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Constipation in Young Women
778
populations of newborn infants-those born to mothers living in catchment areas of general hospitals with specialised obstetric services but without neonatal wards; and those born to mothers living in the catchment areas of central hospitals with specialised obstetric and neonatal departments in the same hospital. They claim that, during the study period 1973-78, the outcome of the pregnancies and deliveries was at least as favourable for the former as for the latter; and their conclusion is that good care can be provided in areas served by smaller hospitals with obstetric services but without specialised neonatal wards, provided that anticipated-risk deliveries can be planned to take place in hospitals with more complete perinatal care and also provided that excellent facilities exist for transfer of sick babies. These Swedish results have already been questioned. One crucial matter is the comparability of the two populations, but this has been dealt with thoroughly by the authors. Even though the comparison of risk factors is based on small numbers (fewer than 50 000 births),14,15 the main differences can hardly have biased the results seriously. Another question concerns how the study areas were selected, because obviously the selection was not purely random. Furthermore, the mid 1970s was a time when several new procedures were being introduced into obstetrics and neonatal care, and this might conceivably have influenced to a differing degree the care in the various types of hospitals. Who knows where the truth lies? There is anyway more to the organisation of perinatal care than mere access to neonatal intensive care and we need more information on other aspects such as antenatal care and delivery care. Should antenatal care be located mostly at outpatient clinics in hospitals, as in the UK, should it be the responsibility of the primary-care physician, or should it be organised through maternity centres run by midwives and public health nurses, as in some of the Scandinavian countries? Paradoxically two of the countries with the lowest perinatal mortality have chosen quite opposite ways of organising their service-Sweden with maternity centres, and Japan with traditional physician-based antenatal care. We need randomised controlled trials. So far, the principal measure of outcome has been mortality, but in future the emphasis must shift to morbidity, psychosocial as well as physical. This means long follow-up. To date, the development of long-term indicators of the quality of perinatal care has received little attention. Even though close surveillance of handicaps is clearly necessary as the chances of survival of the smallest babies increase, Ino country has so far established routine systems for monitoring child health that will permit observations to be related to perinatal and neonatal conditions and
15.
Hagberg B, Hagberg G, Olow I. Gains and hazards of intensive neonatal care: an analysis from Swedish cerebral palsy epidemiology. Devel Med Child Neurol 1982; 24: 13-19.
Provision of perinatal care is a medical, social, economic, and political issue, so in evaluating the care we should draw on the experience of both the professional providers and the childbearing women.
care.
Constipation in Young Women CONSTIPATION is so common in Western society that it is often regarded as trivial and not worthy of medical attention. Women appear to be more susceptible to constipation than men-their average daily stool weight is lower, their stools are harder, mouth-to-anus transit time is longer, and bowel frequency is less. The reason for these differences is not entirely clear, although the effects of female sexsteroids on intestinal motility are commonly implicated. Stool output may vary considerably during the menstrual cycle,’ and constipation is common during pregnancy. Mild-to-moderate constipation may be alleviated by advising the patient to increase the amount of fibre in the diet, increase fluid intake, and take more exercise, and by judicious use of bulk or irritant laxatives.2 In some patients these measures fail and even large doses of irritant laxatives are ineffective. Such patients may only be able to empty their bowels with the aid of enemas or by digital evacuation or even by rectal probing with a proctoscope. Encouragement to take more bran merely increases their discomfort and their disillusionment with the medical profession. Severe idiopathic constipation in young adults is almost entirely confined to women, who often experience considerable discomfort but receive little help or even sympathy from their doctors. These patients are unable to expel a small balloon resembling a stool from the anal canal, whereas normal matched control subjects find no difficulty in doing so.3,4 In their latest study reported in this issue (p 767), the group from St Mark’s Hospital, London, have shown that some of these women have difficulty in expelling even barium or saline from the rectum. In view of these results it is hardly surprising that laxatives or stool softeners and enemas may be ineffective, and why even surgical resection of the colon with ileorectal anastomosis may similarly fail to relieve the
constipation. The reason for this inability to defaecate appears to be related to inappropriate contraction of the striated muscles of the pelvic floor. Electrophysiological recordings have shown that the puborectalis and external anal sphincter muscles do not normally relax when these patients strain to expel a simulated stool; on GJ, Crowder M, Reid B, Dickerson JWT. Bowel function measurements of individuals with different eating patterns Gut 1986; 27: 164-69 2 Tedesco FJ, DiPiro JT. GI drug column. Laxative use in constipation Am J Gastroenterol 1985; 80: 303-08. 3. Preston DM, Lennard-Jones JE. Anismus in chronic constipation. Dig Dis Sci 1985, 30: 413-18. 4. Read NW, Timms JM, Barfield LJ, Donnelly TC, Bannister JJ. Impairment of defecation in young women with severe constipation. Gastroenterology 1986; 90: 53-60. 1. Davies
