Manual Disimpaction
Impaction in older and younger patients
Constipation is the general term for low frequency or reduced transit of stool passage. In some segments of the population, notably older patients in nursing homes and young children, fecal impaction is a common problem that requires some special discussion. Fecal impaction is also known by the name coprostasis.
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The problem arises in older inhabitants of nursing homes due to lengthy immobility. This leads to large stool masses that build up in the lower colon. Furthermore, the build-up causes stretching and relaxation of the anal sphincter, which permits fluids to flow out inadvertently. A simple digital rectal examination can reveal the problem before starting any constipation treatments.
Dislodging feces
Traditional treatment in the elderly calls for something called manual disimpaction, a procedure usually performed by a skilled health care worker who uses one or two digits to loosen and dislodge the fecal material. The health worker would apply lubricant to reduce the risk of damage, as well as warn the patient of the different stages of the procedure so as to minimize the unexpectedness. Intravenous sedation may be necessary to fully relax the muscles. If the problem is ascertained to be mild, manual disimpaction can be substituted in favor of oral administration of a laxative, usually polyethylene glycol (PEG or commercial name Macrogol). Within a few days, the impacted feces may be expelled naturally indicating success of such constipation treatments.
Disimpaction in children
In children, the standard constipation treatments often consist of administration of an enema, such as a phosphate soda, saline or mineral oil version. Although the procedure is fast, children may be traumatized by the invasive procedure. As such, polyethylene glycol laxative can be used instead.
Maintenance therapy
Following these disimpaction constipation treatments, education of the patient in maintenance therapy is required to prevent future incidents. Maintenance therapy just means doing the right things to maintain a health unconstipated, non-impacted colon.
For adults, maintenance therapy after constipation treatments consists of regular but measured use of laxatives as per the direction of a physician. For children, some education may be necessary, as well as adherence to a schedule for toilet usage, in addition to regular use of laxatives. For children older than 3, toilet training is as simple as instructing and ensuring that the child remains on the toilet for several minutes after meals. Physicians and psychiatrists have noted that in very young children younger than 3 years of age, toilet training may actually be counterproductive. Therefore it is not recommended in very young children.
For both age groups, maintenance therapy should also include a good dietary plan that emphasizes intake of fiber. Adequate fluid intake is encouraged to ensure softer stools, although research suggests it may not be necessary to drink more water than is needed normally. Ask your physician whether there are special formulas that act as constipation treatments for infants that soften the stool. The laxatives recommended for medium or long term use are the polyethylene glycol osmotic laxatives (PEG or commercially Macrogol). Clinical studies have shown that they are quite safe and effective but consult your physician.
Sources
Coccorullo et al, Novel and Alternative Therapies for Childhood Constipation, Journal of pediatric gastroenterology and nutrition 48 Suppl 2:S104-6, 2009 Apr
Muller-Lissner, The Pathophysiology, Diagnosis, and Treatment of Constipation, Deutsches Arzteblatt International, 2009; 106(25):424-32