Background

Constipation is the most common digestive complaint in the United States. It is a symptom
rather than a disease and, despite its frequency, often remains unrecognized until the patient
develops sequelae, such as anorectal disorders or diverticular disease.
No widely accepted clinically useful definition of constipation exists. Health care providers
usually use the frequency of bowel movements (ie, less than 3 bowel movements per week)
to define constipation. However, the Rome criteria, initially introduced in 1988 and
subsequently modified twice to yield the Rome III criteria, have become the researchstandard definition of constipation.[1]
According to the Rome III criteria for constipation, a patient must have experienced at least 2
of the following symptoms over the preceding 3 months:

Fewer than 3 bowel movements per week

Straining

Lumpy or hard stools

Sensation of anorectal obstruction

Sensation of incomplete defecation

Manual maneuvering required to defecate

The Rome III criteria also stipulate that a patient should not meet the suggested criteria for
irritable bowel syndrome (IBS) and that loose stools are rarely present without the use of
laxatives.
For surgical purposes, the most useful definition of constipation is simply a change in bowel
habits or defecatory behavior that results in acute or chronic symptoms or diseases that would
be resolved with relief of the constipation.
Acute or subacute constipation in middle-aged or elderly patients should prompt a search for
an obstructing colonic lesion. Acute constipation must be carefully distinguished from ileus
secondary to intra-abdominal emergencies, including infections.
Constipation is frequently chronic, can significantly affect an individuals quality of life, and
may be associated with significant health care costs. It is considered chronic if it occurred for
at least 12 weeks (in total, not necessarily consecutively) during the previous year. Chronic
constipation may be associated with psychological disturbances, and the reverse is true as
well. However, these issues are beyond the scope of this article.
Laboratory evaluation does not play a large role in the initial assessment of the patient.
Imaging studies are used to rule out acute processes that may be causing colonic ileus, to
evaluate causes of chronic constipation, or to rule out sources of sepsis or intra-abdominal
problems. Lower gastrointestinal (GI) endoscopy, anorectal manometry, electromyography
(EMG), and balloon expulsion may be used in the evaluation of constipation.

Medical care should focus on dietary change and exercise rather than laxatives, enemas, and
suppositories, none of which really addresses the underlying problem. Surgical care is
generally restricted to the evaluation of underlying causes; it may also be indicated for the
management of acute complications of constipation. Once acute constipation has resolved
and the associated medical or surgical conditions have been ruled out, additional inpatient
care is rarely indicated.
Next Section: Etiology

Pathophysiology
Constipation is divided, with considerable overlap, into issues of stool consistency (hard,
painful stools) and issues of defecatory behavior (infrequency, difficulty in evacuation,
straining during defecation). Although hard stools frequently result in defecatory difficulties,
soft bulky stools may also be associated with constipation, particularly in elderly patients
with anatomic abnormalities and in patients with impaired colorectal motility.
Constipation may originate primarily from within the colon and rectum or may originate
externally. Processes involved in constipation originating from the colon or rectum include
the following:

Left colon obstruction (neoplasm, volvulus, stricture)

Slow colonic motility, particularly in patients with a history of chronic laxative abuse

Hirschsprung disease

Chagas disease

Outlet obstruction (anatomic or functional) - Anatomic outlet obstruction may derive

from intussusception of the anterior wall of the rectum on straining, rectal prolapse,
and rectocele; functional outlet obstruction may derive from puborectalis or external
sphincter spasm when bearing down, short-segment Hirschsprung disease, and
damage to the pudendal nerve, typically related to chronic straining or vaginal
delivery

Factors involved in constipation originating outside the colon include poor dietary habits (the
most common factor), medications, systemic endocrine or neurologic diseases, and
psychological issues.
Constipation results in various degrees of subjective symptoms and is associated with
abnormalities (eg, colonic diverticular disease, hemorrhoidal disease, anal fissures) that occur
secondary to an increase in colonic luminal pressure and intravascular pressure in the
hemorrhoida l venous cushions.
Nearly 50% of patients with diverticular or anorectal disease, when asked, deny experiencing
constipation. On careful questioning, however, nearly all of these patients report having
symptoms suggestive of defecatory straining or infrequency.
Etiology