779
the contrary, evacuation is inhibited by inappropriate muscle contraction.3-6 This response resembles the normal spinal reflex for preserving continence, whereby the muscles of the external sphincter and puborectalis contract as the intra-abdominal pressure rises.7,8 The spinal reflex is normally inhibited during defaecation,5 permitting puborectalis and external anal sphincter relaxation in order to facilitate passage of stool. Normal inhibition of the continence reflex is probably cortical in origin, and may fail in some patients because they do not perceive the desire to defaecate when stool is in the rectum. It has been shown that although severely constipated women perceive distension of the rectum with a balloon, higher volumes than normal are required to provoke a desire to defaecate.4 If inability to defaecate were the only problem then the rectum should be packed with faeces awaiting expulsion, whereas in women with severe constipation it is usually empty.4 Pronounced reduction in propagative motor activity in the colon has also been documented in patients with severe constipation, both after a meal9 and after stimulation with bisacodyl. 10 A simple explanation is that the irritant laxatives that many of these patients take have produced degeneration of the myenteric plexus." Colons resected from women with severe constipation show quite extensive abnormalities in the myenteric plexus,’2 but similar changes have been found in patients after section of the pelvic nerves13 and in those with injuries of the low spinal cord.14 Canine studies have shown that the pelvic nerves enter the low rectum and travel round as far as the transverse colon as six major nerve trunks; these pathways may serve to integrate the functions of the colon and anorectum.15 It is possible that patients with constipation have a lesion in the pelvic nerves or low spinal cord which impairs the normal integrated actions of the distal colon during defaecation. This hypothesis would explain why some patients become constipated after hysterectomy or childbirth,l2 both of which could damage the pelvic NR, Williams NS, Holmfield JHM, Morrison JFB, Simpkins KC. New method for the dynamic assessment ofanorectal function in constipation. BrJSurg 1985; 72: 994-98. 6 Kuijpers HC, Bleijeuberg G, Morree HDE. The spastic pelvic floor syndrome. Large bowel outlet obstruction caused by pelvic floor dysfunction: A radiological study Int J Colorect Dis 1986; 1: 44-48. 7. Parks AG, Porter NM, Melzak J. Experimental study of the reflex mechanisms controlling the muscles of the pelvic floor. Dis Col Rectum 1962; 5: 407-14. 8 Floyd WF, Walls EW. Electromyography of the sphincter ani externum in man. J Physiol 1953; 122: 599-609. 9 Schang JC, Devroede G. Colonic electrical spiking activity in constipated patients with the irritable bowel syndrome. Gastroenterology 1983; 84: A1299. 10. Preston DM, Lennard-Jones JE. Pelvic colon motility and response to intraluminal bisacodyl in slow transit constipation. Dig Dis Sci 1985; 30: 289-94. 11 Smith B. Effect of irritant purgatives on the myenteric plexus in man and the mouse Gut 1968; 9: 139-43. 12 Krishnamurphy S, Schniffler MD, Rohrmann CA, Ope CE. Severe idiopathic constipation is associated with a distinctive abnormality of the colonic myenteric plexus. Gastroenterology 1985; 88: 26-34. 13 Devroede G, Lamarche J. Functional importance of extrinsic parasympathetic innervation of the distal colon and rectum in man. Gastroenterology 1974; 66: 5. Womack
within the pelvis. It would also explain why with severe constipation have analogous many urological abnormalities such as hesitancy, high residual volume, and increased bladder volume. 16-11 The St Mark’s group, however, have shown that most of their cases of severe constipation in women could not be explained by previous pelvic surgery or childbirth, since the condition often commenced in childhood or adolescence and gradually worsened through the twenties and thirties.17 Do these patients have an occult neurological lesion of the spinal cord? If so, why the female preponderance? Studies of reproductive hormones show that constipated women tend to have lower oestrogen levels than normal and higher prolactin levels,19 but this could be the result of increased degradation of oestrogens by the loaded colon rather than the cause of any disturbance in motor activity. Constipated women also have a higher than normal incidence of irregular and painful periods, breast lumps, dyspareunia, anorgasmy, infertility, and pelvic operations. 17 Similar gynaecological complaints have been noted in a high proportion of patients with irritable bowel syndrome, many of whom are constipated.20 Are these phenomena related to the effects or the causes of the constipation? Women with severe constipation experience blackouts more commonly than normal controls and suffer more from pale cold fingers in cold weather. 17 Symptoms which suggest disease in many different regions and systems in the body are also common in patients with irritable bowel syndrome.2° Do these observations suggest a disturbance in autonomic function, perhaps related to a psychological abnormality? One psychological study indicated that although severely constipated women were mentally normal, they had experienced a greater degree of childhood deprivation and cruelty than normal controls,2’ but these results have been disputed. An alternative hypothesis, popular at the turn of the century, is that prolonged degradation of food residues by colonic bacteria leads to a much higher than normal absorption of toxic metabolites, resulting in widespread symptoms. Perhaps this theory of" autointoxication" should be resurrected in the light of present interest in colonic metabolism. Severe constipation in young women is a serious, common, but neglected condition which can be extremely difficult to treat. Although the pathophysiological mechanisms are better understood, this knowledge has yet to be translated into effective management. nerves
women
17.
