ConstipationConstipation is difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation.

Many people incorrectly believe that daily defecation is necessary and complain of constipation if stools occur less frequently. Others are concerned with the appearance (size, shape, color) or consistency of stools. Sometimes the major complaint is dissatisfaction with the act of defecation or the sense of incomplete evacuation after defecation. Constipation is blamed for many complaints (abdominal pain, nausea, fatigue, anorexia) that are actually symptoms of an underlying problem (eg, irritable bowel syndrome [IBS], depression). Patients should not expect all symptoms to be relieved by a daily bowel movement, and measures to aid bowel habits should be used judiciously.

Obsessive-compulsive patients often feel the need to rid the body daily of “unclean” wastes. Such patients often spend excessive time on the toilet or become chronic users of cathartics.

EtiologyAcute constipation suggests an organic cause, whereas chronic constipation may be organic or functional (Causes of Constipation).

In many patients, constipation is associated with sluggish movement of stool through the colon. This delay may be due to drugs, organic conditions, or a disorder of defecatory function (ie, pelvic floor dysfunction), or a disorder that results from diet (see Table: Foods Often Affecting GI Function). Patients with disordered defecation do not generate adequate rectal propulsive forces, do not relax the puborectalis and the external anal sphincter during defecation, or both. In IBS, patients have symptoms (eg, abdominal discomfort and altered bowel habits) but generally normal colonic transit and anorectal functions. However, IBS-disordered defecation may coexist.

Excessive straining, perhaps secondary to pelvic floor dysfunction, may contribute to anorectal pathology (eg, hemorrhoids, anal fissures, and rectal prolapse) and possibly even to syncope. Fecal impaction, which may cause or develop from constipation, is also common among elderly patients, particularly with prolonged bed rest or decreased physical activity. It is also common after barium has been given by mouth or enema.

Causes of Constipation

Causes Examples

Acute constipation*

Bowel obstruction Volvulus, hernia, adhesions, fecal impaction

Adynamic ileus Peritonitis, major acute illness (eg, sepsis), head or spinal trauma, bed rest

Drugs

Anticholinergics (eg, antihistamines, antipsychotics, antiparkinsonian drugs, antispasmodics), cations

(iron, aluminum, Ca, barium, bismuth), opioids, Ca channel blockers, general anesthetics

Constipation shortly after start of therapy with the drug

Chronic constipation*

Colonic tumor Adenocarcinoma of sigmoid colon

Metabolic disorders Diabetes mellitus, hypothyroidism, hypocalcemia or hypercalcemia, pregnancy, uremia, porphyria

CNS disorders Parkinson disease, multiple sclerosis, stroke, spinal cord lesions

Peripheral nervous

system disorders

Hirschsprung disease, neurofibromatosis, autonomic neuropathy

Systemic disorders Systemic sclerosis, amyloidosis, dermatomyositis, myotonic dystrophy

Functional disorders Slow-transit constipation, irritable bowel syndrome, pelvic floor dysfunction (functional defecatory

disorders)

Causes Examples

Dietary factors Low-fiber diet, sugar-restricted diet, chronic laxative abuse

*There is some overlap between acute and chronic causes of constipation. In particular, drugs are common causes of chronic

constipation.

Foods Often Affecting GI Function

Foods Likely to Cause Loose Bowel Movements and/or Excessive Gas

All caffeine-containing beverages especially coffee with chicory

Peaches, pears, cherries, apples

Fruit juices: Orange, cranberry, apple

Asparagus and cruciferous vegetables such as broccoli, cauliflower, cabbage, and Brussels sprouts

Bran cereal, whole wheat bread, high-fiber foods

Pastry, candy, chocolate, waffle syrup, doughnuts

Wine (> 3 glasses in susceptible people)

Milk and milk products (in lactose-sensitive people)

Foods Likely to Cause Constipation or Help Control Loose Bowel Movements

Rice, bread, potatoes, pasta

Meat, veal, poultry, fish

Cooked vegetables

Bananas

Evaluation.History

History of present illness should ascertain a lifetime history of the patient’s stool frequency, consistency, need to strain or use perineal maneuvers (eg, pushing on the perineum, gluteal region, or recto-vaginal wall) during defecation, and satisfaction after defecation should be obtained, including frequency and duration of laxative or enema use. Some patients deny previous constipation but, when questioned specifically, admit to spending 15 to 20 min per bowel movement. The presence, amount, and duration of blood in the stool should also be elicited.

Review of systems should seek symptoms of causative disorders, including a change in caliber of the stool or blood in the stool (suggesting cancer). Systemic symptoms suggesting chronic diseases (eg, weight loss) should also be sought.

