What are the interventions for severe constipation?

From the Guidelines

Severe constipation can be managed with a combination of lifestyle modifications and pharmacological interventions.

Interventions for Severe Constipation

The following interventions can be used to manage severe constipation:

• Increase fluids and dietary fiber if the patient has adequate fluid intake and physical activity
• Exercise, if appropriate
• Administer prophylactic medications, such as stimulant laxatives (e.g., bisacodyl) or osmotic laxatives (e.g., polyethylene glycol) 1
• Discontinue any non-essential constipating medication
• Rule out impaction, obstruction, or other causes of constipation (e.g., hypercalcemia, hypokalemia, hypothyroidism, diabetes mellitus) 1
• Add and titrate laxatives, such as bisacodyl, as needed, with the goal of achieving one non-forced bowel movement every 1-2 days 1
• Consider using rectal suppositories or enemas, such as glycerine suppository or mineral oil retention enema, for severe constipation 1
• Consider using peripherally acting mu opioid receptor antagonists, such as methylnaltrexone, for opioid-induced constipation 1

Pharmacological Interventions

Pharmacological interventions for severe constipation include:

• Stimulant laxatives: bisacodyl, sennosides
• Osmotic laxatives: polyethylene glycol, lactulose, sorbitol
• Prokinetic agents: metoclopramide
• Peripherally acting mu opioid receptor antagonists: methylnaltrexone, naloxegol, naldemedine
• Other agents: lubiprostone, linaclotide 1

From the Research

Interventions for Severe Constipation

The following interventions are available for managing severe constipation:

• Non-drug interventions, such as:
  • High-fibre diet 2
  • Increasing fluids 2, 3
  • Exercise 2, 3
• Pharmacological interventions, including:
  • Osmotic laxatives 3
  • Stimulant laxatives 3
  • Prokinetics and secretagogues 3
  • Laxatives, such as arachis oil, bisacodyl, cascara, docusate, glycerine suppositories, glycerol, ispaghula husk, lactitol, lactulose, macrogols, magnesium salts, methylcellulose, paraffin, phosphate enemas, seed oils, senna, sodium citrate enemas, sterculia 2
• Physical interventions, such as:
  • Biofeedback therapy 2, 3
  • Rectally administered laxatives or transanal irrigation 3
  • Anorectal physiology tests and assessment of colorectal transit time 3
• Surgical interventions, including:
  • Resection of the dysfunctional colonic segment (rectosigmoid or whole colon) 4
  • Plication, pexy, and STARR techniques for evacuatory disorders secondary to obstructive anatomical features 4
  • Surgery to allow for antegrade enemas (via the appendix or using a button device) 4
  • Permanent stomas as an option of last resort 4

Conservative Interventions

Conservative interventions may result in a large improvement in faecal incontinence and may improve constipation symptoms 5. These interventions include:

• Assessment-based nursing
• Holistic nursing
• Probiotics
• Psyllium
• Faecal microbiota transplantation
• A stepwise protocol of increasingly invasive evacuation methods

Physical Therapies

Physical therapies may make little to no difference to self-reported faecal continence, but may result in a moderate improvement in constipation symptoms 5. These therapies include:

• Massage therapy
• Standing
• Osteopathic manipulative treatment
• Electrical stimulation
• Transanal irrigation
• Conventional physical therapy with visceral mobilisation