18. 19.
273-80. 14 Devroede
G, Ahran P, Duguay C, Tetreault L, Akanry M, Percy B. Traumatic constipation. Gastroenterology 1979; 77: 1258-67. 15 Fukai K, Fukuda K. The intramural pelvic nerves in the colon of dogs.7 Physiol 1984; 354: 89-98.
A, Devroede G, Dunranceau A, et al. Constipation with colonic inertia: A manifestation of systemic disease. Dig Dis Sci 1983, 28: 1025-33. Preston DM, Lennard-Jones JE. Severe chronic constipation of young women: Idiopathic slow transit constipation. Gut 1986; 27: 41-48. Bannister JJ, Lawrence WT, Thomas DG, Read NW. Urological abnormalities in patients with slow transit constipation. Gut 1985; 26: A1131. Preston DM, Rees CH, Lennard-Jones JE. Disorders and hyperprolactinaemia in chronic constipation. Gut 1983; 24: A480. Whorwell PJ, McMallum M, Creed FH, Roberts CT Non-colonic features of irritable bowel syndrome. Gut 1986; 27: 37-40. Preston DM, Pfeffer JM, Lennard-Jones JE. Psychiatric assessment of patients with severe constipation. Gut 1984; 25: A582.
16. Watier
20 21.
populations of newborn infants-those born to mothers living in catchment areas of general hospitals with specialised obstetric services but without neonatal wards; and those born to mothers living in the catchment areas of central hospitals with specialised obstetric and neonatal departments in the same hospital. They claim that, during the study period 1973-78, the outcome of the pregnancies and deliveries was at least as favourable for the former as for the latter; and their conclusion is that good care can be provided in areas served by smaller hospitals with obstetric services but without specialised neonatal wards, provided that anticipated-risk deliveries can be planned to take place in hospitals with more complete perinatal care and also provided that excellent facilities exist for transfer of sick babies. These Swedish results have already been questioned. One crucial matter is the comparability of the two populations, but this has been dealt with thoroughly by the authors. Even though the comparison of risk factors is based on small numbers (fewer than 50 000 births),14,15 the main differences can hardly have biased the results seriously. Another question concerns how the study areas were selected, because obviously the selection was not purely random. Furthermore, the mid 1970s was a time when several new procedures were being introduced into obstetrics and neonatal care, and this might conceivably have influenced to a differing degree the care in the various types of hospitals. Who knows where the truth lies? There is anyway more to the organisation of perinatal care than mere access to neonatal intensive care and we need more information on other aspects such as antenatal care and delivery care. Should antenatal care be located mostly at outpatient clinics in hospitals, as in the UK, should it be the responsibility of the primary-care physician, or should it be organised through maternity centres run by midwives and public health nurses, as in some of the Scandinavian countries? Paradoxically two of the countries with the lowest perinatal mortality have chosen quite opposite ways of organising their service-Sweden with maternity centres, and Japan with traditional physician-based antenatal care. We need randomised controlled trials. So far, the principal measure of outcome has been mortality, but in future the emphasis must shift to morbidity, psychosocial as well as physical. This means long follow-up. To date, the development of long-term indicators of the quality of perinatal care has received little attention. Even though close surveillance of handicaps is clearly necessary as the chances of survival of the smallest babies increase, Ino country has so far established routine systems for monitoring child health that will permit observations to be related to perinatal and neonatal conditions and
15.
Hagberg B, Hagberg G, Olow I. Gains and hazards of intensive neonatal care: an analysis from Swedish cerebral palsy epidemiology. Devel Med Child Neurol 1982; 24: 13-19.