Past medical history should ask about known causes, including previous abdominal surgery and symptoms of metabolic (eg, hypothyroidism, diabetes mellitus) and neurologic (eg, Parkinson disease, multiple sclerosis, spinal cord injury) disorders. Prescription and nonprescription drug use should be assessed, with specific questioning about anticholinergic and opioid drugs.

Physical examination

A general examination is done to look for signs of systemic disease, including fever and cachexia. Abdominal masses should be sought by palpation. A rectal examination should be done not only for fissures, strictures, blood, or masses (including fecal impaction) but also to evaluate anal resting tone (the puborectalis “lift” when patients squeeze the anal sphincter), perineal descent during simulated evacuation, and rectal sensation. Patients with defecatory disorders may have increased anal resting tone (or anismus), reduced (ie, < 2 cm) or increased (ie, > 4 cm) perineal descent, and/or paradoxical contraction of the puborectalis during simulated evacuation.

Red flags

Certain findings raise suspicion of a more serious etiology of chronic constipation:

Distended, tympanitic abdomen Vomiting

Blood in stool

Weight loss

Severe constipation of recent onset/worsening in elderly patients

Interpretation of findings

Certain symptoms (eg, a sense of anorectal blockage, prolonged or difficult defecation), particularly when associated with abnormal (ie, increased or reduced) perineal motion during simulated evacuation, suggest a defecatory disorder. A tense, distended, tympanitic abdomen, particularly when there is nausea and vomiting, suggests mechanical obstruction.

Patients with IBS typically have abdominal pain with disordered bowel habits (see Irritable Bowel Syndrome (IBS)). Chronic constipation with modest abdominal discomfort in a patient who has used laxatives for a long time suggests slow-transit constipation. Acute constipation coincident with the start of a constipating drug in patients without red flag findings suggests the drug is the cause. New-onset constipation that persists for weeks or occurs intermittently with increasing frequency or severity, in the absence of a known cause, suggests colonic tumor or other causes of partial obstruction. Excessive straining or prolonged or unsatisfactory defecation, with or without anal digitation, suggests a defecatory disorder. Patients with fecal impaction may have cramps and may pass watery mucus or fecal material around the impacted mass, mimicking diarrhea (paradoxic diarrhea).

Testing

Testing is guided by clinical presentation and the patient's diet history.

Constipation with a clear etiology (drugs, trauma, bed rest) may be treated symptomatically without further study. Patients with symptoms of bowel obstruction require flat and upright abdominal x-rays, possibly a water-soluble contrast enema to evaluate for colonic obstruction, and possibly a CT scan or barium x-ray of the small intestine (see also Intestinal Obstruction : Diagnosis). Most patients without a clear etiology should have sigmoidoscopy or colonoscopy and a laboratory evaluation (CBC, thyroid-stimulating hormone, fasting glucose, electrolytes, and Ca).

Further tests are usually reserved for patients with abnormal findings on the previously mentioned tests or who do not respond to symptomatic treatment. If the primary complaint is infrequent defecation, colonic transit times should be measured with radiopaque markers (Sitz markers) or scintigraphy. If the primary complaint is difficulty with defecation, anorectal manometry and rectal balloon expulsion should be assessed. In patients with chronic constipation, it is important to distinguish between slow-transit constipation (abnormal Sitz marker radiopaque study) and pelvic floor muscle dysfunction (markers retained only in distal colon).

Treatment Possibly discontinuation of causative drugs (some may be

necessary) Increase in dietary fiber

Possibly trial with a brief course of osmotic laxatives

Any identified conditions should be treated.

Agents used to treat constipation are summarized in Agents Used to Treat Constipation. Laxatives should be used judiciously. Some (eg, phosphate, bran, cellulose) bind drugs and interfere with absorption.

Rapid fecal transit may rush some drugs and nutrients beyond their optimal absorptive locus. Contraindications to laxative and cathartic use include acute abdominal pain of unknown origin, inflammatory bowel disorders, intestinal obstruction, GI bleeding, and fecal impaction.

Diet and behavior

The diet should contain enough fiber (typically 15 to 20 g/day) to ensure adequate stool bulk. Vegetable fiber, which is largely indigestible and unabsorbable, increases stool bulk. Certain components of fiber also absorb fluid, making stools softer and facilitating their passage. Fruits and vegetables are recommended sources, as are cereals containing bran. Fiber supplementation is particularly effective in treating normal-transit constipation but is not very effective for slow-transit constipation or defecatory disorders.

Behavioral changes may help. Patients should try to move their bowels at the same time daily, preferably 15 to 45 min after breakfast, because food ingestion stimulates colonic motility. Initial efforts at regular, unhurried bowel movements may be aided by glycerin suppositories.

Explanation is important, but it is difficult to convince obsessive-compulsive patients that their attitude toward defecation is abnormal. Physicians must explain that daily bowel movements are not essential, that the bowel must be given a chance to function, and that frequent use of laxatives or enemas (>once/3 days) denies the bowel that chance.

