What are the types of stool softeners for treating constipation?

Types of Stool Softeners for Treating Constipation

Stool softeners are just one category of laxatives, with osmotic and stimulant laxatives being more effective and generally preferred for constipation management over traditional stool softeners like docusate sodium. 1

Main Categories of Laxatives for Constipation

Recommended First-Line Options

• Osmotic Laxatives - Strongly endorsed in systematic reviews of chronic constipation 2, 1

  • Polyethylene glycol (PEG/Macrogol): Virtually no net gain or loss of electrolytes; shown to be safe and effective for both short-term and long-term use (up to 12 months) 2, 3, 4
  • Lactulose: Not absorbed by small bowel; has latency of 2-3 days before effect; may cause nausea and abdominal discomfort 2
  • Magnesium and sulfate salts: Commonly used with mainly osmotic action; use cautiously in renal impairment 2

• Stimulant Laxatives - Recommended for quick relief and opioid-induced constipation 2, 1

  • Anthranoid plant compounds (senna, aloe, cascara): Hydrolyzed by colonic bacteria; have both motor and secretory effects; best taken in evening for morning results 2
  • Polyphenolic compounds (bisacodyl, sodium picosulfate): Work similarly to anthranoids; recommended for short-term use in refractory constipation 2

Laxatives Generally Not Recommended

• Bulk Laxatives: Useful for patients who cannot take adequate dietary fiber but require fluid volume; impact wanes over time; not recommended for opioid-induced constipation 2

• Detergent/Stool Softeners (e.g., docusate sodium): Stimulate fluid secretion in intestines but have inadequate experimental evidence supporting their use 2, 1

  • The National Comprehensive Cancer Network (NCCN) explicitly states that docusate has not shown benefit and is not recommended for constipation management 1
  • The European Society for Medical Oncology (ESMO) specifically lists docusate under "Laxatives generally not recommended in advanced disease" 1

• Liquid Paraffin: A mineral oil that softens and lubricates stools but may cause lipoid pneumonia if aspirated, anal seepage, and skin excoriation; less effective than PEG 2

Rectal Options for Constipation

• Suppositories: Containing glycerine, bisacodyl, oxyphenisatin, or CO2-releasing compounds; act as stool softeners and stimulants for rectal motility 2

  • Preferred first-line therapy when digital rectal exam identifies a full rectum or fecal impaction 2

• Enemas: Used if oral treatment fails after several days; increase water content and stimulate peristalsis 2

  • Small-volume self-administered enemas are often adequate 2
  • Larger-volume enemas should be administered by experienced healthcare professionals 2

Evidence-Based Recommendations

• For general constipation management, polyethylene glycol (PEG) has shown efficacy in multiple controlled trials, with 52% of patients achieving treatment success versus 11% with placebo over a 6-month period 4

• PEG laxative has demonstrated safety and efficacy for treating constipation in patients taking constipating medications, with 78.3% treatment success versus 39.1% with placebo 5

• For quick relief of constipation, a 68g dose of PEG has been shown to provide safe and effective relief within 24 hours 6

Common Pitfalls in Constipation Management

• Relying solely on stool softeners like docusate without addressing the need for increased bowel motility or water content is insufficient for effective constipation management 1

• Failing to provide prophylactic laxatives when initiating opioid therapy can lead to significant patient discomfort 1

• Using bulk laxatives without ensuring adequate fluid intake can worsen constipation 2