Provision of perinatal care is a medical, social, economic, and political issue, so in evaluating the care we should draw on the experience of both the professional providers and the childbearing women.
care.
Constipation in Young Women CONSTIPATION is so common in Western society that it is often regarded as trivial and not worthy of medical attention. Women appear to be more susceptible to constipation than men-their average daily stool weight is lower, their stools are harder, mouth-to-anus transit time is longer, and bowel frequency is less. The reason for these differences is not entirely clear, although the effects of female sexsteroids on intestinal motility are commonly implicated. Stool output may vary considerably during the menstrual cycle,’ and constipation is common during pregnancy. Mild-to-moderate constipation may be alleviated by advising the patient to increase the amount of fibre in the diet, increase fluid intake, and take more exercise, and by judicious use of bulk or irritant laxatives.2 In some patients these measures fail and even large doses of irritant laxatives are ineffective. Such patients may only be able to empty their bowels with the aid of enemas or by digital evacuation or even by rectal probing with a proctoscope. Encouragement to take more bran merely increases their discomfort and their disillusionment with the medical profession. Severe idiopathic constipation in young adults is almost entirely confined to women, who often experience considerable discomfort but receive little help or even sympathy from their doctors. These patients are unable to expel a small balloon resembling a stool from the anal canal, whereas normal matched control subjects find no difficulty in doing so.3,4 In their latest study reported in this issue (p 767), the group from St Mark’s Hospital, London, have shown that some of these women have difficulty in expelling even barium or saline from the rectum. In view of these results it is hardly surprising that laxatives or stool softeners and enemas may be ineffective, and why even surgical resection of the colon with ileorectal anastomosis may similarly fail to relieve the
constipation. The reason for this inability to defaecate appears to be related to inappropriate contraction of the striated muscles of the pelvic floor. Electrophysiological recordings have shown that the puborectalis and external anal sphincter muscles do not normally relax when these patients strain to expel a simulated stool; on GJ, Crowder M, Reid B, Dickerson JWT. Bowel function measurements of individuals with different eating patterns Gut 1986; 27: 164-69 2 Tedesco FJ, DiPiro JT. GI drug column. Laxative use in constipation Am J Gastroenterol 1985; 80: 303-08. 3. Preston DM, Lennard-Jones JE. Anismus in chronic constipation. Dig Dis Sci 1985, 30: 413-18. 4. Read NW, Timms JM, Barfield LJ, Donnelly TC, Bannister JJ. Impairment of defecation in young women with severe constipation. Gastroenterology 1986; 90: 53-60. 1. Davies
779
the contrary, evacuation is inhibited by inappropriate muscle contraction.3-6 This response resembles the normal spinal reflex for preserving continence, whereby the muscles of the external sphincter and puborectalis contract as the intra-abdominal pressure rises.7,8 The spinal reflex is normally inhibited during defaecation,5 permitting puborectalis and external anal sphincter relaxation in order to facilitate passage of stool. Normal inhibition of the continence reflex is probably cortical in origin, and may fail in some patients because they do not perceive the desire to defaecate when stool is in the rectum. It has been shown that although severely constipated women perceive distension of the rectum with a balloon, higher volumes than normal are required to provoke a desire to defaecate.4 If inability to defaecate were the only problem then the rectum should be packed with faeces awaiting expulsion, whereas in women with severe constipation it is usually empty.4 Pronounced reduction in propagative motor activity in the colon has also been documented in patients with severe constipation, both after a meal9 and after stimulation with bisacodyl. 10 A simple explanation is that the irritant laxatives that many of these patients take have produced degeneration of the myenteric plexus." Colons resected from women with severe constipation show quite extensive abnormalities in the myenteric plexus,’2 but similar changes have been found in patients after section of the pelvic nerves13 and in those with injuries of the low spinal cord.14 Canine studies have shown that the pelvic nerves enter the low rectum and travel round as far as the transverse colon as six major nerve trunks; these pathways may serve to integrate the functions of the colon and anorectum.15 It is possible that patients with constipation have a lesion in the pelvic nerves or low spinal cord which impairs the normal integrated actions of the distal colon during defaecation. This hypothesis would explain why some patients become constipated after hysterectomy or childbirth,l2 both of which could damage the pelvic NR, Williams NS, Holmfield JHM, Morrison JFB, Simpkins KC. New method for the dynamic assessment ofanorectal function in constipation. BrJSurg 1985; 72: 994-98. 