Agents Used to Treat Constipation

Agent Dosage Some Adverse Effects

Fiber*

Bran Up to 1 cup/day Bloating, flatulence, iron and Ca malabsorption

Psyllium Up to 10–15 g/day in divided doses of Bloating, flatulence

Agent Dosage Some Adverse Effects

2.5–7.5 g

Methylcellulose Up to 6–9 g/day in divided doses of

0.45–3 g

Less bloating than with other fiber agents

Ca polycarbophil 2–6 tablets/day Bloating, flatulence

Emollients

Docusate Na 100 mg bid or tid Ineffective for severe constipation

Glycerin 2–3 g suppository once/day Rectal irritation

Mineral oil 15–45 mL po once/day Lipid pneumonia, malabsorption of fat-soluble vitamins, dehydration, fecal

incontinence

Osmotic agents

Sorbitol

15–30 mL po of 70% solution once/day

or bid

120 mL rectally of 25–30% solution

Transient abdominal cramps, flatulence

Lactulose 10–20 g (15–30 mL) once/day up to qid Same as for sorbitol

Polyethylene glycol 17 g daily Fecal incontinence (related to dosage)

Mg

MgCl2 or Mg sulfate tablets 1–3 g qid

Milk of Mg 30–60 mL/day

Mg citrate 150–300 mL/day (up to 360

mL)

Mg toxicity, dehydration, abdominal cramps, fecal incontinence, diarrhea

Na phosphate 10 g po once as bowel preparation Rare cases of acute renal failure

Stimulants

Agent Dosage Some Adverse Effects

Anthraquinones Depends on brand used Abdominal cramps, dehydration, melanosis coli, malabsorption, possible

deleterious effects on intramural nerves

Bisacodyl

10-mg suppositories up to 3 times/wk

5–15 mg/day po

Fecal incontinence, hypokalemia, abdominal cramps, rectal burning with

daily use of suppository form

Linaclotide 145–290 mcg po once/day at least 30

min before first meal

Abdominal pain, flatulence Contraindicated in children < 6 yr; avoided in

children < 17 yr

Lubiprostone † 24 mcg po bid with food Nausea, particularly on empty stomach

Enemas

Mineral oil/olive oil

retention

100–250 mL/day rectally Fecal incontinence, mechanical trauma

Tap water 500 mL rectally Mechanical trauma

Phosphate 60 mL rectally Accumulated damage to rectal mucosa, hyperphosphatemia, mechanical

trauma

Soapsuds 1500 mL rectally Accumulated damage to rectal mucosa, mechanical trauma

*The dose of fiber supplements should be gradually increased over several weeks to the recommended dose.

† Lubiprostone is available by prescription only and is approved for long-term use.

Adapted from Romero Y, Evans JM, Fleming KC, Phillips SF: Constipation and fecal incontinence in the elderly population. Mayo Clinic

Proceedings 71:81–92, 1996; by permission.

Types of laxatives

Bulking agents (eg, psyllium, Ca polycarbophil, methylcellulose) act slowly and gently and are the safest agents for promoting elimination.

Proper use involves gradually increasing the dose—ideally taken tid or qid with sufficient liquid (eg, 500 mL/day of extra fluid) to prevent impaction—until a softer, bulkier stool results. Bloating may be reduced by gradually titrating the dose of dietary fiber to the recommended dose, or by switching to a synthetic fiber preparation such as methylcellulose.

Osmotic agents contain poorly absorbed polyvalent ions (eg, Mg, phosphate, sulfate), polymers (eg, polyethylene glycol), or carbohydrates (eg, lactulose, sorbitol) that remain in the bowel, increasing intraluminal osmotic pressure and thereby drawing water into the intestine. The increased volume stimulates peristalsis. These agents usually work within 3 h.

In general, osmotic laxatives are reasonably safe even when used regularly. However, Na phosphate should not be used for bowel cleansing because it may rarely cause acute renal failure even after a single use for bowel preparation. These events occurred primarily in elderly patients, those with preexisting renal disease, and those who were taking drugs that affect renal perfusion or function (eg, diuretics, ACE inhibitors, angiotensin II receptor blockers). Also, Mg and phosphate are partially absorbed and may be detrimental in some conditions (eg, renal insufficiency). Na (in some preparations) may exacerbate heart failure. In large or frequent doses, these drugs may upset fluid and electrolyte balance. Another approach to cleansing the bowel for diagnostic tests or surgery or sometimes for chronic constipation uses large volumes of a balanced osmotic agent (eg, polyethylene glycol–electrolyte solution) given orally or via NGT.