The etiology of constipation is usually multifactorial, but it can be broadly divided into 2
main groups: primary constipation and secondary constipation.
Primary constipation

Primary (idiopathic, functional) constipation can generally be subdivided into the following 3
types:

Normal-transit constipation (NTC)

Slow-transit constipation (STC)

Pelvic floor dysfunction (ie, pelvic floor dyssynergia)

NTC is the most common subtype of primary constipation. Although the stool is passing
through the colon at a normal rate, patients find it difficult to evacuate their bowels. Patients
in this category sometimes meet the criteria for IBS with constipation (IBS-C). The primary
difference between chronic constipation and IBS-C is the prominence of abdominal pain or
discomfort in IBS. Patients with NTC usually have a normal physical examination.
STC is characterized by infrequent bowel movements, decreased urgency, or straining to
defecate. It occurs more commonly in female patients. Patients with STC have impaired
phasic colonic motor activity. They may demonstrate mild abdominal distention or palpable
stool in the sigmoid colon.
Pelvic floor dysfunction is characterized by dysfunction of the pelvic floor or anal sphincter.
Patients often report prolonged or excessive straining, a feeling of incomplete evacuation, or
the use of perineal or vaginal pressure during defecation to allow the passage of stool, or they
may report digital evacuation of stool.
Secondary constipation

Dietary issues that may cause constipation include inadequate water intake; inadequate fiber
intake; overuse of coffee, tea, or alcohol; a recent change in bowel habit paralleled by
changes in the diet; and ignoring the urge to defecate. Reduced levels of exercise may play a
role as well.
Structural causes of secondary constipation include anal fissures, thrombosed hemorrhoids,
colonic strictures, obstructing tumors, volvulus, and idiopathic megarectum.
Systemic diseases that may cause constipation include the following:

Endocrinologic and metabolic disorders -Hypercalcemia,

hyperparathyroidism, hypokalemia, hypothyroidism, pregnancy, and
diabetes mellitus (constipation is the most common gastrointestinal
problem affecting the diabetic population)

Neurologic disorders - Stroke, Hirschsprung disease, Parkinson disease,

multiple sclerosis, diabetic autonomic neuropathy, spinal cord lesion, head
injury, cerebrovascular accident, Chagas disease, and familial
dysautonomia

Connective-tissue disorders -Scleroderma, amyloidosis, and mixed

connective-tissue disease

Often, what appears to be acute or subacute constipation may represent a colonic ileus from
systemic or intra-abdominal infection or other intra-abdominal emergencies.
Medications that may contribute to constipation include the following:

Antidepressants (eg, cyclic antidepressants and monoamine oxidase

inhibitors [MAOIs])

Metals (eg, iron and bismuth)

Anticholinergics (eg, benztropine and trihexyphenidyl)

Opioids (eg, codeine and morphine)

Antacids eg, (aluminum and calcium compounds)

Calcium channel blockers (eg, verapamil)

Nonsteroidal anti-inflammatory drugs (NSAIDs; eg, ibuprofen and

diclofenac)

Sympathomimetics (eg, pseudoephedrine)

Many psychotropic drugs[2]

Cholestyramine and stimulant laxatives (long-term use) - Although

laxatives are frequently used to treat constipation, chronic laxative use
becomes habituating and may lead to the development of a dilated atonic
laxative colon, which necessitates increasing laxative use with decreasing
efficacy

Inadequate thyroid hormone supplementation

Constipation may be of toxicologic origin, as with lead poisoning.

Psychological issues (eg, depression, anxiety, somatization, and eating disorders) may also
contribute to the development of constipation.

