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This is a PatientPlus article. PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.

Constipation

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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.¹

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

A careful history helps to determine the possible cause. Ask about frequency, nature and consistency of the stool. Is there blood or mucus in/on the stools? Is there diarrhoea alternating with constipation? Has there been a recent change in bowel habit? Ask about diet and drugs.

Rectal examination is essential.

Causes of constipation
Common Causes	Low fibre diet Inadequate fluid intake or dehydration Immobility (or lack of exercise) Irritable bowel syndrome Old age Post-operative pain Hospital environment (lack of privacy, having to use a bed pan)
Anorectal Disease	Anal fissure Anal stricture (See Around the anus) Rectal prolapse
Intestinal Obstruction	Strictures (eg Crohn's disease) Colorectal carcinoma Pelvic mass (eg fetus, fibroids) Diverticulosis (rectal bleeding is a commoner presentation) Congenital abnormalities Pseudo-obstruction
Metabolic / endocrine	Hypothyroidism Hypercalcaemia Hypokalaemia Porphyria Lead poisoning
Drugs	Opiate analgesics (eg morphine, codeine) Anticholinergics (tricyclics, phenothiazines) Iron
Neuromuscular	Spinal or pelvic nerve injury Aganglionosis (Chagas' disease, Hirschsprung's Disease) Systemic sclerosis Diabetic neuropathy
Other Causes	Chronic laxative abuse (rare - diarrhoea is commoner) Idiopathic slow transit Idiopathic megarectum/colon

Investigations

Most constipation does not need investigation, especially young, mildly affected patients.
Indications for investigation include:
- Age >40yrs
- Recent change in bowel habit
- Associated symptoms (weight loss, rectal bleeding, mucus discharge, or tenesmus)
Possible investigations include:
- Blood tests: FBC , U&E , Ca2+, TFTs.
- Sigmoidoscopy and biopsy of abnormal and normal mucosa.
- Barium enema if suspected colorectal malignancy.
- Special investigations (eg transit studies; anorectal physiology) are occasionally indicated.

Management

Treat the cause
Mobilise the patient
Consider drugs only if above measures fail
Try to use drugs for short durations only

Drug therapy

Drugs for constipation
Bulk producers: Increase faecal mass, which stimulates peristalsis They must be taken with plenty of fluid Contraindications: difficulty in swallowing; intestinal obstruction; colonic atony; faecal impaction.	Examples: Bran powder 3.5g 2-3 times/day with food. Ispaghula husk, eg Fybogel® 3.5g sachet in water after meals. Methylcellulose, eg Celevac® 3-6 500mg tablets/12h with water. Sterculia, eg Normacol® 7g sachets 1-2 sachets in water once or twice a day after meals.
Stool softeners: Side effects can include: anal seepage, lipoid pneumonia, malabsorption of fat-soluble vitamins.	Arachis oil enemas lubricate and soften impacted faeces. Liquid paraffin should not be used for a prolonged period.
Stimulants: Increase intestinal motility and should not be used in intestinal obstruction. Prolonged use should be avoided as it may cause colonic atony and hypokalemia (but there are no good, longterm follow up studies).[R]	Pure stimulant laxatives are bisacodyl tablets (5-10mg at night) or suppositories (10mg in the mornings) and senna (2-4 tablets at night). Docusate sodium and danthron (dantron) have stimulant and softening actions; however danthron is associated with colonic and liver tumours in animals - so reserve its use for the very elderly and terminally ill. Glycerol suppositories act as a rectal stimulant. Sodium picosulfate is useful for rapid bowel evacuation prior to procedures.
Osmotic agents: Retain fluid in the bowel.	Lactulose, a semisynthetic disaccharide, produces an osmotic diarrhoea of low faecal pH that discourages growth of ammonia producing organisms. It is useful in constipation (dose: 15mL/12h) and hepatic encephalopathy (dose: 30-50mL/12h). Magnesium salts (eg magnesium hydroxide and magnesium sulfate) are useful when rapid bowel evacuation is required.
Enemas and suppositories- useful additional treatment	Sodium phosphate enemas and Glycerine suppositories may be useful. Sodium salts (eg Microlette® and Micralax® enemas) should be avoided as they may cause sodium and water retention. Phosphate enemas are useful for rapid bowel evacuation prior to procedures. Excessive use of soapy tap water enemas may lead to water intoxication.
Cost Cheap: Senna, Bran, Co-danthrusate, Bisacodyl. Moderate: Magnesium hydroxide, Methylcellulose, Ispaghula granules, Sterculia. Expensive: Lactulose.

Constipation in children

This is covered in the article on Constipation in Children.

Document references

Constipation, Clinical Knowledge Summaries (January 2008)

Internet and further reading

Jewell DJ, Young G; Interventions for treating constipation in pregnancy. Cochrane Database Syst Rev. 2001;(2):CD001142. [abstract]
Palliative cancer care - constipation; Clinical Knowledge Summaries.

Acknowledgements EMIS is grateful to Dr Richard Draper for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 2001
Document Version: 20
DocRef: bgp841
Last Updated: 18 Apr 2008
Review Date: 18 Apr 2010

The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest. Find out more about updating.

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