What are the treatment options for constipation?

Treatment Options for Constipation

The most effective approach to treating constipation involves a stepwise management strategy beginning with non-pharmacological measures, followed by osmotic or stimulant laxatives as first-line pharmacological therapy, with specialized agents for refractory cases. 1, 2

Initial Assessment

• Comprehensive evaluation should include questions about possible causes, physical examination (abdominal, perineal inspection, digital rectal examination) 1, 2
• Investigations are not routinely necessary but may include calcium levels and thyroid function if clinically indicated 1, 2
• Plain abdominal X-ray may help assess fecal loading and exclude bowel obstruction in severe cases 1, 2

Non-Pharmacological Interventions

• Ensure privacy and comfort for normal defecation 1, 2
• Optimize positioning (small footstool can help apply pressure more effectively) 1, 2
• Increase fluid intake to soften stool 1, 2
• Increase physical activity and mobility within patient limitations 1, 2
• Increase dietary fiber intake if fluid intake is adequate 1, 2, 3
• Consider abdominal massage to improve bowel efficiency, particularly helpful for patients with neurogenic problems 1, 2

Pharmacological Management

First-Line Treatments

• Osmotic laxatives (preferred first-line option):

  • Polyethylene glycol (PEG) - safe and effective, particularly in elderly patients 1, 2
  • Lactulose - effective but may cause bloating and flatulence 1, 2
  • Magnesium salts - use cautiously in renal impairment due to risk of hypermagnesemia 1, 2

• Stimulant laxatives:

  • Senna, bisacodyl, sodium picosulfate - effective for promoting bowel movements 1, 2
  • Typically used when osmotic laxatives are insufficient 1, 2

Second-Line Treatments

• For persistent constipation:

  • Combination therapy with osmotic and stimulant laxatives 1
  • Secretagogues like linaclotide - FDA-approved for chronic idiopathic constipation and IBS-C 4

• For opioid-induced constipation (OIC):

  • Preventive laxative therapy should be initiated with opioid treatment unless contraindicated 1, 2
  • Peripherally acting μ-opioid receptor antagonists (PAMORAs):
    • Methylnaltrexone (0.15 mg/kg subcutaneously every other day) for OIC unresponsive to standard laxatives 1
    • Naloxegol for chronic non-cancer pain patients with OIC 1
  • Avoid bulk laxatives like psyllium for OIC 1

Special Situations

Fecal Impaction

• Digital fragmentation and extraction of stool, followed by maintenance bowel regimen 1, 2
• Suppositories and enemas are preferred first-line therapy when digital rectal examination identifies a full rectum or fecal impaction 1, 2
• Glycerine suppositories may be administered for impaction 1

Elderly Patients

• Pay particular attention to assessment and access to toilets 1, 2
• PEG (17 g/day) is safe and effective in this population 2
• Avoid liquid paraffin in bedridden patients or those with swallowing disorders due to aspiration risk 2

Evidence-Based Fiber Supplementation

• Fiber supplementation is effective for chronic constipation, particularly:
  • Psyllium and pectin show significant benefits 5
  • Doses >10 g/day are more effective than lower doses 5
  • Treatment duration of at least 4 weeks is optimal 5
  • Water-insoluble fibers (cellulose, hemicellulose) are most effective for laxation 6
  • Be aware that increased fiber may cause flatulence 5

Important Considerations

• Discontinue non-essential constipating medications when possible 2
• Monitor patients with chronic renal/cardiac insufficiency when using laxatives, especially with concomitant diuretics or cardiac glycosides 2
• Complete symptom resolution may not be achievable; set realistic expectations 1
• For constipation that is refractory to available laxatives, evaluate for defecatory disorders and slow-transit constipation 7