What are the next steps in managing a 20‑year‑old woman with polycystic ovary syndrome who has had no bowel movement for more than four days despite lactulose and daily enemas?

Management of Severe Refractory Constipation in a Young Woman with PCOS

The next step is to perform a digital rectal examination to rule out fecal impaction, obtain an abdominal X-ray to exclude bowel obstruction, and if impaction is confirmed, proceed with manual disimpaction following premedication with an analgesic ± anxiolytic, followed by glycerin suppository ± mineral oil retention enema. 1

Immediate Diagnostic Assessment

Before escalating therapy, critical exclusions must be made:

• Rule out fecal impaction through digital rectal examination, especially since diarrhea can paradoxically accompany constipation due to overflow around impaction 1
• Rule out mechanical bowel obstruction via physical examination and abdominal radiograph 1
• Assess for metabolic causes including hypercalcemia, hypokalemia, hypothyroidism, and diabetes mellitus—all relevant given her PCOS diagnosis 1
• Review all medications for constipating agents that should be discontinued 1

Management of Confirmed Impaction

If impaction is present (which is likely given >4 days without bowel movement despite enemas):

• Perform manual disimpaction following premedication with an analgesic ± anxiolytic to minimize discomfort 1
• Administer glycerin suppository ± mineral oil retention enema 1
• Consider tap water enema until clear if initial measures fail 1

Escalation of Laxative Therapy

Since lactulose has failed, add alternative osmotic and stimulant laxatives:

• Bisacodyl 10-15 mg daily up to three times daily orally, or 1 suppository rectally daily to twice daily, with goal of 1 non-forced bowel movement every 1-2 days 1
• Polyethylene glycol (PEG) 17 g (1 capful) in 8 oz water twice daily 1
• Magnesium hydroxide 30-60 mL daily to twice daily 1
• Magnesium citrate 8 oz daily for more aggressive bowel cleansing 1
• Sorbitol 30 mL every 2 hours × 3 doses, then as needed 1

Prokinetic Agent Consideration

• Metoclopramide 10-20 mg orally four times daily can be added to stimulate gastrointestinal motility 1, 2

Critical Pitfalls to Avoid

• Do not use docusate (stool softener) as it has been shown ineffective in randomized trials and provides no benefit over stimulant laxatives alone 1
• Avoid supplemental medicinal fiber (such as psyllium) as it is ineffective and may worsen constipation 1
• Do not use sodium phosphate enemas or oral laxatives more than once daily in patients at risk for renal dysfunction or electrolyte abnormalities 1
• Avoid rectal suppositories or enemas if the patient develops neutropenia or thrombocytopenia 1
• Do not prematurely reintroduce oral intake before return of bowel function 2

Ongoing Management Strategy

Once the acute episode resolves:

• Maintain prophylactic bowel regimen with stimulant laxative (sennosides) or polyethylene glycol 17 g twice daily with adequate fluid intake 1
• Ensure adequate hydration and dietary fiber intake (though not supplemental fiber) 1
• Monitor for one non-forced bowel movement every 1-2 days as the therapeutic goal 1
• Address PCOS-related metabolic factors including insulin resistance with metformin if indicated, as metabolic dysfunction can contribute to gastrointestinal dysmotility 3, 4

When to Consider Advanced Interventions

If constipation persists despite the above measures:

• Reassess for obstruction and severity of constipation 1
• Consider opioid antagonists (methylnaltrexone 0.15 mg/kg subcutaneously every other day) only if opioid-induced constipation is confirmed, though this is unlikely in your patient 1
• Consider second-line agents such as lubiprostone or linaclotide, though these are not indicated for mechanical obstruction 1