Constipation, Constipation, Constipation

By Dawn Sandalcidi, PT, PCMT, BCB-PMD

I have decided that I want my tombstone to read “DON'T EVER BE CONSTIPATED!”

Did you know there was a teenage girl in Great Britain who died of constipation?

I had a teenager in my practice that had a bowel movement (BM) once every 3 weeks and the only sensation she had to become aware it was time to empty was goose bumps. Did you know that 50% of the weight of feces is bacteria?  Is that something you really want sitting around inside of your body?

When people hear me speak they occasionally comment that all I talk about is constipation. Well amen! That means I got my point across, however, it’s more than just my soapbox.  It's real. Approximately 95% of my patients present with constipation and it is the single most challenging aspect to convince parents that constipation is a large contributing factor if not the CAUSE of their urinary or fecal incontinence.

Constipation can result from PFM dysfunction. Rectal distension with constipated feces is known to increase the risk of colonization of the urethra and perineum with uropathogens, irritate the bladder and cause over activity of the detrusor, and increase the virulence of the fecal bacteria (Reddy, Redman 2003). 52% of constipated children presented with abnormal voiding parameters. Rectal dilation seen on US was associated with abnormal voiding parameters. (Chung 2014). Stool backed up in the rectum may cause pressure on the bladder or reflex relaxation of urinary sphincters. As a result, 1 in 3 children with encopresis also have bedwetting and 1 in 5 also have daytime dribbling or urinary frequency. (Griffin, et al 1999.) Constipation is more common in children with overactive bladder (OAB) than in those without urinary symptoms (Veiga 2013)

So what is normal?

On the Bristol Scale we encourage patients to have a Type 4 stool consistency that is like a ripe banana. The goal for our patients with comorbidities of constipation and daytime or nighttime urinary leakage is a daily BM of type 3-4 consistencies without straining. To support his goal we encourage the use of the squatty potty, diaphragmatic breathing, ILU massage and other visceral techniques to retrain the bowel. It’s important to help the parents understand the importance of regular bowel movements and it may take the bowel 6 months to 1 year to retrain. That doesn't necessarily mean the child will need therapy that long but that they will get backed up and relapse easily if they don't maintain their bowel program.

Miralax is frequently prescribed for constipation. Parents often discontinue it as their child has stools that are too loose and they experience fecal incontinence. This then causes more constipation and the vicious cycle continues. Please request permission from your referral source to titrate the Miralax until you have a formed stool.

Constipation is so common and a critical component to the success of your treatment. Education and demystifying it will lead to a very positive outcome.



1.     Chung KL, Chao NS, Liu CS, Tang PM, Liu KK, Leung MW. Abnormal voiding parameters in children with severe idiopathic constipation. Pediatr Surg Int. 2014 Jul;30(7):747-9.

2.     Griffin, G., Roberts, SD., Graham, G. How to resolve stool retention in a child. Underwear soiling is not a behavior problem.  1999 Jan;105(1)159-61, 165-6, 172-3.

3.     Koppen IJN, von Gontard A, Chase J, Cooper CS, Rittig CS, Bauer SB, Homsy
Y, Yang SS, Benninga MA. Management of functional nonretentive fecal incontinence in children: recommendations from the International Children’s Continence Society. J of Ped Urol (2015)

4.     Koppen IJ, Di Lorenzo C, Saps M, Dinning PG, Yacob D, Levitt MA, Benninga MA. .Childhood constipation: finally something is moving! Expert Rev Gastroenterol Hepatol. 2015 Oct 14:1-15. 

5.      Reddy, PP., Redman, JF. The management of childhood voiding dysfunction. J Ark Med Soc.  Mar.2003;99(9):295-8.

6.     Veiga ML, Lordêlo P, Farias T, Barroso C, Bonfim J, Barroso U Jr. Constipation in children with isolated overactive bladders. J Pediatr Urol. 2013 Dec;9(6 Pt A):945-9.