Theoretically, it’s so simple! Get Clean and Stay Clean!
1) If there’s backed-up stool in the rectum or colon: clean it out.
2) If there’s an impaction that isn’t easily shifted: persevere and clean that out too.
3) Then don’t let it happen again!
In practice, it can be far from easy, so it’s good to understand why.
(This post explains the mechanism for clearing and treating chronic constipation. If you’ve noticed one of my early warning signs, please don’t panic!
Here I’m relating what I learned while treating my impacted child. It took us 4 doctors and 18 months to finally understand the severity of the problem and embark on a proper treatment plan. It then took months to get back to anything resembling normality, and years of vigilance to stay one step ahead of a relapse.
Staying ahead of the condition for my other children is a far cry from that experience. Paying attention to their poop schedule, adding laxative fruits to their diets as needed, knowing when to insist on more water, and flushing with a laxative if we stray into ‘worrying’ symptoms – these are all very quick fixes.)
Chronic constipation is a build-up of stool in the rectum or colon. It’s something that happens gradually, so by the time you get ‘proper’ symptoms – like encopresis (leaking poo) or enuresis (wetting) or those awful sticky stinky poops I talk about here – the poop that started it all has been stuck in the bowel for a very long time. It’s been compacted into a dense ball with age-old poop in the middle and fresher poop stuck around the outside. And it can be bigger than you think possible (after 6 months of laxatives and cleanouts the impaction in my 4 year old’s rectum was still the size of a grapefruit).
The impaction is stuck; Wedged in a tube that doesn’t have the muscular strength to dislodge it. And it’s a compounding problem because the more the bowel stretches, the weaker the muscle tone becomes.
Then there’s the other problem caused by the impaction: the backup.
If you imagine your gut as a motorway, the impaction is an accident blocking all three lanes and the only way around is to creep along the hard shoulder. Just like traffic would pile up behind the accident, poop piles up behind the impaction – and that’s the backup.
Now, in the traffic analogy, police would clear the accident and traffic would flow again – but that’s not usually how bowel cleanouts work. Flushing from above (by taking oral laxatives) is like opening another lane. All the backed up cars can now maneuver past the accident, but those three lanes are still blocked.
It’s an easy mistake to clear the backup and think you’re done. But if your child is going to heal, it’s really important to completely clear the impaction too.
The After Effects
When both blockage and backup are cleared, you might think you can relax – but again it’s not that simple!
The muscle that once housed so much poop remains stretched and weak – like a balloon that has been inflated and then let down. It can take a long time to return to a tight, springy, healthy state – and it’s not something it can do by itself.
Without help, fresh poop that reaches the stretched section of the gut will get stuck – because the bowel is too saggy to move it along properly. And we all know where that leads..
If this has been going on a long time, all of the rectum and part of the colon will have been stretched to some degree – by either the impaction or the backup. So there might not be much ‘normal’ sized bowel left at the end of the digestive tract, to keep things moving.
That’s why phase two of the treatment “Stay Clean” is not as easy as it sounds.
This is where you’ll hear of long term laxative use, and perhaps be confused by it.
Stimulant and Osmotic Laxatives
You’re likely to come across two types of laxative when treating chronic constipation: Stimulant laxatives and osmotic laxatives. (See the NHS laxative pages for more information.)
Stimulant laxatives act on the wall of the gut and cause it to contract – pushing all the contents forward. This is how peristalsis works, but stimulant laxatives give a lot of extra oomph!
If you don’t have any experience of different types of laxatives, these are probably the kind that you think about- the stuff of cartoons and comedy scenes. (Don’t worry – if you use them to help your child, you won’t be aiming for anything like those extreme reactions!)
Simulant laxatives can be helpful when the muscle tone is so weak that you can’t clear the remains of a blockage, or can’t keep stool moving swiftly enough through the bowel to ensure a poo every day, or you don’t have any involuntary ‘push’ to get all the waiting stool out of the rectum.
Examples: Senna and bisacodyl are stimulant laxatives. Senna is sometimes used during the ‘maintenance’ phase of a cleanout (i.e. when you’re keeping the bowel moving and empty so that it has time to shrink back and heal) – often in conjunction with an osmotic laxative.
Osmotic laxatives cause your gut to retain water. That’s all they do.
One of the functions of colon is to dry out the stool, i.e. extract water back into the body to be regulated and excreted as urine. Osmotic laxatives prevent water from leaving the gut and draw water from the surrounding tissue into the stool.
(They do this by changing the osmotic potential of the liquid in the poo. Essentially, the poopy water contains a high concentration of laxative, the body notices and water enters the bowel to dilute it. When the laxative is consumed with lots of water, the water stays in the bowel because it has a higher concentration of laxative than the surrounding tissue.)
This has two important effects:
1) It keeps the stool soft (and can be taken in different doses to vary the consistency from ‘soft but formed’ to ‘liquid’)
2) It bulks up the stool (i.e. makes it bigger)
PEG3350 (branded as movicol or miralax) is a very popular osmotic laxative – prescribed for both cleanouts and maintenance.
