Constipation is difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation. (See also Constipation in Children Constipation in Children Constipation is responsible for up to 5% of pediatric office visits. It is defined as delay or difficulty in defecation. Normal frequency and consistency of stool varies with children's age... read more .)
No bodily function is more variable and subject to external influences than defecation. Bowel habits vary considerably from person to person and are affected by age, physiology, diet, and social and cultural influences. Some people have unwarranted preoccupation with bowel habits. In Western society, normal stool frequency ranges from 2 to 3/day to 2 to 3/week.
Many people incorrectly believe that daily defecation is necessary and complain of constipation if stools occur less frequently. Others are concerned with the appearance (size, shape, color) or consistency of stools. Sometimes the major complaint is dissatisfaction with the act of defecation or the sense of incomplete evacuation after defecation. Constipation is blamed for many complaints (abdominal pain, nausea, fatigue, anorexia) that are actually symptoms of an underlying problem (eg, irritable bowel syndrome [IBS], depression). Patients should not expect all symptoms to be relieved by a daily bowel movement, and measures to aid bowel habits should be used judiciously.
Obsessive-compulsive patients Obsessive-Compulsive Disorder (OCD) Obsessive-compulsive disorder (OCD) is characterized by recurrent, persistent, unwanted, and intrusive thoughts, urges, or images (obsessions) and/or by repetitive behaviors or mental acts that... read more often feel the need to rid the body daily of “unclean” wastes. Such patients often spend excessive time on the toilet or become chronic users of cathartics.
Etiology of Constipation
Acute constipation suggests an organic cause, whereas chronic constipation may be organic or functional (see Table: Causes of Constipation Causes of Constipation Constipation is difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation. (See also Constipation in Children.) No bodily function is more variable and... read more ).
In many patients, constipation is associated with sluggish movement of stool through the colon. This delay may be due to drugs, organic conditions, or a disorder of defecatory function (ie, pelvic floor dysfunction), or a disorder that results from diet (see Table: Foods Often Affecting Gastrointestinal Function Foods Often Affecting Gastrointestinal Function Constipation is difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation. (See also Constipation in Children.) No bodily function is more variable and... read more ). Patients with disordered defecation Dyschezia Constipation is difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation. (See also Constipation in Children.) No bodily function is more variable and... read more do not generate adequate rectal propulsive forces, do not relax the puborectalis and the external anal sphincter during defecation, or both. In IBS, patients have symptoms (eg, abdominal discomfort and altered bowel habits) but generally normal colonic transit and anorectal functions. However, IBS-disordered defecation may coexist.
Excessive straining, perhaps secondary to pelvic floor dysfunction, may contribute to anorectal pathology (eg, hemorrhoids Hemorrhoids Hemorrhoids are dilated vessels of the hemorrhoidal plexus in the anal canal. Symptoms include irritation and bleeding. Thrombosed hemorrhoids are usually painful. Diagnosis is by inspection... read more , anal fissures Anal Fissure An anal fissure is an acute longitudinal tear or a chronic ovoid ulcer in the squamous epithelium of the anal canal. It causes severe pain, sometimes with bleeding, particularly with defecation... read more , and rectal prolapse Rectal Prolapse and Procidentia Rectal prolapse is painless protrusion of the rectum through the anus. Procidentia is complete prolapse of the entire thickness of the rectum. Diagnosis is by inspection. Surgery is usually... read more ) and possibly even to syncope. Fecal impaction, which may cause or develop from constipation, is also common among older patients, particularly with prolonged bed rest or decreased physical activity. It is also common after barium has been given by mouth or enema.
Evaluation of Constipation
History of present illness should ascertain a lifetime history of the patient’s stool frequency, consistency, need to strain or use perineal maneuvers (eg, pushing on the perineum, gluteal region, or recto-vaginal wall) during defecation, and satisfaction after defecation should be obtained, including frequency and duration of laxative or enema use. Some patients deny previous constipation but, when questioned specifically, admit to spending 15 to 20 minutes per bowel movement. The presence, amount, and duration of blood in the stool should also be elicited.
Review of systems should seek symptoms of causative disorders, including a change in caliber of the stool or blood in the stool (suggesting cancer). Systemic symptoms suggesting chronic diseases (eg, weight loss) should also be sought.
