Prevention & Management of Post-Op Constipation

Dr. Margaret Latham, DPT, CLT-LANA, ALM is a physical therapist and trained by the APTA Academy of Pelvic Health in Bowel Dysfunction. Information used in this article comes from this evidence based training program. It is provided as general advice, and it does not substitute for care and recommendations by your physician or other health care providers.

Let’s talk about poop

The normal frequency of bowel movements can be anywhere from three times a day to three times a week. It is possible that less than three times a week may be normal if it does not represent a change from a person’s usual frequency and does not cause discomfort. Brown is the normal color of stool. Black stools may indicate blood in the stool, and blond stools indicate the lack of bile. Stool may have one of seven general types of consistency based on the Bristol Stool Chart:

Normal stool consistently is the easiest to pass with types 3-5 being considered normal. Type 4, the “smooth sausage,” is ideal.

Causes of post-op constipation

We are at risk of post-op constipation for many reasons including

• History of constipation for other reasons such as fiber deficiency, metabolic issues, use of certain medications, and/or anorectal problems such as anal fissures or colon cancer

• Age over 50

• Use of opiate-type pain medications like Percocet, Percodan, Lortab, Darvocet, and others

• Reduced mobility and activity

• Reduced water intake

• Changes in diet

Prevention and management of post-op constipation

Maintain recommended dietary fiber intake

20-35 grams of fiber/day. Great sources include:

• Beans

• Legumes

• Whole grains

• Fruits

• Vegetables

• Prunes or prune juice

The Mayo Clinic provides a great article on dietary fiber.

Maintain adequate hydration. Dr. Alex Earle of Pure Plastic Surgery recommends his clients drink 1-2 gallons (yes gallons) of water per day. One gallon of water is equal to 128 fluid ounces. Sodas (even diet), milk, sweetened beverages, and juices are not the best choices for hydration, although milk and fresh juice may be helpful from a nutritional standpoint.	Good sources of hydration include: Plain water Plain/unsweetened carbonated water Unsweetened green tea Unsweetened herbal tea.

Avoid food and beverages that may contribute to constipation

• Alcohol

• Milk and dairy products

• Red meat

• Fried or fast foods

• Chocolate

• Chips

• Sugar

• Foods that contain gluten such as grains like wheat, barley, rye, spelt, Kamut, and triticale. Opt for whole-grain oats and rice if possible.

• Processed grains and their products, such as white bread, white rice, and white pasta

• Persimmons, especially astringent varieties (a popular fruit from Eastern Asia)

• Bananas, especially unripe

• .Caffeine

• Frozen dinners

Move! Increase activity as soon as possible

Have a good activity pattern in place before surgery such as walking 5-7 times a week or a regular exercise program. Get up out of your bed or recliner as soon as possible after surgery and begin walking frequently and gradually increasing the distance. Stay within your doctor’s activity limitations, however.

Try to establish a regular bowel routine before surgery

• Keep regular bedtime and waking times

• Be sure to devote enough time for bowel function in the morning

• On waking, drink something warm and eat something high in fiber

• Don’t skip breakfast.

• Respond to any bowel urge or "call to stool"

• Do not delay any urge to defecate, be prepared for the need in public

• Eat regular meals at similar times of day

Talk to your doctor about medications you take that may contribute to constipation and possible alternatives to them

These may include

Antacids that contain aluminum or calcium Iron supplements Opiate-type pain medication Antidepressants Anti-Parkinson drugs Non-steroidal anti-inflammatory drugs (ibuprofen, Aleve)	Medication for high blood pressure Calcium channel antagonists (e.g. Lisinopril, Vasotec, Capoten) Clonidine	Diuretics (cause potassium loss) Nasal decongestants and antihistamines Antispasmodics Anti-cholesterol medications – resins Psychotropics

Take a probiotic daily

Ideally choose one that is targeted for GI health such as Garden of Life Raw Probiotics for Women or Raw Probiotics Colon Care. Be sure yo consult with your physician before starting one.

Use good toileting posture (yes, this is a thing)

The Squatty Potty is a great tool to facilitate food toileting posture. Get 20% off your purchase with this link. (I do not receive a commission on purchases. I just have a special code since I am trained as a pelvic health therapist :-)

• Sit tall with back straight and lean forward at the hips. Avoid flexing (curving) the spine.

• Position feet on a step stool so that knees are higher than hips (simulated squat position).

• If unable to flex at the hips, maintain posture with 90 degrees or less of hip flexion and relax the legs as much as possible.

• Rest hands or forearms on the legs.

• For some of us, we find that once the bowel movement starts, it helps to lean back a little (opens the thoracic outlet) to help evacuation continue.

Practice abdominal breathing several times a day

This help with lymph/fluid drainage as well. In any position breath in through your nose like smelling a flower while allowing the belly to rise. Placing a hand on the belly may help you with this. As you exhale through your mouth, let the belly fall and gently pull your belly button toward your spine (as able). Repeat at least 5-10 times.

Use diaphragmatic breathing while having a bowel movement

Relax (belly and pelvic floor) as you inhale and exhale while trying to evacuate the bowels (push, but not too hard). It may be helpful to be more forceful when exhaling, like when blowing up a balloon. Keep the mouth and throat open to avoid a Valsalva maneuver.

Pressure on the perineal body

It may be helpful to put some gentle pressure on the perineal body. This is the fleshy tissue between the vaginal opening and the rectal opening for female genitalia or between the back of the testicles and the rectal opening for male genitalia.

Massage to the colon

Ask your doctor before trying massgae to the colon. You can use effleurage (long, stroking movements which are performed using a flat hand or fingers) starting along the direction of the ascending colon (right side of abdomen starting just inside the top of the pelvis and ending near the ribs). Continue long strokes along the transverse colon (located horizontally under the edge of the ribs) from the right to left.

Then continue the strokes down the descending colon on the left side of the abdomen. This can be repeated several times with increased pressure (as tolerated) to stimulate the segmental contractions of the large intestine. After a tummy tuck, the strokes need to be especially gentle.

You may also try (if tolerated and approved by your doctor) kneading motions with palms or fingers down the descending colon, up the ascending colon, and then down the descending colon again.

Manual lymph drainage (MLD)

In addition to assisting the body in removing post-surgical fluid more quickly, MLD also helps promote good bowel function.

Management of constipation with fiber supplements and medications

Always speak to your doctor before adding any supplements or medications to help with constipation.

Fiber supplements

Over-the-counter fiber supplements (bulk forming agents) with a gradual increase in dosage may be helpful. They may initially cause abdominal cramping, bloating, and gas. Insoluble fiber, such as cereal bran, is more likely to cause these symptoms. Fiber supplements may be a way to add additional fiber if your dietary fiber intake is not sufficient.

1. Brands such as Metamucil and Konsyl are made of psyllium seed husk and have a high water-binding capacity. They are made of both soluble and insoluble fiber. These ferment in the colon and are not as effective in persons with slow colon transit.

2. Brands such as BeneFiber are made from the soluble fiber wheat dextrin. It may also have prebiotic benefits to help nourish healthy gut bacteria and maintain a healthy digestive system. While it contains only a small amount of gluten, it may not be the best choice for persons who are not tolerant of gluten.

3. Brands such as FiberCon are made with the soluble fiber calcium polycarbophil. They are resistant to bacterial degradation and therefore less likely to cause gas and bloating.

4. Brands such as Citrucel or Celevac are made of the soluble fiber methylcellulose and are resistant to bacterial fermentation, absorb water into the colonic lumen, and increase the mass of the stool while promoting colon transit time.

Hemp seed extract

Hemp seed extract has been shown to increase the frequency of spontaneous bowel movements and reduce constipation severity without side effects.

Lubricating agents

Lubricating agents, such as mineral oil, are a simple and inexpensive but can be effective alternative to laxatives.

Osmotic agents

Osmotic agents are poorly absorbed or non-absorbed substances that increase the secretion of water into the intestine. They are fast acting and available for oral or rectal administration. Some of these agents cause a potent laxative effect and some are used to prepare for colonoscopy. Definitely talk to your doctor before trying an osmotic agent.

1. Magnesium oxide/hydroxide such as Milk of Magnesia, Maalox, or Mylanta

2. Polyethylene glycol such as Miralax

3. Glycerin suppositories which cause the intestine to hold more water and thus soften the stool

4. Magnesium citrate (more bioavailable than magnesium oxide) such as Citroma or LiquiPrep

5. Magnesium sulfate such as Epsom salt which is a potent laxative that produces liquid stool and abdominal distention (not ideal after surgery).

6. Disaccharides such as Lactulose, Enulose, Generlac, Chronulac, Cephulac, or Kristalose. These are typically only available by prescription.

Stool softeners

Stool softeners/surface acting may be useful for short term therapy (1-2 weeks) after surgery. They include docusate salts such as the brand names Colace (docusate sodium), Dulcolax Stool Softener (docusate sodium), and Surfak (docusate calcium). Docusate salts are lubricants that coat the stool, making it easier for it to pass through.

Stimulant laxatives

Stimulant laxatives/contact agents stimulate water and electrolyte secretion and a vigorous pattern of intestinal contraction often associated with abdominal discomfort and cramping.

This is not ideal after surgery and should be reserved for severe episodes of constipation that do not respond to other treatments and only at the direction of your physician. Examples include aloe, cascara, sennosides (Senna/Senokot), casanthrol, Bisacodyl (Dulcolax Laxative), and sodium picosulfate (Ducolax Pico).

Enemas

Enemas work by causing rectal distension and irritation of the rectal mucosa. They are generally safe but may cause trauma to the rectal mucosa if inserted improperly. They may be tap water, saline, soapsuds, or phosphate enemas. Fleet enemas must be evacuated promptly to avoid hyperphosphatemia (serum phosphate level that is too high).

Other medications

There are other classes of prescription medications such as Resolor, Amitiza, Linzess, and antibiotics that are sometimes prescribed for chronic constipation or unresponsive constipation. It is rare to need these, but talk to your doctor about options as needed.

Natural is best

It is always best to try to prevent and manage post-op constipation with a healthy diet that includes about 25 grams of dietary fiber a day, good hydration, and activity. If these are not working for you, be sure to talk to your doctor about medication modification, addition of fiber or other supplements, osmotic agents, stool softeners, or stimulant laxatives. You definitely do not want constipation to persist as it can lead to other post-op issues.