What is the next step in the emergency department for an 85-year-old female patient with a recent hospitalization for urinary tract infection (UTI) who presents with constipation, inability to pass flatus, and has a Foley catheter (indwelling urinary catheter) in place, after having several bowel movements (BM) today?

From the Guidelines

The next step for this 85-year-old female in the ED would be to rule out potential complications such as bowel obstruction, ileus, or fecal impaction, and consider a bowel regimen with a stool softener and a mild stimulant laxative, given her recent history of UTI requiring hospitalization, current Foley catheter, and resolution of constipation with multiple bowel movements today. Given her estimated life expectancy and recent hospitalization, it is essential to assess her for constipation symptom management, reduction of patient/family distress, and acceptable sense of control, as outlined in the palliative care guidelines 1. The patient's ability to have bowel movements today is reassuring; however, her age and recent hospitalization put her at risk for complications. To manage her constipation, the guidelines suggest increasing fluids, increasing dietary fiber if patient has adequate fluid intake and physical activity, exercise if appropriate, and administering prophylactic medications 1. Additionally, reviewing her medication list is essential, as many medications commonly prescribed to elderly patients (such as opioids, anticholinergics, or calcium channel blockers) can contribute to constipation. Considering her recent bowel movements, a thorough abdominal examination and abdominal imaging may not be immediately necessary, but laboratory tests including complete blood count, comprehensive metabolic panel, and urinalysis should be ordered to assess for infection, electrolyte abnormalities, or renal dysfunction. Ensuring adequate hydration and considering a bowel regimen with a stool softener like docusate sodium and a mild stimulant laxative like senna may be appropriate for prevention of recurrence after discharge, as suggested by the guidelines for patients with an estimated life expectancy of years 1. It is also crucial to continue to treat and monitor symptoms and quality of life, with ongoing reassessment, as recommended by the guidelines 1. The use of bisacodyl 10–15 mg daily-TID with a goal of 1 non-forced bowel movement every 1–2 days may also be considered, as outlined in the guidelines for patients with an estimated life expectancy of year to months 1.

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. • you get diarrhea • you need to use a laxative for longer than 1 week WHEN USING THIS PRODUCT you may have loose, watery, more frequent stools

The patient has already had several bowel movements today, which may indicate that the constipation is being managed. However, the presence of an indwelling urinary catheter and recent hospitalization for UTI suggest that the patient may be at risk for complications. Given the information provided, the next step would be to monitor the patient's condition and consult with a doctor to determine the best course of action, as the patient's symptoms and medical history suggest a potential for underlying complications 2. Key considerations include:

• The patient's recent hospitalization for UTI
• The presence of an indwelling urinary catheter
• The patient's age and potential for complications It is essential to err on the side of caution and consult with a doctor to determine the best course of action 2.

From the Research

Patient Presentation

The patient is an 85-year-old female with a recent hospitalization for urinary tract infection (UTI) presenting with constipation, inability to pass flatus, and has a Foley catheter in place. Despite having several bowel movements today, her symptoms persist.

Relevant Studies

• The study by 3 suggests that the next step in the treatment of constipation is the use of an osmotic laxative, such as polyethylene glycol, followed by a stool softener, such as docusate sodium, and then stimulant laxatives.
• The study by 4 evaluated the efficacy and safety of polyethylene glycol plus electrolytes in the treatment of severe constipation and faecal impaction in adults, and found it to be a highly effective and well-tolerated therapy.
• The study by 5 demonstrated the efficacy and safety of polyethylene glycol 3350 in the treatment of chronic idiopathic constipation.
• The study by 6 suggests that osmotic laxatives, such as polyethylene glycol, are considered the first-line gold-standard pharmacological treatment of chronic constipation.

Potential Next Steps

• Consider the use of an osmotic laxative, such as polyethylene glycol, to help manage the patient's constipation symptoms.
• Assess the patient's overall condition and medical history to determine the best course of treatment.
• Monitor the patient's bowel movements and adjust the treatment plan as needed.
• Consider consulting with a gastroenterologist or other specialist if the patient's symptoms persist or worsen.

Key Considerations

• The patient's age and recent hospitalization for UTI should be taken into account when determining the best course of treatment.
• The presence of a Foley catheter may affect the patient's bowel movements and should be considered when assessing her symptoms.
• The patient's inability to pass flatus may indicate a more serious underlying condition and should be further evaluated.