Treatment Options for Constipation
The management of constipation requires a systematic approach beginning with lifestyle modifications and progressing to osmotic or stimulant laxatives as first-line pharmacological treatments, with more targeted therapies for refractory cases. 1
Initial 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, but calcium levels and thyroid function should be checked if clinically suspected 2
- Plain abdominal X-ray may be useful to assess fecal loading and exclude bowel obstruction in severe cases 2
Non-Pharmacological Management
Prevention and Self-Care Strategies
- Ensure privacy and comfort during bowel movements 2, 1
- Optimize positioning (using a small footstool to assist gravity) 2, 1
- Increase fluid intake to adequate levels 2, 1
- Increase physical activity within patient limits 2
- Establish regular toileting habits (attempt defecation twice daily, 30 minutes after meals) 2, 1
- Abdominal massage can be efficacious, particularly for patients with neurogenic problems 2
Dietary Modifications
- Increase dietary fiber (except in opioid-induced constipation) 1, 3
- Dietetic support is particularly important for elderly patients 2
Pharmacological Management
First-Line Treatments
- Senna
- Bisacodyl: 10-15mg daily (for short-term or rescue therapy) 1
- Sodium picosulfate
Special Situations
Opioid-Induced Constipation (OIC)
- All patients receiving opioid analgesics should be prescribed a concomitant laxative unless contraindicated 2
- Osmotic or stimulant laxatives are generally preferred 2
- Avoid bulk laxatives such as psyllium for OIC 2, 1
- For refractory OIC, consider peripherally acting μ-opioid receptor antagonists (PAMORAs) such as methylnaltrexone (0.15mg/kg subcutaneously every other day) 2, 1
Fecal Impaction
- For distal impaction: digital fragmentation and extraction after premedication with analgesics/anxiolytics 2, 1
- Follow with enemas or suppositories when DRE identifies a full rectum 2
- Implement a maintenance bowel regimen to prevent recurrence 2, 1
Elderly Patients
- Pay particular attention to assessment of elderly patients 2
- Ensure access to toilets, especially with decreased mobility 2
- PEG (17g/day) offers an efficacious and tolerable solution with good safety profile 2
- Avoid liquid paraffin for bed-bound patients and those with swallowing disorders 2
Refractory Constipation Management
- For persistent constipation, consider:
Important Cautions and Contraindications
- Enemas are contraindicated 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
- Stop laxative use and consult a doctor if rectal bleeding, worsening abdominal symptoms, or diarrhea occurs 4
- Avoid long-term use of laxatives (>1 week) without medical supervision 4
- Docusate is ineffective for constipation management in adults 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
- Weekly monitoring of bowel movement frequency and consistency is crucial 1
- Always address underlying causes of constipation (medication side effects, metabolic disorders, neurogenic bowel) 1, 5