Self Care 2025: Constipation and Anorectal Disorders

Constipation

A condition characterized by infrequent bowel movements or difficulty in passing stools.

Common Conditions/Medications associated with Consitpation

-Surgery

-Thyroid Disorders

-Neurological Disorders (diabetes, MS, PD, CVA)

-Depression, Eating Disorders

-Antihistamines (Esp 1st gens)

-Tricyclic Antidepressants

-Opioids

-Urinary Incontinence Meds

-Iron Supplements

Exclusions for Self-Treatment for Constipation

-Marked abdominal pain or significant distention or cramping

-Marked or unexplained flatulence

-Fever

-N/V

-Present of a chronic medication condition that may preclude self-care laxative treatment (paraplegia or quadriplegia, inflammatory bowel disease, colostomy)

-Unexplained changes in bowel habits, especially if accompanied by weight loss

-Blood in still or dark, tarry stool

-Marked change in character of stool (e.g., stool becomes pencil thin)

-Any bowel symptoms that persist >2 weeks or recur over a period of at least 3 months

-Any bowel symptoms that recur after dietary or lifestyles changes, or laxative use

-Inflammatory bowel disease

-Anorexia

-Age <2 yrs

non pharm for constipation

-Recommend for every patient with constipation

-Fiber

-Fluid

-Exercise

Key points about fiber intake

•Gradually increase over 1-2 weeks (avoid erratic bowel movements, flatulence, abdominal discomfort)

•Dietary fiber or fiber supplements

•May take 3-5 days for results

Key points about fluid intake

•Eight 8-ounce glasses per day, more for pregnant/lactating women

•Prune, apple juice for kids

Purpose of Bulk Forming Laxatives

•Most Often recommended, their effects most closely mimic the body's natural process

•MUST HAVE ADEQUATE FLUID INTAKE

•May interfere with absorption of other medications

•Best used for: Low fiber diet, New mothers, Irritable bowel syndrome, Post-surgery

•Sugar-free options for diabetics

Onset and ADRs of Bulk Forming Laxatives

Onset: 12-24 hours

ADRs: Abdominal cramping, flatulence, intestinal obstruction

Pediatric, Geriatric and Pregnancy Consideration of Bulk-forming

Peds: >6yrs

Geriatrics: First line, if no CI

Pregnancy: First line

Purpose of Hyperosmotic Laxatives

•PEG 3350 (MiraLax)

•Draw water into the colon

•OTC for >17 years old

•Considered a "first line" agent, works faster than bulking-forming

•Alternative to stimulant for opioid-induced constipation

Onset and ADRs of Hyperosmotic Laxatives

Onset: 12-72 hours

ADRs: Bloating, Abdominal discomfort, Cramping, Flatulence

Purpose of Hyperosmotic Laxatives Glycerin Suppositories

Children's formulation for as young as 2 yrs

Provides quick relief

Onset and ADRs of Hyperosmotic Laxatives Glycerin Suppositories

Onset: 15-30 mins

ADRs: Rectal irritation

Pediatric, Geriatric and Pregnancy Consideration of Hyperosmotic

Peds: PEG use not rec. in <17 yrs; Glycerin supp quick relief in >2yrs

Geriatric: PEG first line

Pregnancy: PEG ok (little systemic absorption), breastfeeding ok

Purpose of Emollients (Stool Softeners)

•Docusate Sodium, Calcium

•Soften fecal mass

•Capsules and liquid

•Best used for: Recent abdominal, rectal surgery; Post-partum; Hard/dry stools

•Most commonly used in combination with stimulant laxative

•"All mush and no push"

Onset of Emollients (stool softeners)

Onset: 12-72 hours

Pediatric, Geriatric and Pregnancy Consideration of Emollient

Peds: Oral decussate Ok in > 2yrs

Geriatric: Helpful for pts with anal fissures, hemorrhoids

Pregnancy: Helpful for dry, hard stools, ok in breastfeeding

Purpose of Lubricants (mineral oil)

•Soften fecal mass

•Interferes with absorption of fat-soluble vitamins (A, D, E, K)

•NOT for patients younger than 6, pregnant women, immobile persons, or difficulty swallowing