Secretory or stimulant cathartics (eg, phenolphthalein, bisacodyl, anthraquinones, castor oil, anthraquinones) act by irritating the intestinal mucosa or by directly stimulating the submucosal and myenteric plexus. Although phenolphthalein was withdrawn from the US market after animal studies suggested the compound was carcinogenic, there is no epidemiologic evidence of this in humans. Bisacodylis an effective rescue drug for chronic constipation. The anthraquinones senna, cascara sagrada, aloe, and rhubarb are common constituents of herbal and OTC laxatives. They pass unchanged to the colon where bacterial metabolism converts

them to active forms. Adverse effects include allergic reactions, electrolyte depletion, melanosis coli, and cathartic colon. Melanosis coli is a brownish black colorectal pigmentation of unknown composition. Cathartic colon refers to alterations in colonic anatomy observed on barium enema in patients with chronic stimulant laxative use. It is unclear whether cathartic colon, which has been attributed to destruction of myenteric plexus neurons by anthraquinones, is caused by currently available agents or other neurotoxic agents (eg, podophyllin), which are no longer available. There does not seem to be an increased risk of colon cancer with long-term anthraquinone use.

Enemas can be used, including tap water and commercially prepared hypertonic solutions.

Emollient agents (eg, docusate, mineral oil) act slowly to soften stools, making them easier to pass. However, they are not potent stimulators of defecation. Docusate is a surfactant, which allows water to enter the fecal mass to soften and increase its bulk.

Fecal impaction

Fecal impaction is treated initially with enemas of tap water followed by small enemas (100 mL) of commercially prepared hypertonic solutions. If these do not work, manual fragmentation and disimpaction of the mass is necessary. This procedure is painful, so perirectal and intrarectal application of local anesthetics (eg, lidocaine 5% ointment or dibucaine 1% ointment) is recommended. Some patients require sedation.

Geriatrics EssentialsConstipation is common among elderly people because of low-fiber diets, lack of exercise, coexisting medical conditions, and use of constipating drugs. Many elderly people have misconceptions about normal bowel habits and use laxatives regularly. Other changes that predispose the elderly to constipation include increased rectal compliance and impaired rectal sensation (such that larger rectal volumes are needed to elicit the desire to defecate).

Key Points Drug causes are common (eg, chronic laxative abuse, use of anticholinergic or

opioid drugs). Be wary of bowel obstruction when constipation is acute and severe.

Symptomatic treatment is reasonable in the absence of red flag findings and after excluding pelvic floor dysfunction.

DYSCHEZIA(Disordered Evacuation; Dysfunction of Pelvic Floor or Anal Sphincters; Functional Defecatory Disorders; Dyssynergia)

Dyschezia is difficulty defecating. Patients sense the presence of stool and the need to defecate but are unable. It results from a lack of coordination of pelvic floor muscles and anal sphincters. Diagnosis requires anorectal testing. Treatment is difficult, but biofeedback may be of benefit.

EtiologyNormally, when a person tries to defecate, rectal pressure rises in coordination with relaxation of the external anal sphincter. This process may be affected by one or more dysfunctions (eg, impaired rectal contraction, excessive contraction of the abdominal wall, paradoxic anal contraction, failure of anal relaxation) of unclear etiology. Functional defecatory disorders may manifest at any age. In contrast, Hirschsprung disease, which is due to an absent recto-anal inhibitory reflex, is almost always diagnosed in infancy or childhood.

Symptoms and SignsThe patient may or may not sense that stool is present in the rectum. Despite prolonged straining, evacuation is tedious or impossible, frequently even for soft stool or enemas. Patients may complain of anal blockage and may digitally remove stool from their rectum or manually support their perineum or splint the vagina to evacuate. Actual stool frequency may or may not be decreased.

DiagnosisRectal and pelvic examinations may reveal hypertonia of the pelvic floor muscles and anal sphincters. With bearing down, patients may not demonstrate the expected anal relaxation and perineal descent. With excessive straining, the anterior rectal wall prolapses into the vagina in patients with impaired anal relaxation; thus rectoceles are usually a secondary rather than a primary disturbance. Long-standing dyschezia with chronic straining may cause a solitary rectal ulcer or varying degrees of rectal prolapse or excessive perineal descent or an enterocoele. Anorectal manometry and rectal balloon expulsion, occasionally supplemented by defecatory or magnetic resonance proctography, are necessary to diagnose the condition.

TreatmentBecause treatment with laxatives is unsatisfactory, it is important to assess anorectal functions in patients with refractory constipation. Biofeedback therapy can improve coordination between abdominal contraction and pelvic floor relaxation during defecation, thereby alleviating symptoms. However, pelvic floor retraining for defecatory disorders is highly specialized and available at select centers only. A collaborative approach (physiotherapists, dietitians, behavior therapists, gastroenterologists) is necessary.