What are the treatment options for constipation?

Treatment Options for Constipation

The management of constipation requires a systematic approach beginning with lifestyle modifications and osmotic or stimulant laxatives as first-line treatments, followed by prescription medications for refractory cases. 1

Assessment and Diagnosis

• All patients should be evaluated for constipation with questions to determine possible causes 2
• Physical examination should include abdominal examination, perineal inspection, and digital rectal examination (DRE) 2
• Investigations are not routinely necessary unless there are severe symptoms, sudden changes in bowel movements, blood in stool, or in older adults 2

First-Line Treatment: Prevention and Self-Care

Lifestyle Modifications

• Ensure privacy and comfort during defecation 2, 1
• Optimize positioning (use a small footstool to assist with gravity) 2, 1
• Increase fluid intake to adequate levels 2, 1
• Increase physical activity within patient limits 2
• Attempt defecation twice daily, 30 minutes after meals 1

Dietary Modifications

• Increase dietary fiber (except in opioid-induced constipation) 1, 3
• Consider dietetic support, especially for elderly patients 2

Pharmacological Management

First-Line Medications

1. Osmotic Laxatives (preferred options) 2, 1:

   • Polyethylene glycol (PEG): 17-34g daily
   • Lactulose: 15-30ml twice daily
   • Magnesium salts (use cautiously in renal impairment)

2. Stimulant Laxatives 2, 1:

   • Senna
   • Bisacodyl: 10-15mg daily
   • Sodium picosulfate

For Fecal Impaction

• Suppositories and enemas are preferred first-line therapy when DRE identifies a full rectum or fecal impaction 2
• Digital fragmentation and extraction after premedication with analgesics/anxiolytics 1
• Follow with maintenance bowel regimen to prevent recurrence 1

For Opioid-Induced Constipation (OIC)

• All patients receiving opioid analgesics should be prescribed a concomitant laxative 2
• Osmotic or stimulant laxatives are generally preferred 2
• Do not use bulk laxatives such as psyllium for OIC 2, 1
• For refractory OIC, consider peripherally acting μ-opioid receptor antagonists (PAMORAs) 2, 1

Second-Line Treatment for Refractory Constipation

• Prescription medications like linaclotide for adults with irritable bowel syndrome with constipation (IBS-C) or chronic idiopathic constipation (CIC) 4
• Linaclotide has been shown to improve stool frequency, consistency, and reduce straining 4
• Other options include plecanatide or prucalopride 1

Special Considerations for Elderly Patients

• Pay particular attention to assessment of elderly patients 2
• Review medication list thoroughly as many medications can contribute to constipation 1
• Ensure access to toilets, especially in cases of decreased mobility 2
• Provide dietetic support 2

Contraindications and Cautions

• Avoid enemas in patients with neutropenia, thrombocytopenia, paralytic ileus, intestinal obstruction, recent colorectal or gynecological surgery, recent anal or rectal trauma, severe colitis, inflammation or infection, toxic megacolon, undiagnosed abdominal pain, or recent pelvic radiotherapy 2, 1
• Use magnesium salts cautiously in renal impairment 2, 1

Monitoring and Follow-up

• Monitor for red flags such as severe abdominal pain, no bowel movement for >3 days, vomiting, and signs of bowel obstruction 1
• Address underlying causes of constipation, such as medication side effects, metabolic disorders, or neurogenic bowel 1

By following this systematic approach to constipation management, most patients will experience significant improvement in their symptoms and quality of life.