What is the appropriate management for a patient who has not had a bowel movement for seven days without red‑flag symptoms?

Management of 7-Day Constipation Without Red Flags

For a patient with no bowel movement for 7 days without alarm symptoms, immediate manual disimpaction with premedication (analgesia ± anxiolytic) followed by an oil retention enema and oral polyethylene glycol is the recommended approach. 1

Immediate Assessment and Intervention

Digital Rectal Examination

• Perform a digital rectal examination first to identify if there is a hard, impacted fecal mass in the rectum 1
• Seven days without a bowel movement strongly suggests fecal impaction requiring mechanical intervention rather than simple laxatives 2

Manual Disimpaction Protocol

• Premedicate the patient with analgesics ± anxiolytics before the procedure to minimize distress and pain 1
• Perform digital fragmentation and manual extraction of the impacted stool mass if a hard fecal ball is identified 1
• This is the first-line intervention for confirmed fecal impaction 1

Enema Administration

Oil Retention Enema (Preferred)

• Administer an oil retention enema (mineral oil, olive oil, or cottonseed oil) immediately after manual disimpaction 1
• The enema should be retained for at least 30 minutes for maximum effect 1
• Alternatively, use osmotic micro-enemas or normal saline enemas 1

Important Contraindications

Do not use enemas if the patient has: 1

• Neutropenia or thrombocytopenia
• Paralytic ileus or intestinal obstruction
• Recent colorectal/gynecological surgery
• Recent anal or rectal trauma
• Severe colitis or abdominal inflammation
• Undiagnosed abdominal pain

Maintenance Therapy to Prevent Recurrence

First-Line Maintenance

• Start polyethylene glycol (PEG) 17 grams daily as the preferred maintenance agent 1
• PEG has superior efficacy and safety profile for preventing recurrence 1

Adjunctive Therapy if Needed

• Add bisacodyl 10-15 mg daily to three times daily if PEG alone is insufficient 1
• The goal is one non-forced bowel movement every 1-2 days 1
• Avoid bulk-forming laxatives (psyllium, methylcellulose) if the patient has low fluid intake or limited mobility, as these increase risk of mechanical obstruction 1

Red Flags to Exclude

Before proceeding with the above management, ensure the patient does NOT have: 3, 4

• Rectal bleeding
• Unintentional weight loss
• Severe or worsening abdominal pain
• Nausea, bloating, or cramping that worsens (may indicate serious condition requiring imaging)

Common Pitfall to Avoid

Do not start with oral laxatives alone in a patient with 7 days of no bowel movement—this duration strongly suggests impaction requiring mechanical disimpaction first 1, 2. Starting with oral agents alone risks worsening obstruction or causing overflow incontinence without addressing the impacted mass 2.

If Initial Management Fails

• If symptoms persist after 4-8 weeks of maintenance therapy, perform anorectal manometry to exclude defecatory disorders 5, 4
• Consider colonic transit studies if slow-transit constipation is suspected 4, 6
• Biofeedback therapy is the preferred treatment for dyssynergic defecation if identified 4, 6