From the Guidelines
For a patient with constipation and fecal impaction, the initial treatment should focus on disimpaction, usually through digital fragmentation and extraction of the stool, followed by the implementation of a maintenance bowel regimen to prevent recurrence. This approach is based on the most recent and highest quality study available, which emphasizes the importance of disimpaction and maintenance therapy in managing constipation and fecal impaction 1.
Disimpaction Methods
Disimpaction can be achieved through manual disimpaction by a healthcare provider or through the use of medication. Oral polyethylene glycol (PEG) solutions, such as MiraLAX (17g in 8oz water daily), or high-dose mineral oil (15-30ml twice daily) can be used for medication-based disimpaction. Alternatively, enemas like sodium phosphate (Fleet, 118ml per rectum) or mineral oil enemas can provide relief. The choice of disimpaction method may depend on the severity of the impaction and patient preferences.
Maintenance Therapy
After disimpaction, maintenance therapy is crucial to prevent recurrence. This can include stool softeners like docusate sodium (100mg twice daily), osmotic laxatives such as PEG (17g daily) or lactulose (15-30ml daily), as supported by recent guidelines 1. Stimulant laxatives like bisacodyl (5-10mg daily) or senna (8.6-17.2mg daily) may be added if needed. Lifestyle modifications, including increased fluid intake (2-3 liters daily), dietary fiber (25-30g daily), and regular physical activity, are also essential.
Considerations
The use of suppositories and enemas may be perceived as invasive but can be effective, especially when a full rectum or fecal impaction is identified 1. These methods increase water content and stimulate peristalsis to aid in expulsion and work more quickly than oral laxatives. However, patient preferences and the severity of the condition should guide the choice of treatment.
Monitoring and Adjustment
Patients should be monitored for recurrence, and treatment adjusted as needed. The goal is to achieve regular bowel movements and prevent future episodes of constipation and fecal impaction, thereby improving the patient's quality of life and reducing morbidity and mortality associated with these conditions.
From the FDA Drug Label
STOP USE AND ASK A DOCTOR IF • you have rectal bleeding or your nausea, bloating, cramping or abdominal pain gets worse. These may be signs of a serious condition. PRECAUTIONS General Since lactulose solution contains galactose (less than 1.6 g/15 mL) and lactose (less than 1.2 g/15 mL) it should be used with caution in diabetics.
The FDA drug label does not answer the question.
From the Research
Treatment Options for Constipation with Fecal Impaction
- Manual disimpaction or fragmentation, the use of distal and/or proximal softening or washout procedures such as enemas and suppositories, and oral or nasogastric tube placement for the administration of polyethylene glycol solutions containing electrolytes are common treatment options for fecal impaction of the rectum 2.
- Polyethylene glycol with or without electrolytes is more efficacious than placebo for the treatment of functional constipation, either in adults or in pediatric patients, with great safety and tolerability 3.
- A high-dose oral protocol using polyethylene glycol with electrolytes combined with sodium picosulphate can successfully and safely disimpact children with acute/chronic constipation presenting to a suburban clinic 4.
Comparison of Treatment Options
- Lactulose may be a good alternative to polyethylene glycol in the treatment of fecal impaction in constipated children, as both agents were safe, effective, and well tolerated 5.
- Home-based disimpaction using polyethylene glycol is as effective as hospital-based disimpaction, with fewer side effects and lower cost, making it a preferable option in children 6.
Key Considerations
- Early identification and treatment of fecal impaction minimize complications and patient discomfort 2.
- Post-treatment evaluation should include a colonic evaluation by flexible sigmoidoscopy, a colonoscopy, or a barium enema after the fecal impaction resolves 2.
- A preventive therapy plan should be created after treatment to address the underlying causes of constipation and fecal impaction 2.