Past medical history should ask about known causes, including previous abdominal surgery and symptoms of metabolic (eg, hypothyroidism, diabetes mellitus) and neurologic (eg, Parkinson disease, multiple sclerosis, spinal cord injury) disorders. Prescription and nonprescription drug use should be carefully assessed, with specific questioning about anticholinergic and opioid drugs.
A general examination is done to look for signs of systemic disease, including fever and cachexia. Abdominal masses should be sought by palpation. A rectal examination should be done not only for fissures, strictures, blood, or masses (including fecal impaction) but also to evaluate anal resting tone (the puborectalis “lift” when patients squeeze the anal sphincter), perineal descent during simulated evacuation, and rectal sensation. Patients with defecatory disorders may have increased anal resting tone (or anismus), reduced (ie, 2 cm) or increased (ie, > 4 cm) perineal descent, and/or paradoxical contraction of the puborectalis during simulated evacuation.
Certain findings raise suspicion of a more serious etiology of chronic constipation:
Distended, tympanitic abdomen
Blood in stool
Severe constipation of recent onset/worsening in older patients
Interpretation of findings
Certain symptoms (eg, a sense of anorectal blockage, prolonged or difficult defecation, need for digital disimpaction), particularly when associated with abnormal (ie, increased or reduced) perineal motion during simulated evacuation, suggest a defecatory disorder Dyschezia Constipation is difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation. (See also Constipation in Children.) No bodily function is more variable and... read more . A tense, distended, tympanitic abdomen, particularly when there is nausea and vomiting, suggests mechanical obstruction.
Chronic constipation with modest abdominal discomfort in a patient who has used laxatives for a long time suggests slow-transit constipation. Acute constipation coincident with the start of a constipating drug in patients without red flag findings suggests the drug is the cause. New-onset constipation that persists for weeks or occurs intermittently with increasing frequency or severity, in the absence of a known cause, suggests colonic tumor Colorectal Cancer Colorectal cancer is extremely common. Symptoms include blood in the stool and change in bowel habits. Screening using one of several methods is recommended for appropriate populations. Diagnosis... read more or other causes of partial obstruction. Excessive straining or prolonged or unsatisfactory defecation, with or without anal digitation, suggests a defecatory disorder. Patients with fecal impaction may have cramps and may pass watery mucus or fecal material around the impacted mass, mimicking diarrhea (overflow diarrhea).
Patients with IBS Irritable Bowel Syndrome (IBS) Irritable bowel syndrome is characterized by recurrent abdominal discomfort or pain with at least two of the following characteristics: relation to defecation, association with a change in frequency... read more typically have abdominal pain with disordered bowel habits. Patients with chronic constipation who do not meet the criteria for IBS may have functional constipation (1 Evaluation reference Constipation is difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation. (See also Constipation in Children.) No bodily function is more variable and... read more ).
Testing is guided by clinical presentation and the patient's diet history.
Constipation with a clear etiology (drugs, trauma, bed rest) may be treated symptomatically without further study. Patients with symptoms of bowel obstruction require flat and upright abdominal x-rays, possibly a water-soluble contrast enema to evaluate for colonic obstruction, and possibly a CT scan or barium x-ray of the small intestine (see also diagnosis of intestinal obstruction Diagnosis Intestinal obstruction is significant mechanical impairment or complete arrest of the passage of contents through the intestine due to pathology that causes blockage of the bowel. Symptoms include... read more ). Most patients without a clear etiology should have colonoscopy and a laboratory evaluation (complete blood count, thyroid-stimulating hormone, fasting glucose, electrolytes, and calcium).
Further tests are usually reserved for patients with abnormal findings on the previously mentioned tests or who do not respond to symptomatic treatment. The current American Gastroenterological Association's medical position statement on constipation suggests a trial of fiber and/or over-the-counter laxatives. If this trial fails, anorectal manometry with balloon expulsion should be done to identify pelvic floor disorders. If manometry is negative and the primary complaint is infrequent defecation, colonic transit times should be measured with radiopaque markers (Sitz markers), scintigraphy, or a wireless motility capsule. In patients with chronic constipation, it is important to distinguish between slow-transit constipation (abnormal Sitz marker radiopaque study) and pelvic floor muscle dysfunction (markers retained only in distal colon).
Treatment of Constipation
Possibly discontinuation of causative drugs (some may be necessary)
Increase in dietary fiber
Possibly trial with a brief course of osmotic laxatives
Any identified conditions should be treated.
