What are the treatment options for constipation?

Treatment Options for Constipation

The treatment of constipation should begin with non-pharmacological interventions including increased fluid intake, dietary fiber, physical activity, and proper toileting habits, followed by osmotic or stimulant laxatives when needed, with specialized treatments for specific types of constipation. 1, 2

Assessment and Diagnosis

Before initiating treatment, proper assessment is essential:

• Physical examination should include abdominal examination, perineal inspection, and digital rectal examination (DRE) 1
• DRE should assess:
  • Resting tone of the sphincter
  • Ability to contract during squeeze
  • Ability to "expel" the examiner's finger during simulated defecation 1
• Complete blood count is recommended; thyroid function, calcium, and glucose tests may be considered if clinically indicated 1
• Plain abdominal X-ray may be useful to assess fecal loading and exclude obstruction 1

Non-Pharmacological Management

First-Line Approaches:

• Lifestyle modifications:
  • Increase fluid intake to ensure adequate hydration 1, 2, 3
  • Increase dietary fiber (aim for 20-30g daily) 3, 4
  • Increase physical activity within patient limits 1, 2
  • Establish regular toileting routine 2

Proper Toileting Techniques:

• Ensure privacy and comfort 1
• Use proper positioning (small footstool to elevate knees above hips) 1, 5
• Attempt defecation 30 minutes after meals to utilize gastrocolic reflex 1, 2
• Strain no more than 5 minutes 1

Additional Non-Pharmacological Options:

• Abdominal massage may help reduce gastrointestinal symptoms, particularly in patients with neurogenic problems 1

Pharmacological Management

Osmotic Laxatives (First-Line):

• Polyethylene glycol (PEG): Preferred first-line treatment 1, 2
• Lactulose: Alternative to PEG 1, 2
• Magnesium salts: Effective but use cautiously in renal impairment 1, 2

Stimulant Laxatives (First-Line):

• Options include senna, bisacodyl, and sodium picosulfate 1
• Particularly useful for opioid-induced constipation 1

Rectal Therapies:

• Suppositories and enemas are preferred first-line therapy when DRE identifies a full rectum or fecal impaction 1
• Contraindications for enemas: neutropenia, thrombocytopenia, paralytic ileus, intestinal obstruction, recent colorectal surgery, anal trauma, severe colitis, or pelvic radiation 1, 2

Specialized Treatments:

• For opioid-induced constipation (OIC):

  • Prophylactic laxatives should be prescribed with opioid therapy 1
  • Avoid bulk laxatives (psyllium) in OIC 1
  • Peripheral opioid antagonists (PAMORAs) for refractory OIC 1, 2
  • Combined opiate/naloxone medications can reduce OIC risk 1

• For chronic idiopathic constipation:

  • Linaclotide (145 mcg daily) is FDA-approved and effective 6
  • Improves stool frequency, consistency, and straining 6

Management of Special Situations

Fecal Impaction:

1. Digital fragmentation and extraction of stool (if no perforation or bleeding suspected) 1
2. Implement maintenance bowel regimen to prevent recurrence 1
3. Consider neostigmine for severe cases when conservative measures fail 2

Defecatory Disorders:

• Pelvic floor retraining with biofeedback therapy is recommended rather than continued laxative use 2
• Referral to specialized centers for colonic manometry may be needed for documented slow-transit constipation that fails aggressive medical management 2

Elderly Patients:

• Ensure access to toilets, especially with decreased mobility 1
• Provide dietetic support 1
• Manage decreased food intake which affects stool volume and consistency 1
• Optimize toileting schedule (attempt defecation twice daily, 30 minutes after meals) 1

When to Refer to a Specialist

• Persistent constipation despite appropriate interventions 2, 7
• Presence of alarm symptoms (blood in stool, abdominal distension, severe pain, vomiting, signs of obstruction) 2
• Suspected defecatory disorders 4, 7
• Treatment-refractory symptoms 4, 7

Treatment Algorithm

1. Initial approach: Non-pharmacological measures (fluid, fiber, activity, toileting habits)
2. If unsuccessful: Add osmotic laxatives (PEG preferred) or stimulant laxatives
3. For fecal impaction: Rectal therapies (suppositories/enemas) followed by maintenance regimen
4. For OIC: Prophylactic laxatives + consider PAMORAs if refractory
5. For refractory cases: Consider specialized testing (anorectal manometry) and referral to gastroenterologist