Management of chronic constipation in adults
- Arnold Wald, MD
Arnold Wald, MD
- Professor of Medicine
- University of Wisconsin School of Medicine and Public Health, Madison
Constipation is a common complaint that may be due to a variety of causes. Appropriate management requires an evaluation for secondary etiologies, such as systemic disorders and drugs (table 1A-B). Once secondary causes have been eliminated, idiopathic constipation may be associated with normal or slow colonic transit, defecatory dysfunction (pelvic floor dysfunction), or both.
This topic review will discuss the management of idiopathic chronic constipation. The etiology and evaluation of chronic constipation, as well as the management of constipation related to chronic opiates, are discussed elsewhere. (See "Etiology and evaluation of chronic constipation in adults" and "Cancer pain management with opioids: Prevention and management of side effects".)
The approach to a patient with chronic constipation will depend on whether studies indicate normal or slowed colonic transit and whether there is a defecatory dysfunction (algorithm 1). The specific choice of agents and order of their introduction varies with the etiology of the condition.
- Management of normal and slow transit chronic constipation includes patient education, behavior modification, dietary changes, and laxative therapy. Severe, intractable, slow transit constipation is rare and may be treated with surgery, but with extreme caution; patients should be referred to specialized centers for a full evaluation prior to surgery. Treatment for normal or slow transit constipation is shown in an algorithm (algorithm 2).
- Management of defecatory dysfunction involves suppositories, biofeedback, botulinum toxin injections into the puborectalis muscle, or relaxation exercises (algorithm 3).
Patients with both slow transit and defecatory dysfunction should be reevaluated after treatment of the defecatory dysfunction.
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- GENERAL APPROACH
- INITIAL MANAGEMENT
- Patient education
- Dietary changes and bulk forming laxatives
- - Fiber
- - Bulk forming laxatives
- Other laxatives
- - Surfactants
- - Osmotic agents
- - Stimulant laxatives
- MANAGEMENT OF SEVERE CONSTIPATION
- Behavioral approaches
- - Biofeedback
- Pharmacologic therapy
- - Linaclotide
- - Lubiprostone
- - Misoprostol
- - Colchicine
- - Prucalopride
- Botulinum toxin
- Other surgical approaches
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS