How to help a patient who is having difficulty passing stool?

Management of Constipation in Patients

For patients having difficulty passing stool, a structured approach including lifestyle modifications, osmotic laxatives, and stimulant laxatives should be implemented, with the goal of achieving one non-forced bowel movement every 1-2 days. 1, 2

Initial Assessment and Non-Pharmacological Approaches

• Rule out impaction, obstruction, and treatable causes such as hypercalcemia, hypokalemia, hypothyroidism, and diabetes mellitus 1
• Ensure privacy and comfort for defecation, as environmental factors significantly impact bowel function 1, 2
• Optimize positioning - a small footstool may help patients exert pressure more easily 1, 2
• Increase fluid intake to soften stool and improve laxative efficacy 1
• Encourage physical activity and mobility within patient limits (even bed to chair movement can help) 1
• Consider increasing dietary fiber if patient has adequate fluid intake and physical activity 1, 2

Pharmacological Management Algorithm

First-Line Options:

• Osmotic Laxatives:

  • Polyethylene glycol (PEG) is strongly recommended as first-line therapy due to proven efficacy 2
  • Lactulose 30-60 mL BID-QID can be effective for drawing water into the intestine 1
  • Sorbitol 30 mL every 2 hours × 3, then as needed 1

• Stimulant Laxatives:

  • Bisacodyl 10-15 mg daily to TID with goal of one non-forced bowel movement every 1-2 days 1, 3
  • Senna (often combined with docusate) 2-3 tablets BID-TID 1

For Persistent Constipation:

• Add rectal interventions: bisacodyl suppository (one rectally daily-BID) 1
• Consider combination therapy (osmotic plus stimulant) 2
• For opioid-induced constipation: methylnaltrexone 0.15 mg/kg subcutaneously every other day (no more than once daily) 1

Management of Severe Constipation/Impaction

• Administer glycerine suppository or mineral oil retention enema 1
• If impaction persists, perform manual disimpaction following pre-medication with analgesic and/or anxiolytic 1
• Consider tap water enema until clear for severe cases 1
• For gastroparesis-related constipation, consider adding a prokinetic agent such as metoclopramide 1

Special Considerations

• Patients on opioids should receive prophylactic laxative therapy at initiation of opioid treatment 1, 2
• Elderly patients require individualized regimens considering drug interactions and potential adverse effects 2
• Avoid bulk-forming laxatives (psyllium) in patients with inadequate fluid intake or immobility 4, 5
• Discontinue any non-essential constipating medications when possible 1
• Docusate sodium may be added as a stool softener but has limited efficacy alone 6, 7

Monitoring and Follow-up

• Reassess for cause and severity of constipation if initial management fails 1
• Monitor for adequate constipation symptom management with goal of one non-forced bowel movement every 1-2 days 1, 2
• Recheck for impaction or obstruction if symptoms persist 1
• If constipation persists despite multiple interventions, consider specialized palliative care services or gastroenterology referral 1, 8

Common Pitfalls to Avoid

• Relying solely on lifestyle modifications without pharmacological intervention in severe cases 1, 5
• Failing to provide prophylactic laxative therapy when initiating opioid treatment 1, 2
• Using bulk-forming laxatives in patients with inadequate fluid intake, which can worsen constipation 2, 7
• Overlooking the need for manual disimpaction in cases of severe impaction 1
• Continuing ineffective single-agent therapy without progressing to combination approaches 2, 5