Constipation

 

Constipation is a symptom-based disorder which describes defecation that is unsatisfactory because of infrequent stools, difficulty passing stools, or the sensation of incomplete emptying.  Stools are often dry, hard, or lumpy, and may be abnormally large or small.  Constipation is often defined as passage of stools less frequently than the person's normal pattern.  Chronic constipation usually describes symptoms which are present for at least 12 weeks in the preceding six months.  Faecal loading/impaction describes retention of faeces to the extent that spontaneous evacuation is unlikely.  Constipation is a common problem which may occur at any age, but is more common with increasing age.  The incidence of constipation is 2–3 times higher in women than in men, and is more common during pregnancy than in the general population, affecting about 40% of women

.

Diagnosis

Suspect a diagnosis of constipation if an adult presents with defecation which is unsatisfactory because of infrequent stools, difficulty passing stools, or a sensation of incomplete emptying

  • Typically, bowel movements occurring less than three times a week may be regarded as constipation
  • There may be daily bowel movements but associated symptoms such as excessive straining
  • Additional symptoms may include lower abdominal pain or discomfort, distension, or bloating
  • In reality, constipation is often defined as passage of stools less frequently than the person's normal pattern

.

Consider a diagnosis of constipation in the elderly if there are non-specific symptoms, such as:

  • Confusion or delirium, functional decline
  • Nausea or loss of appetite
  • Overflow diarrhoea
  • Urinary retention

.

Suspect a diagnosis of faecal loading or impaction if there is history of:

  • Hard, lumpy stools, which may be large and infrequent (for example passed every 7–10 days), or small and relatively frequent (for example passed every 2–3 days)
  • Having to use manual methods to extract faeces
  • Overflow faecal incontinence, or loose stool

.

Assessment

If a diagnosis of constipation is suspected, ask about:

  • Any red flag symptoms or signs that may suggest a serious underlying cause, such as colorectal cancer
  • What the person means by 'constipation' and their normal pattern of defecation
  • The duration of constipation, and the frequency and consistency of stools, such as hard/small (pebble-like) or large stools (for example, do they block the toilet); any nocturnal symptoms
    • Consider the use of the Bristol Stool Chart to provide an objective record of the person's stool form
  • Associated symptoms such as rectal discomfort, excessive straining, feeling of incomplete evacuation, or rectal bleeding; abdominal pain or distension
  • Associated fevernauseavomiting, loss of appetite and/or weight
  • Associated urinary symptoms, urinary incontinence or retention, dyspareunia
  • Any family history of colorectal cancer or inflammatory bowel disease
  • How symptoms affect the person and impact on quality of life and daily functioning
  • Any self-help measures or drug treatments tried, including over-the-counter medication, and symptom response

.

To assess for any risk factors, ask about:

  • The person's diet, including fibre and fluid intake; normal routine or lifestyle; level of activity and mobility
  • The person's toileting habits, for example feeling hurried or being disturbed when trying to defecate; withholding or ignoring the urge to defecate; access to the toilet at home or work, and level of privacy
  • Any associated psychological or mental health conditions, such as anxietydepression, cognitive impairment, or an eating disorder
  • Any drug treatment or clinical features of an underlying organic cause of secondary constipation, and manage appropriately

.

To assess for faecal loading and/or impaction, ask about:

  • A history of faecal incontinence, for example underwear regularly soiled, excessive wiping, or loose stools
  • Whether the person has needed to use manual measures to relieve constipation:
    • A finger having to be inserted into the vagina suggests a rectocele
    • A finger in the rectum to push away a flap suggests a rectal ulcer
    • Pressure behind the anus may assist defecation if the levator muscles are weak
    • Digital rectal evacuation of faeces confirms severe faecal loading and/or impaction

.

Examination

  1. Assess for signs of weight loss and general nutritional status
  2. Perform an abdominal examination to check for abdominal paindistensionmasses, or a palpable colon (suggesting retained faecal masses)
  3. Perform an internal rectal examination, checking for:
    1. Anal fissureshaemorrhoidsskin tagsrectal prolapserectocele, skin erythema or excoriation (may be a sign of faecal leakage)
    2. Resting anal sphincter tone; rectal mass lesions and retained faecal masses, which may also be felt on external peri-anal palpation
      1. NOTE: a faecal mass can be distinguished from a tumour or cyst, as firm pressure exerted by a finger will typically leave a palpable indentation in hard faeces
    3. Pelvic floor dysfunction (if appropriate) — while asking the person to 'bear down', there may be paradoxical contraction of the anal sphincter on straining
    4. Leakage of stool; rectal or anal pain

.

Investigations

No investigations are normally needed in an adult with functional constipation, where there is no suspected underlying cause

.

Self-care advice

Encourage the person or carer to manage their symptoms by giving advice on:

  1. Sources of information and support, such as the NHS Choices patient information leaflets on Constipation and Bowel incontinence
  2. Eating a healthy, balanced diet that is high in fibre and having regular meals
    1. The Association of UK Dietitians has a useful Food Fact Sheet on Fibre and as well as one on Fruit and vegetables - how to get five-a-day
    2. Public Health England's booklet The Eatwell Guide has patient information on eating a healthy, balanced diet
  3. Drinking an adequate fluid intake, especially if there is a risk of dehydration
    1. The Association of UK Dietitians has a useful Food Fact Sheet on Fluid
  4. Increasing activity and exercise levels, if needed
  5. A regular, unhurried toilet routine, giving time to ensure that defecation is complete, and ensuring that people with limited mobility have appropriate help to access the toilet and adequate privacy

.

Management of short-duration constipation

  1. Manage any underlying secondary cause of constipation, and advise the person to reduce or stop any drug treatment that may be causing or contributing to symptoms, if possible and appropriate
  2. Advise on lifestyle measures, such as increasing dietary fibre, fluid intake, and activity levels
  3. If these measures are ineffective, or symptoms do not respond adequately, offer treatment with oral laxatives using a stepped approach
  4. If the person has opioid-induced constipation, do not prescribe bulk-forming laxatives, but offer an osmotic laxative and a stimulant laxative
  5. Advise the person to gradually reduce and stop laxatives once the person is producing soft, formed stool without straining at least three times per week
  6. Arrange to review the person regularly, depending on clinical judgement

.

Management of chronic constipation

NOTE If the initial management of chronic constipation should be the same as that for the management of short-duration constipation

If the person has ongoing symptoms despite these measures:

  1. Consider the use of drug treatment with prucalopride or lubiprostone if at least two laxatives from different classes have been tried at the highest tolerated recommended doses for at least 6 months, and failed to relieve symptoms, where invasive treatment (such as suppositories, enemas, rectal irrigation and/or manual disimpaction) is being considered
  2. Gradually titrate the laxative dose(s) up or down aiming to produce soft, formed stool without straining at least three times per week
  3. Arrange to review the person regularly, depending on clinical judgement

.

Management of faecal loading and/or impaction

NOTE For the management of faecal loading and/or impaction, the aim is to achieve complete disimpaction with minimal discomfort. Adjust the dose, choice, and combination of laxatives used, depending on the person's response to treatment and their personal preference

Following an assessment including examination of the person:

  1. If there are hard stools, consider prescribing a high dose of an oral macrogol
  2. If there are soft stools, or ongoing hard stools after a few days of treatment with an oral macrogol, consider starting or adding an oral stimulant laxative
  3. If the response to oral laxatives is inadequate or too slow, consider prescribing a suppository such as bisacodyl for soft stools; or a mini enema such as docusate (softener and weak stimulant) or sodium citrate (osmotic)
  4. If the response to treatment is still inadequate, consider prescribing a sodium phosphate or arachis oil retention enema (placed high if the rectum is empty but the colon is full)
  5. Reinforce advice on lifestyle measures such as increasing dietary fibre, fluid intake, and activity levels, to help maintain regular bowel movements and prevent recurrent faecal loading
  6. Consider the need for regular laxative use to maintain regular bowel movements, or the use of intermittent laxatives for episodes of faecal loading
  7. Arrange to review the person every few days to assess the response to treatment, depending on clinical judgement

.

