Constipation

Last reviewed: 22 Feb 2023

Last updated: 10 Sep 2020

A detailed history and physical examination, including a digital rectal examination, is the first step in the evaluation of constipation.

Diagnostic evaluation may include a colonoscopy if indicated, colonic transit study, anorectal manometry, and a balloon expulsion study.

Initial treatment consists of lifestyle modification and laxatives.

Medical treatment should be tailored to the underlying etiology. Patients who do not respond to medical treatment may need specialized evaluation for pelvic floor dysfunction and biofeedback therapy. Surgery is only rarely indicated.

Definition

Chronic constipation is a polysymptomatic heterogeneous disorder. Patients define constipation on the basis of excessive straining, a sense of incomplete evacuation, failed or lengthy attempts to defecate, hard stools, and, less frequently, by the number of stools per week.[1][2][3] The American College of Gastroenterology describes constipation as unsatisfactory defecation characterized by infrequent stools, difficult stool passage, or defecation that is both infrequent and/or difficult.[4]

History and exam

Key diagnostic factors

infrequent stools
difficult defecation
sensation of incomplete evacuation
excessive straining

More key diagnostic factors

Other diagnostic factors

hard stools
abdominal mass
signs suggestive of underlying medical disorder
anorectal lesions
abnormality on digital rectal examination (DRE)

Other diagnostic factors

Risk factors

female sex
age >65 years
African ancestry
lower socioeconomic status
family history
sedentary lifestyle
low fiber intake
inadequate calorie intake
inadequate fluid intake
surgical procedures and childbirth
medications that induce constipation

More risk factors

Diagnostic investigations

1st investigations to order

complete blood count (CBC)
thyroid function tests
serum electrolytes, calcium, and magnesium
blood glucose
abdominal x-ray
barium enema

More 1st investigations to order

Investigations to consider

defecography
magnetic resonance defecography
colonoscopy
colonic transit study
anorectal manometry
balloon expulsion studies
colonic manometry

More investigations to consider

Treatment algorithm

ACUTE

symptoms <3 months

ONGOING

symptoms >3 months

refractory to laxatives

Contributors

Authors

Satish Rao, MD, PhD, FRCP (Lon), FACG, AGAF

Professor of Medicine

Chief, Section of Gastroenterology and Hepatology

Director, Digestive Health Center and Neurogastroenterology and GI Motility

Medical College of Georgia

Georgia Regents University

Augusta

Disclosures

SR serves on the advisory board for Smartpill Corporation, Greenwood Pharmaceuticals, Forest Research Institute, and Takeda Pharmaceuticals of North America. SR is an author of a reference cited in this topic.

Amol Sharma, MD, MS

Assistant Professor

Section of Gastroenterology & Hepatology

Augusta University

Augusta

Disclosures

AS declares that he is on the advisory board for Ironwood Pharmaceuticals.

Acknowledgements

Dr Satish Rao and Dr Amol Sharma would like to gratefully acknowledge Dr Humberto Sifuentes and Dr Ashok Attaluri, previous contributors to this topic. HS declares that he has no competing interests. AA is an author of one reference cited in this topic.

Peer reviewers

Stefan Muller-Lissner, MD

Professor

Abteilung fur Innere Medizin

Park-Klinik Weissensee

Berlin

Germany

Disclosures

SML declares that he has no competing interests.

Eamonn M.M. Quigley, MD, FRCP, FACP, FACG, FRCPI

Professor of Medicine and Human Physiology

Department of Medicine

Clinical Sciences Building

Cork University Hospital

Cork

Ireland

Disclosures

EMMQ has served as a consultant or on advisory boards for the following companies: Sucampo, Movetis, Norgine, Procter and Gamble, Boehringer Ingelheim, Reckitts Benckiser, Schering, Novartis, Salix, Ironwood, and McNeill Consumer Health and has been paid for his time involved. EMMQ is an author of several references cited in this topic.

Ned Snyder, MD

Chief of Gastroenterology and Hepatology

Kelsey-Seybold Clinic

Adjunct Professor of Medicine

University of Texas Medical Branch

Houston

Disclosures

Not disclosed.

Differentials
- Anal fissure
- Medication-induced constipation
- Hypercalcemia
More Differentials
Guidelines
- American Gastroenterology Association Institute Guideline on the medical management of opioid-induced constipation
- Clinical practice guideline for the evaluation and management of constipation
More Guidelines
Patient leaflets
Constipation
More Patient leaflets
Log in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer

Constipation

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

symptoms <3 months

symptoms >3 months

refractory to laxatives

Contributors

Authors

Satish Rao, MD, PhD, FRCP (Lon), FACG, AGAF

Disclosures

Amol Sharma, MD, MS

Disclosures

Acknowledgements

Peer reviewers

Stefan Muller-Lissner, MD

Disclosures

Eamonn M.M. Quigley, MD, FRCP, FACP, FACG, FRCPI

Disclosures

Ned Snyder, MD

Disclosures

Differentials

Guidelines

Patient leaflets

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice