Table 1 Interventions for habit training (HT – group 1)

a. Provision of a written information leaflet covering normal bowel function; causes of constipation; diet and fluid advice; getting into a good bowel habit

b. Review of written information using locally available teaching tools such as models or diagrams

c. Advice to stop all laxatives including drugs which have a laxative effect or over the counter herbal teas that contain strong purgatives. One or two glycerin suppositories are permitted as rescue if no stool is passed for 3 days. No use of irrigation devices or enemas

d. Encouragement to follow a daily routine: sit on the toilet for 20–30 min after first meal and/or hot drinks (sooner if urge felt)

e. Advice to attempt defaecation after meals or when urge is felt, but no more than 3 times per day

f. Advice to sit on toilet with knees bent to 45° position with feet elevated on stool or equivalent; abdominal brace and breathe while performing anal relaxation

g. Advice only to attempt to push for 5–10 min maximum

h. Teaching on defaecation manoeuvres, taught while the patient is positioned sitting on chair with verbal coaching to breathe while pushing

i. Strong discouragement from multiple attempts and prolonged straining

j. Advice not to digitate anally

k. Where appropriate, the participant will be taught rectocoele (vaginal), perineal and perianal splinting;

l. Therapist prohibited from using digital rectal exam to train manoeuvres

m. Diet and lifestyle advice, e.g. moderate but not excessive fibre; moderate but not excessive fluid intake; increase physical exercise, e.g. walking if possible

n. Participants with evacuation difficulty and/or perineal descent will be taught pelvic floor exercises

o. Plenty of optimism, encouragement and personal attention

p. Suggestions of what to work on until next intervention session

q. Therapist to complete relevant sections of patient booklet