Management of constipation during pregnancy and breastfeeding

For the management of constipation during pregnancy:

  1. Advise on sources of information and support, such as the UK Teratology Information Service (UKTIS) patient information leaflet Treating constipation during pregnancy
  2. Advise on lifestyle measures, such as increasing dietary fibre, fluid intake, and activity levels, as appropriate
  3. If these measures are ineffective, or symptoms do not respond adequately, offer short-term treatment with oral laxatives. Adjust the dose, choice, and combination of laxatives used, depending on the woman's symptoms, the desired speed of symptom relief, the response to treatment, and their personal preference.
    1. Offer a bulk-forming laxative first-line, such as ispaghula
    2. If stools remain hard, add or switch to an osmotic laxative, such as lactulose
    3. If stools are soft but difficult to pass, or there is a sensation of incomplete emptying, consider a short course of a stimulant such as senna
  4. If the response to treatment is still inadequate, consider prescribing a glycerol suppository
  5. If there is uncertainty about the use or safety of laxatives during pregnancy, contact the UKTIS:
    1. To discuss with a teratology specialist, telephone 0344 892 0909
    2. For information on the safety of specific laxatives, see the website www.uktis.org

.

For the management of constipation during breastfeeding:

  1. Advise on sources of information and support, such as the Breastfeeding Network drug factsheet Constipation treatment in breastfeeding mothers
  2. Advise on lifestyle measures, such as increasing dietary fibre, fluid intake, and activity levels, as appropriate
  3. If these measures are ineffective, or symptoms do not respond adequately, offer short-term treatment with oral laxatives. Adjust the dose, choice, and combination of laxatives used, depending on the woman's symptoms, the desired speed of symptom relief, the response to treatment, and their personal preference.
    1. Offer a bulk-forming laxative first-line, such as ispaghula
    2. If stools remain hard or difficult to pass, add or switch to an osmotic laxative such as lactulose or a macrogol
    3. If stools are soft but difficult to pass or there is a sensation of inadequate emptying, consider a short course of a stimulant laxative such as bisacodyl or senna
  4. If the response to treatment is still inadequate, consider prescribing a glycerol suppository
  5. If there is uncertainty about the use or safety of laxatives during breastfeeding, contact the UK Drugs in Lactation Advisory Service (UKDILAS) provided by the UK Medicines Information Network:
    1. To discuss with a specialist pharmacist, telephone 0116 2586491 or 0121 4247298
    2. For information on the safety of specific laxatives, see the website at www.sps.nhs.uk

.

Follow up in primary care

Arrange regular follow-up of the person depending on clinical judgement

  1. If oral laxatives have been prescribed, advise that:
    1. Laxatives should not be stopped suddenly
    2. Laxative doses should be reduced gradually
    3. Relapses are common and should be treated early with increased doses of laxatives
    4. Laxatives may need to be continued long term for people with a medical condition or taking a medication (if it cannot be reduced or stopped) causing secondary constipation
  2. If symptoms are ongoing or refractory to laxative treatment, consider:
    1. Checking blood tests for full blood count, thyroid function tests, HbA1c, and serum electrolytes and calcium, to look for an underlying cause, and manage appropriately
  3. Seek specialist advice or arrange referral to a gastroenterologist or colorectal surgeon for specialist investigations and management, depending on clinical judgement, if:
    1. A serious underlying cause such as colorectal cancer is suspected
    2. An underlying secondary cause of constipation is suspected, which cannot be managed in primary care
    3. Symptoms persist or recur despite optimal management in primary care
  4. Arrange referral to the Kent Continence Service if there are symptoms of faecal incontinence which have been fully investigated and are ongoing
  5. Arrange referral to a dietitian if support with dietary changes and increasing fibre content is needed

.

Abdominal Pain Poster

.

Bristol Stool Chart

The Bristol Stool Chart can be used to assess stool patterns in people with suspected constipation

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

Have a question or query?

Get in touch