N Engl J Med 2003;349:1360-8. Copyright © 2003 Massachusetts Medical Society. onstipation is a common symptom affecting between 2 percent 1,2 and 27 percent 3 of the population in Western countries. In the United States, it results in more than 2.5 million visits to physicians, 92,000 hospitalizations, 2 and laxative sales of several hundred million dollars a year. Constipation is more prevalent in women than in men, 4 in nonwhites than in white persons, 5 in children than in adults, 6 and in elderly than in younger adults. 5 Severe constipation (e.g., bowel movements only twice a month) is seen almost exclusively in women. 4 Physical inactivity, low income, limited education, a history of sexual abuse, and symptoms of depression are all risk factors for constipation. 7

Current concepts: Chronic constipation

Because the range of bowel habits and stool types in the community is unknown we questioned 838 men and 1059 women, comprising 72.2% of a random stratified sample of the East Bristol population. Most of them kept records of three consecutive defecations, including stool form on a validated six point scale ranging from hard, round lumps to mushy. Questionnaire responses agreed moderately well with recorded data. Although the most common bowel habit was once daily this was a minority practice in both sexes; a regular 24 hour cycle was apparent in only 40% of men and 33% of women. Another 7% of men and 4% of women seemed to have a regular twice or thrice daily bowel habit. Thus most people had irregular bowels. A third of women defecated less often than daily and 1% once a week or less. Stools at the constipated end of the scale were passed more often by women than men. In women of child bearing age bowel habit and the spectrum of stool types were shifted towards constipation and irregularity compared with older women and three cases of severe slow transit constipation were discovered in young women. Otherwise age had little effect on bowel habit or stool type. Normal stool types, defined as those least likely to evoke symptoms, accounted for only 56% of all stools in women and 61% in men. Most defecations occurred in the early morning and earlier in men than in women. We conclude that conventionally normal bowel function is enjoyed by less than half the population and that, in this aspect of human physiology, younger women are especially disadvantaged.

https://gut.bmj.com/content/gutjnl/33/6/818.full.pdf

Defecation frequency and timing, and stool form in the general population: a prospective study.

American Gastroenterological Association Technical Review on Constipation

https://sites.ualberta.ca/~loewen/Medicine/GIM%20Residents%20Core%20Reading/DIARRHEA,%20CONSTIPATION%20ETC/Myths%20and%20constipation.pdf

Myths and misconceptions about chronic constipation.

Background: It is uncertain whether subtotal abdominal hysterectomy results in better bladder, bowel, or sexual function than total abdominal hysterectomy. Methods: We conducted a randomized, double-blind trial comparing total and subtotal abdominal hysterectomy in 279 women referred for hysterectomy because of benign disease; most of the women were premenopausal. The main outcomes were measures of bladder, bowel, and sexual function at 12 months. We also evaluated postoperative complications. Results: The rates of urinary frequency (urination more than seven times during the day) were 33 percent in the subtotal-hysterectomy group and 31 percent in the total-hysterectomy group before surgery, and they fell to 24 percent and 20 percent, respectively, at 12 months (P=0.03 for the change over time within each group; P=0.84 for the interaction between the treatment assignment and time). The reduction in nocturia and stress incontinence and the improvement in bladder capacity were similar in the two groups. The frequency of bowel symptoms (as indicated by reported constipation and use of laxatives) and measures of sexual function (including the frequency of intercourse and orgasm and the rating of the sexual relationship with a partner) did not change significantly in either group after surgery. The women in the subtotal-hysterectomy group had a shorter hospital stay (5.2 days, vs. 6.0 in the total-hysterectomy group; P=0.04) and a lower rate of fever (6 percent vs. 19 percent, P<0.001). After subtotal abdominal hysterectomy, 7 percent of women had cyclical bleeding and 2 percent had cervical prolapse. Conclusions: Neither subtotal nor total abdominal hysterectomy adversely affects pelvic organ function at 12 months. Subtotal abdominal hysterectomy results in more rapid recovery and fewer short-term complications but infrequently causes cyclical bleeding or cervical prolapse.

Outcomes after total versus subtotal abdominal hysterectomy.

A series of 64 women complaining of severe constipation is described, in each of whom delayed elimination of markers from the colon was demonstrated but a barium enema was normal. All completed a detailed questionnaire and the responses are compared with those obtained in an age-matched series of healthy women with no bowel complaint. In each group 40 women also recorded in a manner suitable for analysis all food eaten over a period of seven days. The patients passed about one stool weekly with the aid of laxatives, and were greatly troubled by abdominal pain, bloating, malaise and nausea, to the extent that the symptoms were a major social disability and many lost time from work. Decreased bowel frequency and other symptoms were often first noticed around the age of puberty and slowly became worse until they were severe by the third decade. In a few, the symptoms began suddenly after an abdominal operation c-accident. Comparison with the control group showed no evidence that the patients had been underweight at any time or that they took less fibre; treatment with a bran supplement did not usually help them. The patients experienced rectal sensation before defaecation less often than the control subjects and they used digital pressure to assist defaecation more frequently. The women with constipation tended to have more painful and irregular menstrual periods, and there was an increased incidence of ovarian cystectomy and hysterectomy. Hesitancy in starting to pass urine was more common, as were some somatic symptoms such as cold hands or blackouts. Attention is drawn to this distinctive combination in young women of slow total gut transit time and a colon of normal width on barium enema, associated with abdominal, anorectal, gynaecological and somatic symptoms, as a disorder which can be disabling and particularly difficult to treat.

https://gut.bmj.com/content/gutjnl/27/1/41.full.pdf

D M Preston

Papers

Severe chronic constipation of young women: 'idiopathic slow transit constipation'.