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Pelvic floor dysfunction: bowel management for the gynecologist.

Constipation is estimated to affect up to 27% of the general population and is more common in women, with a 2:1 female-to-male ratio. (1) Because gynecologists are frequently the main care provider for many women, understanding the diagnosis and treatment options for constipation is important. Additionally, gynecologists must manage bowel function during the perioperative period.

The diagnosis of constipation is based on the Rome III criteria. (2) Besides frequency of bowel movements (BMs), these criteria include evacuation symptoms and the presence of hard stools (TABLE 1). These symptoms can result from delay in colonic transit or outlet dysfunction. Constipation may be secondary to medical illness, such as central or peripheral neurologic disease, diabetes mellitus, hypothyroidism, or medications. Evaluation begins with a careful history and vaginal and perianal/anal examination. (3) Initially, a trial of fiber supplementation with or without over-the-counter (OTC) laxatives may be tried (TABLE 2). If patients have an inadequate response to this therapy, further evaluation may be pursued (FIGURE; See "Evaluation algorithm for chronic constipation," at

In this article, we review the results of randomized trials comparing the efficacy of OTC medical treatments for constipation, including daily, low-dose polyethylene glycol (PEG) and probiotics. Additionally, we review key trials evaluating perioperative bowel management prior to laparoscopic gynecologic and vaginal surgery.

Michael R. Polin, MD

Dr. Polin is Fellow, Female Pelvic Medicine and Reconstructive Surgery, and Clinical Instructor, Obstetrics and Gynecology, Department of Obstetrics and Gynecology, at Duke University in Durham, North Carolina.

Cindy L. Amundsen, MD

Dr. Amundsen is Professor and Female Pelvic Medicine and Reconstructive Surgery Fellowship Director, Department of Obstetrics and Gynecology, at Duke University.

Dr. Polin reports no financial relationships relevant to this article. Dr. Amundsen reports that she receives grant or research support from the National Institutes of Health.
TABLE 1 Rome III criteria for
functional constipation in adults *

1. Must include >2 of the following signs
or symptoms:

* Straining during >25% of defecations
* Lumpy or hard stools in >25% of
* Sensation of incomplete evacuation for
  >25% of defecations
* Sensation of anorectal obstruction/
  blockage for > 25% of defecations
* Manual maneuvers to facilitate >25% of
  defecations (ie, digital evacuation,
  support of the pelvic floor)
* <3 defecations per week

2. Loose stools are rarely present without
the use of laxatives

3. Insufficient criteria for irritable bowel

* At least 3 months, with symptoms beginning
[greater than or equal to]6 months before

TABLE 2 Common treatments
for constipation

Bulk-forming laxatives absorb water, increasing
fecal mass

* psyllium seed (Metamucil)
* methylcellulose (Citrucel)
* calcium polycarbophil (FiberCon)
* wheat Dextran (Benefiber)

Surfactant agents lower the surface tension of
stool, allowing water to enter the stool

* docusate sodium (Colace)

Osmotic laxatives contain poorly/nonabsorbed
substances, leading to intestinal water secretion

* polyethylene glycol (MiraLAX)
* magnesium citrate (Milk of Magnesia)
  Stimulant laxatives increase colonic transit
  and alter electrolyte transport across the colonic
* bisacodyl (Dulcolax)
* senna (Senokot)
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Title Annotation:UPDATE
Author:Polin, Michael R.; Amundsen, Cindy L.
Publication:OBG Management
Date:Nov 1, 2014
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