What is the treatment for constipation?

Treatment of Constipation

The first-line treatment for constipation should include osmotic laxatives such as polyethylene glycol (PEG), combined with lifestyle modifications including increased fluid intake, physical activity, and dietary fiber. 1, 2

Initial Assessment

• Comprehensive evaluation should include questions about possible causes, physical examination with abdominal assessment, perineal inspection, and digital rectal examination 1
• Rule out secondary causes such as medications, metabolic disorders (hypothyroidism, hypercalcemia), or mechanical obstruction 2, 1
• Laboratory tests are generally not necessary but may include complete blood count, thyroid function, and calcium levels if clinically indicated 2, 1
• Plain abdominal X-ray may be useful to evaluate fecal loading and exclude obstruction in severe cases 1, 2

Non-Pharmacological Management

• Ensure privacy and comfort for defecation 2, 1
• Adopt proper positioning (using a small footstool can help apply pressure more effectively) 1
• Increase fluid intake to maintain adequate hydration 1, 3
• Increase physical activity within patient's capabilities, even minimal movement from bed to chair can help 1
• Increase dietary fiber intake if fluid intake and physical activity are adequate 2, 4
• Consider abdominal massage to improve bowel efficiency, particularly in patients with neurological issues 1

Pharmacological Management

First-Line Treatment

• Osmotic laxatives: polyethylene glycol (PEG) is preferred due to efficacy and safety profile 2, 1
• Stimulant laxatives (senna, bisacodyl) can be used alone or in combination with stool softeners 2, 1

Second-Line Treatment

• Secretagogues such as linaclotide for chronic idiopathic constipation when first-line treatments fail 5, 2
• Lactulose or magnesium salts as alternative osmotic agents 1, 6

For Opioid-Induced Constipation

• Prophylactic laxative therapy should be initiated concurrently with opioid therapy 2, 1
• Combination of stool softener and stimulant laxative (e.g., docusate and senna) 2
• For refractory cases, methylnaltrexone 0.15 mg/kg subcutaneously every other day (maximum once daily) 2, 1

Special Situations

Fecal Impaction

• Digital fragmentation and extraction of stool, followed by enemas 2, 1
• Implementation of maintenance bowel regimen to prevent recurrence 2
• PEG solution for proximal impaction in the absence of complete obstruction 2

Elderly Patients

• Pay particular attention to medication review and discontinue unnecessary constipating medications 1
• Ensure access to toilets and privacy 1
• PEG (17g/day) is particularly safe and effective in this population 1
• Avoid liquid paraffin in bedridden patients due to risk of aspiration and lipoid pneumonia 1

Treatment Algorithm

1. Initial approach: Lifestyle modifications + osmotic laxative (PEG) 2, 1
2. If inadequate response: Add or switch to stimulant laxative (senna, bisacodyl) 2, 1
3. For persistent constipation: Consider adding another agent (magnesium hydroxide, lactulose) or combining different classes 2, 6
4. For refractory cases: Consider secretagogues like linaclotide 5
5. For opioid-induced constipation: Use prophylactic stimulant laxatives; consider methylnaltrexone for refractory cases 2, 1

Common Pitfalls to Avoid

• Relying solely on increased fiber without adequate fluid intake can worsen constipation 4, 7
• Failing to discontinue medications that contribute to constipation 2, 1
• Overlooking defecatory disorders that may require biofeedback therapy rather than laxatives 2, 8
• Using liquid paraffin in patients with swallowing disorders or who are bedridden 1
• Expecting complete symptom resolution with medications alone; a multimodal approach is often necessary 2

Remember that constipation treatment should be tailored based on the underlying cause, with the goal of achieving regular, non-forced bowel movements every 1-2 days 2.