Constipation, in general, is a very common health concern representing a substantial proportion of visits and referrals to healthcare providers.1The disorder can have a significantly negative effect on health-related quality of life, and has even been associated with psychological distress in those who are severely affected. Approximately 14% of the adult population globally - mainly women - are affected by constipation,2 either temporary or chronic in nature. The cost burden associated with the evaluation and management of the disorder can be substantial to both patients and payers alike, and up to 40% of sufferers indicate dissatisfaction with the medications commonly used to treat it.3Primary causes include those lifestyle related, disease related, and drug induced.4 Constipation can be stressful, uncomfortable – and painful! – for those affected.

Among the most frequent triggers are constipation-dominant Irritable Bowel syndrome (IBS-C), slow movement of stool through the colon, delayed emptying of the colon as a result of various pelvic disorders (again, particularly in women), poor bowel habits (such as ignoring the desire to "go," which can initiate a cycle of progressive constipation), and post-surgical factors. While many different pathophysiological mechanisms have been implicated in the development of constipation, in some instances, the causes are not easily determined, and it can have more than one cause at a time. Often, the disorder is transient, largely treatable, and usually not cause for serious concern. However, patients undoubtedly feel much better when they are ‘back to normal.’ As many patients experience post-operative constipation, it is on this specific aspect which we will focus.

A constipated patient may sometimes be asymptomatic, but more commonly may complain of any of the following signs and symptoms: fewer than normal bowel movements (less than three a week is a standard guide), dyschezia (painful defecation), abdominal bloating, lower back pain, a feeling of incomplete evacuation, feeling as though a blockage in the rectum is preventing bowel movements, straining, lumpy or hard stools, and/or manual maneuvering is required to defecate.5In severe cases, vomiting may also occur.

Though we are focused post-surgically for the purposes of this article, it is important to understand that constipation is not a “complication” of surgery - even in presence of severe disease requiring bowel resection. Indeed, according to a retrospective study by Jelenc et al. conducted with 52 patients who had laparoscopic bowel resections from 2002–2009, only six patients had actual complications. These included intra-abdominal bleeding, rectovaginal fistula and anastomotic leakage. In a similar retrospective study conducted by Boileau et al. with 23 patients, three patients (13%) experienced major complications including anastomotic stenosis, bowel fistula, and bladder fistula. Other complications included constipation in 23% of patients, dyschezia in 43% of patients, and dysuria in 18% of patients. In a comprehensive study of 1,128 full laparoscopic bowel resections for intestinal endometriosis and 19 robot-assisted resections, the overall complication rate was 8.7% (94 complications out of 1,147 procedures). These major complications included anastomotic leaks (2.1%), rectovaginal fistulas (1.5%), intra-abdominal bleeds (1.1%), pelvic fluid collections (0.7%), and urinary injuries (0.2%). The minor complications included transient bowel obstructions (0.8%), minor rectal bleedings (0.3%), wound infections (0.9%), urinary infections (0.2%), and transient urinary retentions (0.3%). Recurrence of pain was found in 38 patients. Overall, 99% of symptoms were alleviated from the surgeries.6Postoperative rectal bleeding, rectal pain and/or any abdominal or other pain not directly related to your incisions should of course be brought to your surgeon’s attention immediately.

Even if you had regular bowel movements prior to having surgery, post-operative constipation is incredibly common. Several reasons for this include post-surgical inactivity, post-operative pain itself, changes to your diet such as insufficient fiber intake, use of opioids and other pain relievers, and exposure to general anesthesia. All anesthetic and analgesic drugs have the potential to contribute to decreased bowel motility and constipation. Opioid analgesics in particular have direct and indirect effects on bowel function, and the effects on the GI tract are multifactorial.7Although highly effective in pain management, bothersome gastrointestinal adverse effects are experienced by a substantial proportion of opioid-treated patients. This can lead to difficulties with your medical therapy and subsequently, inadequate pain relief. Collectively referred to as opioid-induced bowel dysfunction, three important gastrointestinal functions can be interfered with by use of opioids: motility, coordination of sphincter function and secretion. This can result in a wide range of symptoms like reflux, bloating, abdominal cramping, hard, dry stools and incomplete evacuation - though the most known effect is opioid-induced constipation.8

Fortunately, there are numerous lifestyle, medical and dietary interventions which may help prevent constipation - or at lessen the duration. These include:

Limiting postoperative opioid use:  when tolerable, and with your physician’s approval, try switching from narcotics to acetaminophen or ibuprofen.