Epidemiology
United States statistics
Chronic constipation is highly prevalent and affects approximately 15% of persons in the
United States.[3] In 2006, the number of constipation-related physician visits reached 5.7
million, and of these, 2.7 million visits had constipation as the primary diagnosis.[4] About 2%
of the population describes constant or frequent intermittent episodes of constipation.

International statistics

Prevalence of self-reported constipation substantially varies because of differences among

ethnic groups in how constipation is perceived. In North America alone, chronic constipation
affects approximately 63 million people. Worldwide, approximately 12% of people suffer
from self-defined constipation; people in the Americas and the Asian Pacific suffer twice as
much as their European counterparts.
A meta-analysis of patients in Europe and Oceania cited prevalence rates as high as 81%,
with a general incidence of approximately 17%. Female gender, age, and educational class
were strongly associated with prevalence of constipation.[5]

Age-related demographics
Constipation can occur in all ages, from newborns to elderly persons. An age-related increase
in the incidence of constipation has been observed, with 30-40% of adults older than 65 years
citing constipation as a problem.[6] The increased frequency of constipation in adults older
than 65 years may reflect a combination of dietary alterations, decreases in muscle tone and
exercise, and the use of medications that may result in relative dehydration or colonic
dysmotility.[7] Some researchers suggest that cumulative exposure to environmental
neurotoxins may play a role.
In some patients, chronic or repeated pelvic injury (eg, from pregnancies) or the development
of anatomic abnormalities (eg, rectal prolapse or rectocele [weakness in the posterior vaginal
wall that allows the rectum to prolapse into the vagina upon straining]) may lead to functional
outlet obstruction.

Sex-related demographics
In the United States, self-reported constipation and admissions to hospital for constipation are
more common in women than in men. The overall female-to-male ratio is approximately 3:1.
Women are also more likely to receive care for constipation. The condition is seen fairly
frequently during pregnancy and is a common problem after childbirth. Surveys of apparently
healthy young men and women demonstrate a slightly higher stool frequency among women.

Race-related demographics
In the United States, the prevalence of constipation is 30% higher among nonwhite
populations than among white populations.[3] Both self-reported constipation and constipation
requiring admission to a hospital are more frequent in black people than in white people.
Whereas constipation is less common in Asians, it is more frequent in those who adopt a
Western diet.
In contrast, constipation is less frequent among black Africans than white Africans, further
suggesting that diet and other environmental factors play an important role.

Prognosis
Most active patients do well with medical management and appropriate dietary management.
Recurrence depends on the patients long-term compliance to therapy. A small percentage of
patients are quite debilitated as a result of constipation. Some patients with functional

(primary or idiopathic) constipation (ie, colonic inertia) require total abdominal colectomy
with ileorectal anastomosis.
After a careful preoperative workup that includes physical and psychological assessment,
patients with outlet obstruction generally respond well to surgical correction and have a good
prognosis.
Dyskinesias of the pelvic floor musculature and of the sphincter mechanism may be managed
via biofeedback therapy, but the results are mixed.
Patients who are chronically dependent on increasing doses of self-prescribed laxatives are
perhaps the most difficult patients to treat. Most such patients can be treated with a
combination of fiber, water, and osmotic agents (eg, sorbitol). However, the need for
increasing doses of laxatives and the intermittent use of other agents becomes problematic.
In rare situations in which patients are virtually refractory to laxatives, total abdominal
colectomy may be performed after careful workup. Postoperatively, these patients often
experience a greatly improved quality of life. A careful preoperative evaluation and a detailed
informed consent discussion are required.

Patient Education
Patient education typically involves instructions for improving dietary management. Dietary
deficiency requires increased fluid and fiber supplementation for life. For patients who
implement recommended dietary changes, the prognosis is excellent.
For patient education resources, see the Esophagus, Stomach, and Intestine Center, as well as
Constipation in Adults and Constipation in Children.
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