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.
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.
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- Candy B, Jones L, Goodman ML, et al; 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.
- Lubiprostone for treating chronic idiopathic constipation; NICE Technology Appraisal Guidance, July 2014
- Naloxegol for treating opioid‑induced constipation; NICE Technology Appraisal Guidance, July 2015
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- Constipation; NICE CKS, October 2015 (UK access only)
- Prucalopride for the treatment of chronic constipation in women; NICE Technology Appraisal Guidance, December 2010
- Liu LW; Chronic constipation: current treatment options. Can J Gastroenterol. 2011 Oct 25 Suppl B:22B-28B.
- Stapled transanal rectal resection for obstructed defaecation syndrome; NICE Interventional Procedure Guidance, June 2010
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