What is the best suppository option for treating constipation?

Best Suppository Options for Treating Constipation

For constipation treatment, bisacodyl suppositories (10 mg) are the preferred first-line suppository option when digital rectal examination identifies a full rectum or fecal impaction. 1

First-Line Suppository Options

• Bisacodyl suppositories (10 mg) provide gentle, predictable, and fast relief as a stimulant laxative, with effects typically occurring within 15-20 minutes after insertion 2
• Glycerine suppositories act as stool softeners and stimulate rectal motility, commonly used for short-term treatment with good effectiveness 1
• CO2-releasing suppositories distend the rectal ampulla to stimulate peristalsis, with studies showing 51.7% of patients experiencing evacuation within 30 minutes compared to 6.9% with placebo 3

When to Use Suppositories

• Suppositories are preferred first-line therapy specifically when digital rectal examination identifies a full rectum or fecal impaction 1, 4
• They work more quickly than oral laxatives by increasing water content and stimulating peristalsis to aid in expulsion 1
• For adults and children 12 years and older, one bisacodyl suppository (10 mg) can be used in a single daily dose; children 6-12 years should use half a suppository; not recommended for children under 6 years 2

Administration Technique

• Peel open plastic packaging and insert suppository well into rectum, pointed end first 2
• Patient should retain the suppository for about 15-20 minutes for optimal effect 2
• Ensure privacy and comfort during administration to minimize embarrassment and stress for the patient 5

Alternative Options When Suppositories Are Insufficient

• If constipation persists despite suppository use, consider small-volume self-administered enemas which are often adequate 1
• Larger volume clinician-administered enemas should only be used if oral treatment fails after several days and should be administered by an experienced health professional 1
• Soap suds enema can be prepared with 1 mL of mild liquid soap per 200 mL of solution (1:200 ratio) with a total volume of 1000 mL 4

Cautions and Contraindications

• Enemas carry risks of perforation of the intestinal wall, rectal mucosal damage, and bacteremia 1
• Patients on anticoagulation or with coagulation/platelet disorders are at risk of bleeding complications 1, 4
• Contraindications for enemas include: neutropenia, thrombocytopenia, paralytic ileus, intestinal obstruction, recent colorectal surgery, severe colitis, and undiagnosed abdominal pain 1

Comprehensive Approach to Constipation Management

• Best practice combines suppositories with strategies for prevention including ensuring privacy and comfort, proper positioning, increased fluid intake, and increased mobility within patient limits 1
• Oral laxatives that are generally preferred include osmotic laxatives (PEG, lactulose, magnesium salts) and stimulant laxatives (senna, bisacodyl, sodium picosulfate) 1
• For opioid-induced constipation that doesn't respond to standard therapy, consider peripherally acting μ-opioid receptor antagonists like methylnaltrexone (0.15 mg/kg every other day) 1

Evidence Quality Considerations

• There is limited high-quality evidence directly comparing different suppository options for constipation 1
• The CO2-releasing suppository study showed statistically significant improvement over placebo (p<0.05) but had a small sample size of 29 patients 3
• Most clinical recommendations for suppository use in constipation are based on expert consensus rather than large randomized controlled trials 1