An 82-year-old man with advanced stage prostate cancer and multiple metastases was diagnosed with fecal impaction through digital rectal examination and assessment of stool consistency. He was managed by regular digital evacuation of stool, however, ultrasonic imaging indicated constipation with fecal retention in both the rectum and the colon despite the bowel evacuation program. Thus, a bowel management program was advocated that considered intestinal elimination dysfunction as well as fecal transport dysfunction. Based on ultrasonic imaging, stool consistency was altered by promoting water intake and self-defecation by asking the patient to attempt to move his bowels by sitting on the toilet every morning. Consequently, there were reductions in the number of weekly enemas and digital disimpaction episodes while the number of spontaneous defecations increased. This case highlights the importance of ultrasonography in improving bowel management in this patient with clinically severe chronic constipation.