Onset and ADRs of Lubricants (mineral oil)

Onset: 6-8 hours (oral), 5-15 mins (rectal)

ADRs: Aspiration pneumonia (with oral use), Anal irritation (with rectal use)

Pediatric, Geriatric and Pregnancy Consideration of Lubricant

Peds: Not for <6 yrs

Geriatrics: NO

Pregnancy: NO

Purpose of Saline Laxatives

•Mg Citrate, MgOH aka MOM

•Draw water into the intestines

•Several options, dose forms

•Best used for: patients prepping for colonoscopy

•NOT for patients with renal dysfunction, CHF, those with sodium-restricted diets

Onset and ADRs of Saline Laxatives

Onset: 30 mins to 6 hours for oral MgOH, 2-15 mins for rectal saline

ADRs: Abdominal cramping, N/V, Dehydration, Electrolyte imbalances

Pediatric, Geriatric and Pregnancy Consideration of Saline

Peds: MgOH chew tab first line is 3-5 yrs; Mg Citrate in >6yrs

Geriatrics: NOT for CHF, fluid restriction, diuretic use

Pregnancy: NO

Purpose of Stimulant Laxatives

•Senna, Bisacodyl

•Increase intestinal motility

•Best used for: colonoscopy prep, in combo with docusate for prevention of opioid-induced constipation

•Senna may cause urine, stool discoloration

•Do NOT break, crush, chew enteric-coated bisacodyl tabs, may lead to gastric irritation

•Castor oil is NOT recommended

•Best used for: patients who need a quick response, opioid-induced constipation

Onset and ADRs of Stimulant Laxatives

Onset: 6-10 hours oral, 15-60 mins rectal

ADRs: N/V/D, Severe abdominal cramping, Fluid loss, Electrolyte imbalances

Pediatric, Geriatric and Pregnancy Consideration of Stimulant

Peds: Lower doses ok in 2yrs

Geriatrics: May be necessary for quick relief

Pregnancy: Short-term use ok, breastfeeding ok, NO castor oil

Signs/Symptoms of Hemorrhoids

•Burning

•Itching

•Discomfort

•Swelling

•Irritation

Exclusions for self-treatment for hemorrhoids

•Children <12 years

•GI disease or FH colon cancer

•Seepage, bleeding, thrombosis

•Severe itching, burning, pain

•Fever

•Symptoms persisting > 7 days

Non-Pharm treatment for anorectal disorders

•Avoid heavy lifting

•Avoid foods that aggravate symptoms

•Eat a high fiber diet

•Increase fluid intake

•Proper post-void hygiene

•Avoid straining to pass gas or BM

•Do not sit on toilet for long periods of time

•Sitz bath

What is the purpose of vasocronstrictors

•Phenylephrine, ephedrine

•External or internal use to reduce swelling in anorectal area

•Avoid in patients with diabetes, thyroid disorders, heart disease, HTN, BPH, taking antidepressants

ADRs of Vasoconstrictors

ADRs: Numerous cardiac, Nervous effects, esp. with internal use

What is the purpose of protectants?

•Cocoa butter, petrolatum

•External or internal use to relieve discomfort, irritation

•Remove product before applying next application

What is the purpose of Astringents

•External or internal use to reduce swelling in anorectal area

•Witch hazel external only

•Zinc and calamine external and internal

What are the purpose of Analgesic/ Anesthetic/ Antipruritics?

•Also known as counterirritants

•Menthol, juniper camphor

•External use to relief of burning, pain, itching

•Cool, warm, or tingling sensation

•Keep out of reach of children, oral ingestion can be fatal

What is the purpose of corticosteroids

•Approximately 60% of combination products contain hydrocortisone

•External use to reduce swelling and itching

•May take up to 12 hours to work, but longer duration of effect

ADRs of Corticosteroids

ADRs: Skin atrophy with long-term use

Considerations for special populations

•Non pharm, external products preferred in pregnant women

•Children younger than 12 should be referred

•Ensure patient understanding of dose forms (applicators, suppositories)

•Combination products are common, preferred

•Know which products should not be used internally

•Refer if not improved after 7 days treatment