in five people felt embarrassed talking to their GP about constipation.

More than a fifth would try to solve it themselves, without seeking advice.

Patients tend to say everything is fine, unless they are specifically asked, says Ms Burch. ‘But if you ask, “How are your bowel motions, is it easy to go?”, people are more likely to tell you,’ she says.

‘Sometimes we expect patients to voice issues, but we forget that some are more difficult to talk about.’

Nurses can help patients with initial awkwardness

Nurses can play a crucial role in helping patients divulge any problems and overcome initial awkwardness. ‘Sometimes it’s just about giving them the opportunity to discuss it,’ says Ms Burch. ‘As a profession, we’re great at assessing non-verbally how someone is coping with our questions.’

A quiet room, where someone can talk without being overheard, is ideal.

Making it part of a routine nursing assessment can also be effective, while choosing the right language is important. ‘I’ve had patients not like the words poo or stool, preferring bowel motion,’ she says. ‘Use words that your patient is more comfortable with.’

The Bristol stool chart tool for faeces type classification Picture: Shutterstock

Approach discussions about bowel problems with sensitivity

The Bristol Stool Chart can be a vital tool to make conversations easier. ‘Instead of asking people to describe their stool, you can show them the images and ask them to point at which one looks most like theirs,’ says Ms Burch.

In its bowel care guidance for nurses, the RCN says discussions about bowel problems should be approached with sensitivity to minimise the patient’s embarrassment and to build a therapeutic relationship.

The RCN says people should be encouraged to discuss their bowel problems with friends and relatives. They should be also told about the Just Can’t Wait toilet card to inform others that they have a medical condition that requires quick access to a toilet.

Risk of faecal impaction or overloading

Individuals with severe constipation are at risk of faecal impaction, which can be become severe or even life-threatening if not treated, and often requires hospital admission.

More common in older people, impaction or overloading happens when the rectum and often the lower colon is full with hard or soft stool, and the patient is unable to evacuate their bowel unaided.

This impaction can also lead to overflow with diarrhoea.

‘If you’ve got a hard lump of faeces that gut motility can’t move forward, liquid will pass around it,’ explains Ms Burch.

As prescribing medication for diarrhoea can make things worse, it’s vital to find out what’s happening with the patient, which may entail a rectal examination.

Yes, digital rectal examination can be embarrassing

‘While there can be a perception that a digital rectal examination is easy, actually it’s embarrassing for the patient and can be for nurses too, especially if they haven’t done it before or for a while,’ says Ms Burch.

She suggests reading the RCN’s guidelines beforehand and also seeking support from a more experienced colleague, if confidence is an issue.

Ultimately the aim of treatment is to ensure complete disimpaction with minimal discomfort for the patient, says NICE. Depending on assessment, management may include oral medications, suppositories or enemas, with follow-up advice on how to avoid it happening in the future.


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