Lactulose is also an osmotic laxative, as is sorbitol – an indigestible sugar similar to lactulose that occurs naturally in apples, apricots, gooseberries, grapes (and raisins), peaches, pears, plums, prunes, raspberries and strawberries.
The role of laxatives in treatment
1) Cleaning out a soft backup.
High-ish doses of an osmotic laxative will turn fresh poo moving through the gut into poo soup. This soup has two functions:
a) To flush any loose stool along with it
b) To soften anything that’s too big to be swept along
For the laxative to do its job, you need to be flushing fluid through the colon. If you’re trying to clear a backup with a maintenance dose of laxative you’re not going to get very far! A maintenance dose is enough to bulk up the stool while keeping it soft – but it’s not going to dissolve or flush anything…
2) Clearing an impaction
This takes longer, because the impaction needs to dissolve in the poo soup. If the soup is too thick, rather than dissolving the impaction, it will coat the blockage with another layer of fresh poo. Not at all what we’re after!
The impaction has probably been around for months (or years) and will be very dense. It’s not going to dissolve easily. You need to flood it with fluid that’s as close to water as you can get and ideally you want it to sit there a soak for a bit. Even then it can take days to see the first breakdown products come out: dark gritty poop that stinks to high heaven.
I know what you’re thinking… “Wouldn’t it be better to use actual water, rather than poo soup?” And you’re right! That’s why enemas are so effective (and not nearly as scary as you probably imagine – especially if your only point of reference is the old Carry On films.)
A micro enema comes in a soft squirty bottle that is smaller than your smartphone. It takes a few seconds to administer and a few minutes to work. But it can only work on an impaction in the rectum – it won’t flush anything backed up in the colon.
3) Keeping the rectum and colon empty during the ‘saggy balloon’ period.
With the impaction and backup cleared you move into the maintenance phase: i.e. maintaining a clear bowel.
At this point, bulking the stool is just as important as keeping it soft.
If you’ve just completed a clean out, you’ll be anxiously looking for signs that the bowel is healing. Does your child poop every day? Are they responding to their body’s messages (i.e. do they seem to be holding or not noticing when they need to poop?)
Unfortunately, neither efficient peristalsis nor stimulation of the rectal nerves is likely to happen with just one day’s worth of poo if the gut is used to accommodating several weeks’ or months’ worth at a time…
A maintenance dose of osmotic laxative bulks the poop out enough for it to ‘touch the sides’ so the gut can practice working properly. Without that bulking agent, one day’s worth of poop might be too small to be moved properly by peristalsis, get stranded, and have to wait around until it’s big enough to be squeezed along. Any poop left stranded in the colon would get dehydrated (that’s the colon’s job) so you’d end up with smaller denser poop by the time it reached the rectum.
You want to avoid this!
Which is why long term laxatives are prescribed – and why you need to remember to keep taking them (even if the idea of being on long term medication fills you with horror). If it helps, try not to think of it as medication, so much as a crutch. You’re not altering the way the body works, just giving it a chance to work with what it’s got.
Don’t be fooled by the wrong type of fibre
It took me a long time to understand the fibre dilemma, so I’m going to outline it here. Hopefully you’re more clued up than I was and this is old news!
There are two types of fibre: insoluble and soluble. You want to focus on soluble fibre.
Until we were at least 6 months into treating the constipation, I equated ‘roughage’ (as my mum used to call it), with fibre.
Bran, brown bread, brown rice, fruit skins, vegetable skins – these things meant fibre to me and are often listed as helpful when treating constipation in adults.
So, when faced with chronic constipation, I assumed that kind of fibre was going to be a big part of the solution – even though we already ate everything in that list.
But it turns out, too much roughage isn’t helpful at all. You need some – yes – but keep an eye on it! Too much causes big poops and stretches the gut that you’re trying to shrink.
Everything I listed above contains insoluble fibre.
What you really need, in the aftermath of chronic constipation, is soluble fibre. Soluble fibre acts like an osmotic laxative, drawing water into the stool to bulk it up while keeping it soft.
For soluble fibre you need porridge (oatmeal), nuts, beans, apples…
So when I thought I was helping by giving my 5 year old shreddies for breakfast, I really wasn’t. Porridge would have been a much better idea.
(That’s one of the things I do now, actually. If I spot any warning signs, porridge becomes the breakfast staple for a while. Then, when things are ticking along, the kids get more choice again.)
Nerve Damage and Self Initiation
Unfortunately, it’s not only muscle tone that is affected by stretching the bowel. You also need to deal with nerve damage.
If your child was leaking poop, or had crumbly poop falling out of them, or completely stopped self initiating (taking themselves to the toilet without prompting from you) – it might have been due to nerve damage in the rectum.
Nerves in the rectum, near the sphincter, fire when the rectum stretches – to tell the brain that there’s a poo waiting to come out.