See table Agents Used to Treat Constipation Agents Used to Treat Constipation Constipation is difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation. (See also Constipation in Children.) No bodily function is more variable and... read more for a summary. Laxatives should be used judiciously. Some (eg, phosphate, bran, cellulose) bind drugs and interfere with absorption. Rapid fecal transit may rush some drugs and nutrients beyond their optimal absorptive locus. Contraindications to laxative and cathartic use include acute abdominal pain of unknown origin, inflammatory bowel disorders, intestinal obstruction, gastrointestinal bleeding, and fecal impaction.
Diet and behavior
The diet should contain enough fiber (typically 15 to 20 g/day) to ensure adequate stool bulk. Vegetable fiber, which is largely indigestible and unabsorbable, increases stool bulk. Certain components of fiber also absorb fluid, making stools softer and facilitating their passage. Fruits and vegetables are recommended sources, as are cereals containing bran. Fiber supplementation is particularly effective in treating normal-transit constipation but is not very effective for slow-transit constipation or defecatory disorders.
Behavioral changes may help. Patients should try to move their bowels at the same time daily, preferably 15 to 45 minutes after breakfast, because food ingestion stimulates colonic motility. Initial efforts at regular, unhurried bowel movements may be aided by glycerin suppositories.
Patients with obsessive-compulsive disorder require treatment for that disorder. In addition, physicians must explain that daily bowel movements are not essential, that the bowel must be given a chance to function, and that frequent use of laxatives or enemas (> once every 3 days) denies the bowel that chance.
Types of laxatives
Bulking agents (eg, psyllium, calcium polycarbophil, methylcellulose) act slowly and gently and are the safest agents for promoting elimination. Proper use involves gradually increasing the dose—ideally taken 3 or 4 times a day with sufficient liquid (eg, 500 mL/day of extra fluid) to prevent impaction—until a softer, bulkier stool results. Bloating may be reduced by gradually titrating the dose of dietary fiber to the recommended dose, or by switching to a synthetic fiber preparation such as methylcellulose.
Osmotic agents contain poorly absorbed polyvalent ions (eg, magnesium, phosphate, sulfate), polymers (eg, polyethylene glycol), or carbohydrates (eg, lactulose, sorbitol) that remain in the bowel, increasing intraluminal osmotic pressure and thereby drawing water into the intestine. The increased volume stimulates peristalsis. These agents usually work within 3 hours.
In general, osmotic laxatives are reasonably safe even when used regularly. However, sodium phosphate should not be used for bowel cleansing because it may rarely cause acute renal failure even after a single use for bowel preparation. These events occurred primarily in older patients, those with preexisting renal disease, and those who were taking drugs that affect renal perfusion or function (eg, diuretics, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers). Also, magnesium and phosphate are partially absorbed and may be detrimental in some conditions (eg, renal insufficiency). Sodium (in some preparations) may exacerbate heart failure. In large or frequent doses, these drugs may upset fluid and electrolyte balance. Another approach to cleansing the bowel for diagnostic tests or surgery or sometimes for chronic constipation uses large volumes of a balanced osmotic agent (eg, polyethylene glycol–electrolyte solution) given orally or via nasogastric tube.
Secretory or stimulant cathartics (eg, phenolphthalein, bisacodyl, anthraquinones, castor oil, anthraquinones) act by irritating the intestinal mucosa or by directly stimulating the submucosal and myenteric plexus. Although phenolphthalein was withdrawn from the US market after animal studies suggested the compound was carcinogenic, there is no epidemiologic evidence of this in humans. Bisacodyl is an effective rescue drug for chronic constipation. The anthraquinones senna, cascara sagrada, aloe, and rhubarb are common constituents of herbal and over-the-counter laxatives. They pass unchanged to the colon where bacterial metabolism converts them to active forms.
Adverse effects include allergic reactions, electrolyte depletion, melanosis coli, and cathartic colon. Melanosis coli is a brownish black colorectal pigmentation of unknown composition. Cathartic colon refers to alterations in colonic anatomy observed on barium enema in patients with chronic stimulant laxative use. Cathartic colon can cause constipation that leads to more laxative use and thus more constipation, creating a vicious circle. It is unclear whether cathartic colon, which has been attributed to destruction of myenteric plexus neurons by anthraquinones, is caused by currently available agents or other neurotoxic agents (eg, podophyllin), which are no longer available. There does not seem to be an increased risk of colon cancer with long-term anthraquinone use.
