What are the management options for constipation?

Management of Constipation

For the management of constipation, polyethylene glycol (PEG) is strongly recommended as the first-line pharmacological treatment due to its excellent efficacy and safety profile. 1

Assessment and Diagnosis

Before initiating treatment, proper assessment is crucial:

• Evaluate for underlying causes including medications, metabolic disorders, and mechanical obstruction 2
• Perform physical examination including abdominal examination, perineal inspection, and digital rectal examination 2
• Consider plain abdominal X-ray in severe cases to assess fecal loading and exclude bowel obstruction 1
• Rule out impaction, especially if diarrhea accompanies constipation 2

Treatment Algorithm

Step 1: Non-pharmacological Approaches

• Ensure privacy and comfort for normal defecation 1
• Optimize positioning (use a small footstool to assist with defecation) 1
• Increase fluid intake 1
• Encourage physical activity within patient limits 1
• Gradually increase dietary fiber to 20-25g per day, focusing on soluble fiber sources 2

Step 2: First-line Pharmacological Treatment

• Polyethylene glycol (PEG) - strongly recommended due to excellent efficacy and safety profile 1
  • Caution: Discontinue if rectal bleeding, worsening abdominal pain, or diarrhea occurs 3
  • Should not be used for more than one week without medical supervision 3

Step 3: Alternative or Add-on Treatments

Based on response and patient characteristics:

• Stimulant laxatives - strong recommendation for sodium picosulfate; conditional recommendation for senna 1

  • Particularly useful for short-term rescue therapy (bisacodyl 5-10mg daily) 2

• Osmotic laxatives - conditional recommendation for lactulose and magnesium oxide 1

• Fiber supplements - conditional recommendation 1

  • Methylcellulose - helps relieve occasional constipation without causing excess gas 4
  • Psyllium - discontinue if constipation persists beyond 7 days or rectal bleeding occurs 5

Step 4: Advanced Pharmacological Options

For refractory constipation:

• Secretagogues - strong recommendation for linaclotide and plecanatide 1
• Serotonin type 4 agonist - strong recommendation for prucalopride 1
• Lubiprostone - conditional recommendation 1

Step 5: For Opioid-induced Constipation

• Start prophylactic stimulant laxative plus stool softener 2
• Increase laxative dose when increasing opioid dose 2
• For refractory cases, consider peripherally acting mu-opioid receptor antagonists (methylnaltrexone, naloxegol, naldemedine) 2

Special Considerations

For Severe Constipation/Impaction

• Manual disimpaction following pre-medication with analgesic/anxiolytic 2
• Glycerine suppository or mineral oil retention enema 2
• Tap water enema until clear for severe cases 2

Contraindications and Precautions

• Docusate has not shown benefit and is not recommended 2
• Supplemental medicinal fiber may worsen constipation in many cases 2
• Limit sodium phosphate laxatives in patients at risk for renal dysfunction 2
• Peripherally acting mu-opioid receptor antagonists should not be used with suspected mechanical bowel obstruction 2

For Defecatory Disorders

• Biofeedback therapy improves symptoms in >70% of patients and should be considered before laxatives 2

Monitoring and Follow-up

• Schedule follow-up within 2-4 weeks of initiating treatment 2
• Monitor frequency and consistency of bowel movements, abdominal pain, and medication compliance 2
• Adjust treatment based on response 2
• For chronic constipation, gradually taper medication once a regular bowel pattern is established 2

Common Pitfalls to Avoid

• Relying solely on lifestyle modifications without appropriate pharmacological intervention 1, 2
• Using fiber supplements in patients with severe constipation or suspected obstruction 2
• Continuing ineffective treatments without reassessment 2
• Failing to prophylactically treat constipation when prescribing opioids 2
• Using peripherally acting mu-opioid receptor antagonists as first-line treatment 2

By following this structured approach to constipation management, clinicians can effectively address this common condition while minimizing complications and improving patient quality of life.