CONSTIPATION & FAECAL INCONTINENCE ALGORITHM

NB: This algorithm summarises the guidelines for management of constipation, especially in the elderly.

Too Soft 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

• Loperamide (titrate dose carefully)

if necessary add: • Codeine phosphate

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

Trial of short-term oral senna or bisacodyl

With soft/ formed stool

With hard stool or “overflow”

Regular/daily suppository/enema*: • Glycerine suppos

↓ • Bisacodyl suppos (or ‘microlax’)

↓ • Enema (Fleet oil &/or phosphate) *

Appropriate history

• Past bowel habit • Awareness of call to stool • Stool consistency • Laxative use/ medication • Mobility • Diet Examination • Abdominal exam • Anorectal exam • Digital rectal exam • Cognitive assessment

REFERRAL if required

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

• 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 followedby any attending clinician in thetimes ahead.

STOOL CONSISTENCY?

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)