Enemas can be used, including tap water and commercially prepared hypertonic solutions.
Emollient agents (eg, docusate, mineral oil) act slowly to soften stools, making them easier to pass. However, they are not potent stimulators of defecation. Docusate is a surfactant, which allows water to enter the fecal mass to soften and increase its bulk.
Peripherally acting mu-opioid receptor antagonists (PAMORAs; eg, methylnaltrexone, naloxegol, naldemedine) can be used to treat opioid-induced constipation that does not resolve with other measures. Alvimopan is a mu-opioid antagonist that is available for short-term hospital use in surgical patients for the treatment of postoperative ileus.
Fecal impaction is treated initially with enemas of tap water followed by small enemas (100 mL) of commercially prepared hypertonic solutions. If these do not work, manual fragmentation and disimpaction of the mass may be necessary. This procedure is painful, so perirectal and intrarectal application of local anesthetics (eg, lidocaine 5% ointment or dibucaine 1% ointment) is recommended. Some patients require sedation.
Constipation is common among older people because of low-fiber diets, lack of exercise, coexisting medical conditions, and use of constipating drugs. Many older people have misconceptions about normal bowel habits and use laxatives regularly. Other changes that predispose older people to constipation include increased rectal compliance and impaired rectal sensation (such that larger rectal volumes are needed to elicit the desire to defecate).
Drug causes are common (eg, use of anticholinergic or opioid drugs).
Be wary of bowel obstruction when constipation is acute and severe.
If a trial of fiber and/or laxatives fails, anorectal manometry with balloon expulsion should be done to exclude pelvic floor dysfunction.
Etiology of Dyschezia
Normally, when a person tries to defecate, rectal pressure rises in coordination with relaxation of the external anal sphincter. This process may be affected by one or more dysfunctions (eg, impaired rectal contraction, excessive contraction of the abdominal wall, paradoxic anal contraction, failure of anal relaxation) of unclear etiology. Functional defecatory disorders may manifest at any age. In contrast, Hirschsprung disease Hirschsprung Disease Hirschsprung disease is a congenital anomaly of innervation of the lower intestine, usually limited to the colon, resulting in partial or total functional obstruction. Symptoms are obstipation... read more , which is due to an absent recto-anal inhibitory reflex, is almost always diagnosed in infancy or childhood. People with irritable bowel syndrome Irritable Bowel Syndrome (IBS) Irritable bowel syndrome is characterized by recurrent abdominal discomfort or pain with at least two of the following characteristics: relation to defecation, association with a change in frequency... read more (IBS) may have IBS-disordered defecation, causing dyschezia.
Symptoms and Signs of Dyschezia
The patient may or may not sense that stool is present in the rectum. Despite prolonged straining, evacuation is tedious or impossible, frequently even for soft stool or enemas. Patients may complain of anal blockage and may digitally remove stool from their rectum or manually support their perineum or splint the vagina to evacuate. Actual stool frequency may or may not be decreased.
Diagnosis of Dyschezia
Anorectal manometry and rectal balloon expulsion
Rectal and pelvic examinations may reveal hypertonia of the pelvic floor muscles and anal sphincters. With bearing down, patients may not demonstrate the expected anal relaxation and perineal descent. With excessive straining, the anterior rectal wall prolapses into the vagina in patients with impaired anal relaxation; thus rectoceles are usually a secondary rather than a primary disturbance. Long-standing dyschezia with chronic straining may cause a solitary rectal ulcer or varying degrees of rectal prolapse or excessive perineal descent or an enterocoele.
Anorectal manometry and rectal balloon expulsion, occasionally supplemented by defecatory or magnetic resonance proctography, are necessary to diagnose the condition.
Treatment of Dyschezia
Because treatment with laxatives is unsatisfactory, it is important to assess anorectal functions in patients with refractory constipation Constipation Constipation is difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation. (See also Constipation in Children.) No bodily function is more variable and... read more . Biofeedback Biofeedback For biofeedback, a type of mind-body medicine, electronic devices are used to provide information to patients about biologic functions (eg, heart rate, blood pressure, muscle activity, skin... read more therapy can improve coordination between abdominal contraction and pelvic floor relaxation during defecation, thereby alleviating symptoms. However, pelvic floor retraining for defecatory disorders is highly specialized and available at select centers only. A collaborative approach (physiotherapists, dietitians, behavior therapists, gastroenterologists) is necessary.