If the rectum is always stretched, those nerves stop firing. Your child might lose sensation altogether (be unable to feel when they need to go and not notice when a bit of soft body temperature poop leaks out). They might also lack the cues that help them ‘push’ to help their body poo (and their stretched impacted rectum can make pushing ineffectual anyway).
The nerves can take a long time to heal. So if you’re certain your child is clean but they’re not self initiating as you expect – consider the physical reasons for that before jumping to behavioural conclusions (hates the bathroom, is frightened of the potty, is too lazy to go etc).
Withholding Habits and Leaking Poo
If your child has a holding habit, it might be due to the type of poop that was always ‘knocking at the door’. The anal sphincter can tell the difference between solid, liquid and gas waiting in the rectum. Solids give you plenty of warning, liquids cause a clamping of the sphincter to keep them in, and gases can be released.
In some cases of chronic constipation, poop always arrives in the rectum very soft – because there was no space in the colon for it to be processed properly and it had to squeeze past the large blockage. The sphincter goes into ‘liquid panic’ mode and clamps shut. This should trigger your child to race to the toilet, but if it doesn’t… the sphincter muscle stays clamped tightly shut. If it’s clamped for long periods of time every day it can get tired – so tired that it doesn’t close properly in it’s default ‘relaxed but closed’ state.
A tired sphincter can cause problems long after the bowel is apparently back to normal – with small unexpected leaks at the first sign of soft poop for several months or years.
(This is one of the reasons that finding a good maintenance dose of laxative can be tricky. Too much and the soft poop leaks out, too little and there’s not enough bulk to trigger the daily bowel movement. Again, enemas and suppositories can really help with this.)
What if you’re in the early stages?
If you’ve experienced some of my early warning signs and are worried that you might be at risk of developing chronic constipation – don’t be alarmed by what you’ve read here. The difference between early warnings and the full blown condition are like chalk and cheese.
Clearing a large impaction and allowing the gut to recover – that takes time and treatment.
Clearing the beginnings of a backup that hasn’t had time to impact, or hasn’t reached a problematic size – that’s not nearly such a big deal. Cleaning out will be quick and easy. If the gut has only been stretched a little bit and not for very long, then staying clean will be more about monitoring your lifestyle and diet than anything else.
Diet and Food Intolerances
If your child has a problem with constipation and you know it, then you’ve probably already looked at their diet. Hopefully they’re eating plenty of fruit and vegetables and not too much processed food. You might also have added in a few extra sorbitol containing fruits and some soluble fibre foods for good measure.
But do you need to consider ‘special’ diets?
Should you go dairy free? Or gluten free? Or both?
You’ll find plenty of internet advice that recommends restricting your diet for good gut health, but when I took my daughter to the consultant and asked about this he couldn’t have been less interested.
So assess your situation on its own merits and do what you will. You can get tested for celiac disease (gluten intolerance) but read up on it first so that you know in what circumstances the test works best.
I know of parents who swear that taking probiotics or eating natural yogurt makes a daily-soft-but-formed poop massively more achievable. I know other parents who have tried this and not noticed any miracles.
Whatever you try to tinker with, keep in mind the aim of the game: Clear the backup, clear the impaction, don’t let it happen again.
Remember: Any change in diet only counts towards preventing a relapse.
Don’t use dietary changes to try to manage the chronic constipation you’re facing right now. Use a proper cleanout regimen. And if your child was impacted, don’t rely on diet to control the immediate aftermath of the cleanout. Make sure you have an alternative plan in place to keep the bowel clean and empty while it shrinks back to size.
Unfortunately, relapses are very common.
In his book “It’s no accident” Dr Hodges says 50% of patients relapse. On the internet groups I’ve participated in, relapse is always under discussion.
Relapse can mean one of two things:
1) The cleanout wasn’t 100% effective so stool backed up again
2) You didn’t manage to stay clean even with a clean start
Take a deep breath and start again.
Get support from anywhere you can find it, but especially your doctor. Parents who have been through the same thing will have a huge amount of empathy – and also inspirational tales of what life is like on the other side.
Your child needs your help.
I know this blog needs better links to other resources. I’m publishing it now so that anyone following this series has my story to use as a springboard for more research. I’ll try to come back and update it over the next few weeks.
If you’re worried this is the beginning of a long road for you, spend an evening reading Dr Hodges blog over on www.bedwettingandaccidents.com. Bear in mind that all his patients come to him with urinary problems, but he treats them for constipation. You might not see any urinary symptoms but that doesn’t make his treatment plans any less helpful.
I hope this was purely of academic interest and you’re not actually dealing with chronic constipation (keep an eye out for these signs to keep it at bay).
But if you are, I wish your child all the very best for a speedy recovery.
Get in touch via the comments below, or email me: firstname.lastname@example.org
– Born Ready Jenn.
P.S. You might also be interested in the first two blogs in this series: