For children, see separate Constipation in Children article.
Chronic constipation is common with a reported prevalence of 14% worldwide, with a significantly higher prevalence in women and people of lower socio-economic status. Symptoms often fluctuate and persistent symptoms over 10-20 years affect only 3% of adults.Chronic constipation refers to patients who have had symptoms for more than six months.
Constipation can affect quality of life and may be associated with haemorrhoids, anal fissures and serious underlying causes, such as colorectal cancer. Constipation may be associated with a modest reduction in survival.
What is constipation?
Constipation is a symptom not a diagnosis and means different things to different people. Always ask patients exactly what they mean by the term constipation. There are various formal (and different) definitions of constipation. It is defined as defecation that is unsatisfactory because of infrequent stools (<3 times weekly), difficult stool passage (with straining or discomfort), or seemingly incomplete defecation. Stools are often dry and hard, and may be abnormally large or abnormally small.
Patients may mean that:
- Faeces are too hard.
- They do not defecate often enough for 'inner cleanliness'.
- Defecation hurts.
- They have diarrhoea.
Causes of constipation
Taking a careful history helps to determine the possible cause. Always consider the possibility of a serious underlying cause. Particularly enquire whether there are associated 'red flags' such as weight loss or rectal bleeding.
Ask about frequency, nature and consistency of the stool; whether there is blood or mucus in/on the stools; whether there is diarrhoea alternating with constipation; whether there has been a recent change in bowel habit. Ask about diet and drugs.
Always perform a thorough examination of the abdomen, which should include a rectal examination.
|Causes of Constipation|
|Common causes||Low-fibre diet.|
Inadequate fluid intake or dehydration.
Immobility (or lack of exercise).
Irritable bowel syndrome.
Hospital environment (lack of privacy, having to use a bedpan).
|Anorectal disease||Anal fissure.|
|Intestinal obstruction||Strictures (eg, Crohn's disease).|
Pelvic mass (eg, fetus, fibroids).
Diverticulosis (rectal bleeding is a more common presentation).
|Drugs||Opioid analgesics (eg, morphine, codeine).|
Anticholinergics (tricyclics, phenothiazines).
|Neuromuscular||Spinal or pelvic nerve injury.|
American trypanosomiasis, Hirschsprung's disease.
|Other causes||Chronic laxative abuse (rare - diarrhoea is more common).|
Idiopathic slow transit.
- Most constipation does not need investigation, especially in young, mildly affected patients.
- Indications for investigation include:
- Age >40 years.
- A recent change in bowel habit.
- Associated symptoms (weight loss, rectal bleeding, mucous discharge, or tenesmus).
- Possible investigations include:
- Blood tests: FBC, U&E, Ca2+, TFTs.
- Sigmoidoscopy and biopsy of abnormal and normal mucosa.
- Barium enema if there is suspected colorectal malignancy.
- Special investigations (eg, transit studies, anorectal physiology) which are occasionally indicated.
- Treat the cause.
- Mobilise the patient.
- Increase fluid intake; increase intake of high-fibre foods (including fruits, vegetables, whole wheat and bran).
- Consider drugs only if the above measures fail.
- Try to use drugs for short durations only.
|Drugs for Constipation|
|Enemas and suppositories - useful additional treatment.|
- Prucalopride is a selective serotonin 5HT4-receptor agonist with prokinetic properties.
- Prucalopride is recommended as an option for the treatment of chronic constipation only in women for whom treatment with at least two laxatives from different classes, at the highest tolerated recommended doses for at least six months, has failed to provide adequate relief and invasive treatment for constipation is being considered.
- If treatment with prucalopride is not effective after four weeks, the woman should be re-examined and the benefit of continuing treatment reconsidered.
- Prucalopride should only be prescribed by a clinician with experience of treating chronic constipation, who has carefully reviewed the woman's previous courses of laxative treatments.
Clinical Editor's Comments (September 2017)
Dr Hayley Willacy recently read about treatment options for patients who are not responding to at least two standard laxatives. Where invasive treatment is being considered, lubiprostone enhances intestinal fluid secretion to soften stools and accelerate transit. It may be considered in addition to prucalopride. If treatment with lubiprostone has not worked after two weeks, your doctor will talk to you about whether or not you should keep taking this medicine. Lubiprostone should only be prescribed for you by a doctor who is experienced in treating chronic idiopathic constipation.
Obstructed defecation syndrome
- Obstructed defecation syndrome (ODS) is characterised by an urge to defecate but an impaired ability to expel the faecal bolus.
- Symptoms include unsuccessful attempts at faecal evacuation, excessive straining, pain, bleeding after defecation and a sense of incomplete faecal evacuation.
- Women, especially multiparous women, are more likely than men to present with symptoms of ODS.
- ODS is often associated with structural defects in the rectum, such as rectocele, internal rectal prolapse and perineal descent.
- Conservative treatments include diet, biofeedback, laxatives and pelvic floor retraining.
- Surgery may be considered for patients not responding to conservative treatment or if a structural abnormality is present, Surgical options include stapled transanal prolapsectomy, perineal levatorplasty (STAPL), stapled transanal rectal resection (STARR) and laparoscopic ventral mesh sacrocolporectopexy.
Further reading and references
; Treating constipation during pregnancy. Can Fam Physician. 2012 Aug58(8):836-8.
; Laxatives or methylnaltrexone for the management of constipation in palliative care patients. Cochrane Database Syst Rev. 2011 Jan 19(1):CD003448. doi: 10.1002/14651858.CD003448.pub3.
; NICE Technology Appraisal Guidance, July 2014
; NICE Technology Appraisal Guidance, July 2015
; Laxatives for chronic constipation in adults. BMJ. 2012 Oct 1345:e6168. doi: 10.1136/bmj.e6168.
; Chronic constipation: new diagnostic and treatment approaches. Therap Adv Gastroenterol. 2012 Jul5(4):233-47. doi: 10.1177/1756283X12443093.
; NICE CKS, October 2015 (UK access only)
; NICE Technology Appraisal Guidance, December 2010
; Chronic constipation: current treatment options. Can J Gastroenterol. 2011 Oct25 Suppl B:22B-28B.
; NICE Technology Appraisal Guidance, July 2014
; NICE Interventional Procedure Guidance, June 2010
I know that constipation in old age is fairly common but I wonder if anyone realises how upsetting it is. Younger people seem to think it's fairly amusing when a parent complains about lack of bowel...iris11541
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