What is the recommended workup and treatment for constipation in a middle-aged male?

Workup and Treatment for Constipation in Middle-Aged Males

The recommended workup for constipation in middle-aged males should include a thorough history, physical examination with digital rectal examination, complete blood count, and consideration of colonoscopy for those with alarm symptoms or who are over 50 years old and have not undergone age-appropriate colorectal cancer screening. 1, 2

Initial Assessment

History and Physical Examination

• Evaluate for:
  • Stool frequency, consistency, and size
  • Straining during defecation
  • Sensation of incomplete evacuation
  • Need for manual maneuvers to facilitate defecation
  • Duration of symptoms
  • Medication review (opioids, antidepressants, calcium channel blockers)
  • Dietary habits and fluid intake
  • Recent changes in bowel habits

Red Flag Symptoms Requiring Urgent Evaluation

• Rectal bleeding
• Unintentional weight loss
• Change in stool caliber
• Progressive abdominal pain
• Family history of colorectal cancer or inflammatory bowel disease
• Acute onset of constipation

Physical Examination

• Abdominal examination for masses, tenderness, or distension
• Digital rectal examination (DRE) to assess:
  • Resting anal tone and squeeze pressure
  • Presence of masses or impaction
  • Perineal descent during simulated evacuation
  • Ability to "expel examiner's finger" 1

Diagnostic Testing

First-Line Testing

• Complete blood count (strong recommendation) 1, 2
• Metabolic tests (thyroid-stimulating hormone, glucose, calcium) are NOT routinely recommended unless clinically indicated 1

Structural Evaluation

• Colonoscopy is indicated for:
  • Patients with alarm symptoms
  • Patients over 50 who have not undergone age-appropriate colorectal cancer screening
  • Abrupt onset of constipation 1, 2

Advanced Testing (for refractory cases)

• Colonic transit study (if symptoms persist despite initial treatment)
• Anorectal manometry and balloon expulsion test (to evaluate for defecatory disorders)
• Defecography (for suspected structural abnormalities) 1, 2

Treatment Algorithm

Step 1: Lifestyle Modifications

• Increase fluid intake to at least 8 glasses of water daily
• Gradually increase dietary fiber to 20-25g per day
• Increase physical activity within patient limits
• Optimize toileting habits:
  • Establish regular toileting schedule
  • Ensure privacy and comfort
  • Use footstool to elevate knees above hips 2

Step 2: First-Line Pharmacological Treatment

• Osmotic laxatives:
  • Polyethylene glycol (PEG) 3350: 17g dissolved in 8oz of water once daily
  • Expected results within 1-3 days
  • Safe for long-term use (up to 12 months) with no evidence of tachyphylaxis 2

Step 3: Add or Switch to Other Agents if Inadequate Response

• Stimulant laxatives:
  • Senna (8.6-17.2mg daily)
  • Bisacodyl (5-10mg daily)
• Bulk-forming laxatives:
  • Psyllium: 1 packet in 8oz of liquid up to 3 times daily 3
  • Note: Start with 1 dose per day and gradually increase; ensure adequate fluid intake

Step 4: For Refractory Constipation

• Evaluate for defecatory disorders with specialized testing
• Consider referral for biofeedback therapy if defecatory disorder is confirmed
• For opioid-induced constipation, consider peripherally acting mu-opioid receptor antagonists:
  • Naldemedine 0.2mg daily
  • Naloxegol
  • Methylnaltrexone subcutaneously 2

Management of Complications

Fecal Impaction

• Digital fragmentation and extraction of stool
• Glycerin suppositories or mineral oil retention enemas
• Once disimpacted, implement maintenance bowel regimen to prevent recurrence 1, 2

Monitoring and Follow-up

• Reassess treatment efficacy within 2-4 weeks of initiating therapy
• Goal: One non-forced bowel movement every 1-2 days
• Consider using the Bowel Function Index to assess severity and monitor response 2

Common Pitfalls to Avoid

1. Continuing ineffective treatments without reassessment
2. Using fiber supplements in patients with severe constipation or suspected obstruction
3. Inadequate fluid intake when using bulk-forming laxatives
4. Failure to identify medication-induced constipation
5. Missing defecatory disorders in patients with refractory symptoms 2

Remember that surgical treatment is rarely needed and should be reserved for cases of refractory constipation with documented slow transit after thorough evaluation and failure of conservative measures 4, 5.