6 Kuijpers HC, Bleijeuberg G, Morree HDE. The spastic pelvic floor syndrome. Large bowel outlet obstruction caused by pelvic floor dysfunction: A radiological study Int J Colorect Dis 1986; 1: 44-48. 7. Parks AG, Porter NM, Melzak J. Experimental study of the reflex mechanisms controlling the muscles of the pelvic floor. Dis Col Rectum 1962; 5: 407-14. 8 Floyd WF, Walls EW. Electromyography of the sphincter ani externum in man. J Physiol 1953; 122: 599-609. 9 Schang JC, Devroede G. Colonic electrical spiking activity in constipated patients with the irritable bowel syndrome. Gastroenterology 1983; 84: A1299. 10. Preston DM, Lennard-Jones JE. Pelvic colon motility and response to intraluminal bisacodyl in slow transit constipation. Dig Dis Sci 1985; 30: 289-94. 11 Smith B. Effect of irritant purgatives on the myenteric plexus in man and the mouse Gut 1968; 9: 139-43. 12 Krishnamurphy S, Schniffler MD, Rohrmann CA, Ope CE. Severe idiopathic constipation is associated with a distinctive abnormality of the colonic myenteric plexus. Gastroenterology 1985; 88: 26-34. 13 Devroede G, Lamarche J. Functional importance of extrinsic parasympathetic innervation of the distal colon and rectum in man. Gastroenterology 1974; 66: 5. Womack
within the pelvis. It would also explain why with severe constipation have analogous many urological abnormalities such as hesitancy, high residual volume, and increased bladder volume. 16-11 The St Mark’s group, however, have shown that most of their cases of severe constipation in women could not be explained by previous pelvic surgery or childbirth, since the condition often commenced in childhood or adolescence and gradually worsened through the twenties and thirties.17 Do these patients have an occult neurological lesion of the spinal cord? If so, why the female preponderance? Studies of reproductive hormones show that constipated women tend to have lower oestrogen levels than normal and higher prolactin levels,19 but this could be the result of increased degradation of oestrogens by the loaded colon rather than the cause of any disturbance in motor activity. Constipated women also have a higher than normal incidence of irregular and painful periods, breast lumps, dyspareunia, anorgasmy, infertility, and pelvic operations. 17 Similar gynaecological complaints have been noted in a high proportion of patients with irritable bowel syndrome, many of whom are constipated.20 Are these phenomena related to the effects or the causes of the constipation? Women with severe constipation experience blackouts more commonly than normal controls and suffer more from pale cold fingers in cold weather. 17 Symptoms which suggest disease in many different regions and systems in the body are also common in patients with irritable bowel syndrome.2° Do these observations suggest a disturbance in autonomic function, perhaps related to a psychological abnormality? One psychological study indicated that although severely constipated women were mentally normal, they had experienced a greater degree of childhood deprivation and cruelty than normal controls,2’ but these results have been disputed. An alternative hypothesis, popular at the turn of the century, is that prolonged degradation of food residues by colonic bacteria leads to a much higher than normal absorption of toxic metabolites, resulting in widespread symptoms. Perhaps this theory of" autointoxication" should be resurrected in the light of present interest in colonic metabolism. Severe constipation in young women is a serious, common, but neglected condition which can be extremely difficult to treat. Although the pathophysiological mechanisms are better understood, this knowledge has yet to be translated into effective management. nerves
women
17.
18. 19.
273-80. 14 Devroede
G, Ahran P, Duguay C, Tetreault L, Akanry M, Percy B. Traumatic constipation. Gastroenterology 1979; 77: 1258-67. 15 Fukai K, Fukuda K. The intramural pelvic nerves in the colon of dogs.7 Physiol 1984; 354: 89-98.
A, Devroede G, Dunranceau A, et al. Constipation with colonic inertia: A manifestation of systemic disease. Dig Dis Sci 1983, 28: 1025-33. Preston DM, Lennard-Jones JE. Severe chronic constipation of young women: Idiopathic slow transit constipation. Gut 1986; 27: 41-48. Bannister JJ, Lawrence WT, Thomas DG, Read NW. Urological abnormalities in patients with slow transit constipation. Gut 1985; 26: A1131. Preston DM, Rees CH, Lennard-Jones JE. Disorders and hyperprolactinaemia in chronic constipation. Gut 1983; 24: A480. Whorwell PJ, McMallum M, Creed FH, Roberts CT Non-colonic features of irritable bowel syndrome. Gut 1986; 27: 37-40. Preston DM, Pfeffer JM, Lennard-Jones JE. Psychiatric assessment of patients with severe constipation. Gut 1984; 25: A582.
16. Watier
20 21.