Walk it off: regular exercise is not easy – or permitted - after surgery, and it’s critical that you allow your body to recover. However, lack of physical activity can make it hard to maintain proper bowel function, resulting in constipation. Walking – slowly and at your own pace - is helpful. Many of our patients are up and walking around in PACU with their nurse’s assistance shortly after surgery. Walking helps the healing process, reduces chances of blood clots, and aids in constipation, among other beneficial effects. Strenuous exercise like lifting, carrying, pulling, or moving heavy objects is not permitted or safe until your surgeon says it is, but try to take several, small walks (inside your home is fine!) in the post-operative phase. Do not remain seated for long periods of time. This is particularly important as well for those patients who travel long distances for their surgery.

Medical therapy: if appropriate and as approved by your surgeon, consider purchasing a laxative or stool softener before your surgery so you have it available when you return home. If necessary, prescription drug therapy can be provided by your doctor. Don’t overtreat! Follow instructions exactly. Stimulant laxatives or suppositories (taken with your doctor’s approval) should work within 24 hours.

Diet is critical! Whole grains, fresh fruits, vegetables, beans and other high fiber ingredients should be your dietary mainstays post-operatively. Prunes and prune juice are still the oldest trick in the book! Raw apples (apples stimulate the gallbladder to contract and release bile, which then gets the intestines moving), pumpkin, soaked whole chia seeds, high fiber cereals, coconut water, Dandelion root tea, and high doses of Vitamin C (found in citrus fruits, berries, potatoes, tomatoes, melons and sweet bell peppers) can all help get things moving.

Lean proteins are also important, as the amino acids found in protein sources will help with wound healing and tissue regeneration (not to mention strength and energy!). Lean chicken, turkey, pork and seafood are good sources of protein, as are eggs, nuts, beans and tofu. Healthy fats such as those found in olive oil, avocados, coconut oil, nuts and seeds can boost immune response and aid your body’s absorption of vitamins as well, and fat can help increase energy levels after surgery. Be sure to also include orange and dark green leafy vegetables like carrots, sweet potatoes, kale and spinach to increase your Vitamin A intake. Of course, if you have any questions about food/drug interactions or any concerns, ask your doctor.

We do not recommend high intake of constipation-inducing items like dairy or cheese products, white bread or rice, or processed foods which are often nutritionally devoid but contain high sodium and preservative content.  For more information on how diet can relieve (and even prevent) constipation, check out http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/constipation/Pages/eating-diet-nutrition.aspx.

Drink up: proper hydration (preferably water) not only promotes proper healing, but also helps your body absorb your medications post-operatively. If not caffeine sensitive, coffee may anecdotally speed up bowel function post-surgically [Müller et. al]; however, we strongly recommend at least 6–8 eight ounce glasses of water per day, both in the days leading up to your surgery and thereafter.

Following the above suggestions can be helpful. Most of the time, post-surgical constipation is short-term and not related to any complications or resulting disorder from their procedure. Still, even the most prepared patients may experience continued difficulty. If persistent, other adjuncts - when and if appropriate – may also be helpful. These include biofeedback,9herbal medicines, nutraceuticals or botanicals such as senna, cascara, frangula, aloe, and rhubarb,10and working with a highly qualified woman’s health Physical Therapist to recover any lost function of pelvic floor muscles.11

Above all, remember that everyone recovers differently and at different paces. If your attempts to resolve post-surgical constipation do not lead to the desired results or if the symptoms persist or worsen, be sure to notify your doctor.

Further Reading & Resources:
Managing Chronic Constipation: a Patient Guide
 
Practice Guidelines for the Management of Constipation in Adults
 
The Girlfriend’s Guide to Constipation Relief
 
Sallie Sarrel, DPT

Erin Luyendyk RHN
 
High-fiber Diet (Beyond the Basics)

The National Institute of Diabetes and Digestive and Kidney Diseases

Management of Opioid Induced Constipation: Clinical Minute
 
Wondering What’s Normal & What’s Not? The Bristol Stool Chart can be found here
 
Very special thanks to Dr Sarrel, Erin Luyendyk RHN, Ashley B., Angie W. and Lisa M. for their contributions to this article.

Note that any and all material(s) presented herein are offered for informational purposes only. Such material is not intended to offer or replace medical advice offered by your personal physicians or healthcare professionals.

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