Study design, materials and methods
This retrospective cohort study was carried out within the time frame of January 2018 and December 2018. To assess the effectiveness of the protocol, a retrospective analysis of the medical records of 25% of the patients seen in 2018, observed in one outpatient service of a teaching hospital in the city of Paraná, which are specialized in caring for adults with Pelvic Floor Dysfunction, drawn at random—a total of 246 patients who were evaluated for CF.
Functional Constipation (FC) was assessed according to the Rome Criteria. It classifies functional gastrointestinal disorders into six broad domains for adults. For the evaluation of the 246 patients, the part of functional bowel disorders (category C) was applied, which is based on six criteria: straining to defecate, complex or fragmented stools, the sensation of incomplete evacuation, the sensation of anorectal obstruction or blockage, manual maneuvers to facilitate bowel movements and less than three bowel movements per week. People who present two or more criteria in the last six months are considered to have CF.
Of the 246 patients, only 72 (29%) were treated with Functional Constipation according to the Criteria. Thirty patients with CF (30%) were lost to follow-up due to not presenting data regarding the Rome Criteria in your final evaluation. Finally, 42 patients with CF were included.
These 42 patients received a proposed protocol developed by nurses at a pelvic floor dysfunction clinic in Paraná, Brazil. In addition, a comprehensive literature review of interventions applied to CF was carried out.
These were incorporated into interventions carried out by these nurses, such as:
1. Guidance for recommended water intake (30 ml/kg/day) up to two hours before bedtime;
2. Insoluble fiber intake (vegetables with skins, whole grains, legumes, or orange with pomace) after a large meal;
3. Choice of one of the meals to attempt the daily evacuation 20 minutes after it;
4. Positioning to attempt evacuation, resting the feet on support approximately halfway up the toilet, or of the 15 cm, resting the elbows on the knees;
5. Maintain full attention with relaxation techniques supported by deep breaths: Inhale deeply for 4 seconds, focusing the air on filling the abdomen and expanding the abdomen forward. Exhale in 4 seconds, pulling the abdomen inwards;
6. In cases where the patient has less than two bowel movements per week or In the case of failure to evacuate without effort by applying the measures for a week, add the introduction of a glycerin suppository before the meal of choice, in item 3.
Introduce the suppository before starting the meal, make quick contractions of the anus to keep the suppository in the rectal region, and follow the sequence of items 3 to 5. Continue use of the suppository for one week of effective defecation and then discontinue use, maintaining the other measures of water and fiber intake, use of the gastrocolic reflex, and positioning.
Interpretation of results
It is estimated that about 3.2 million FC patients in the United States visited medical centers in 2012, and the direct cost per patient for chronic Constipation ranged from $1912 to $7522 per year. Unfortunately, FC is a condition that is often neglected and underreported due to embarrassment when reporting symptoms, making the physical and psychosocial condition even more debilitating with a devastating impact on quality of life.
The treatment of functional Constipation remains challenging, the most common being the use of osmotic laxatives, irritant laxatives, and stool softeners that are commonly used. However, its use for an extended period without treating the root cause or developing healthy habits in patients worsens the symptoms even more, often requiring more invasive treatments such as surgical procedures. Moreover, studies show that almost half of the people who undergo this treatment (47%) are unsatisfied, mainly due to concerns about effectiveness, safety, adverse reactions, and cost.
This protocol proposal focuses on behavioral changes, with simple, low-cost measures that can be incorporated into the routine according to the patient's life context it encourages self-management and self-knowledge and places the patient as a central agent and driver in their treatment. Studies show that patients with CF who assume their treatment and adopt self-management tend to seek healthier complementary therapies within financial reach and social and habitual context, consequently having more success in their treatment.
Concluding message
In this study, we found that simple measures, when incorporated into the patient's routine and that encourage self-management, are more likely to be successful, in addition to having potential benefits in increasing the number of bowel movements, improving stool characteristics, and alleviating global symptoms in patients with FC. However, it was impossible to reach a firm conclusion due to study limitations, such as the lack of data in the medical records. Therefore, it is intended to apply this protocol in higher-quality trials that substantiate our statements.