eMedicine Specialties > Gastroenterology > Colon

Constipation

Author: Marc D Basson, MD, PhD, MBA, Professor, Chair, Department of Surgery, Michigan State University
Contributor Information and Disclosures

Updated: Jan 28, 2010

Introduction

Background

Constipation is a common symptom, but it often remains unrecognized until the patient develops sequelae, such as anorectal disorders or diverticular disease. Several definitions of constipation have been proposed based on stool frequency in different populations. However, for surgical purposes, the most useful definition of constipation is a change in the bowel habit 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.

Although chronic constipation may be associated with psychological disturbances, the reverse is true as well. However, these issues are beyond the scope of this article.

The definition of constipation includes the following: infrequent bowel movements (typically <3 times per wk), difficulty during defecation (straining during more than 25% of bowel movements or a subjective sensation of hard stools), or the sensation of incomplete bowel evacuation.

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 is the end effect of several factors: poor diet, lack of exercise, motility abnormalities, and anatomic defects, along with the patient's expectations and psychological factors.

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. However, nearly all of these patients have symptoms suggestive of defecatory straining or infrequency upon careful questioning.

Frequency

United States

Self-reported constipation is one of the most common GI disorders in the United States. About 2% of the population describe constant or frequent intermittent episodes of constipation.

International

Prevalence of self-reported constipation substantially varies because of differences among ethnic groups in how constipation is perceived.

One meta-analysis depicted 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.1

Mortality/Morbidity

Difficulty in defecation may cause substantial discomfort, abdominal cramping, and a general feeling of malaise.

  • Actual or perceived constipation typically results in self-medicating with various laxatives. Although laxatives may correct the acute problem, the chronic use of them leads to habituation, requiring ever-increasing doses that result in drug dependency and, ultimately, a hypotonic laxative colon.
  • Acute or chronic episodes of straining may cause acute or chronic hemorrhoidal disease (characterized by pain, itching, or bleeding) or acute hemorrhoidal thrombosis (characterized by intense pain and acute engorgement of 1 or more of the hemorrhoidal columns). Whether constipation actually causes hemorrhoidal disease is controversial. Upon careful questioning, these patients frequently provide a history of recent defecatory difficulties (with the exception of patients in the early postpartum period). Furthermore, conservative management of hemorrhoidal disease is more likely successful when future straining is prevented.
  • The passage of hard stools may result in an acute anal fissure, which is a painful tear in the anoderm that may bleed. The regular passage of hard stools and the painful anal spasms during defecation that impinge the hard stools against the fresh wound prevent the anal fissure from healing. In addition to local wound care and analgesia, softening of stools is essential for successful management of an anal fissure.
  • Constipation may be one cause of pelvic floor damage in women.2 Using structured questionnaires, Amselem et al determined that 61 out of 596 women (10%) attending a gynecologic clinic had pelvic floor damage. Constipation was present in 19 of the 61 women (31%), rivaling the frequency of obstetric trauma (also 19 women) among these patients. The authors also determined that in the 535 women without pelvic floor damage, 86 of them (16%) had constipation, and 83 of them (15.5%) had obstetric trauma. Employing univariate analysis, Amselem and colleagues reported odds ratios of 2.36 and 2.46 for, respectively, constipation and obstetric trauma associated with pelvic floor damage. Based on their data, the authors suggested that constipation and obstetric trauma are equally important in the development of pelvic floor damage.

Race

  • In the United States, both self-reported constipation and constipation requiring admission to a hospital are more frequent in black people than in white people.
  • While 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.

Sex

In the United States, self-reported constipation and admissions to hospital for constipation are more common in women than in men. Surveys of apparently healthy young men and women demonstrate a slightly higher stool frequency among women.

Age

  • The prevalence of constipation increases exponentially in adults older than 65 years. This may reflect a combination of dietary alterations, decreases in muscle tone and exercise, and the use of medications, which may result in relative dehydration or colonic dysmotility.3
  • Some researchers have suggested that cumulative exposure to environmental neurotoxins may play a role in the age-related increase in the prevalence of constipation.
  • In some patients, chronic or repeated pelvic injury (eg, from pregnancies) or the development of anatomic abnormalities (eg, rectal prolapse, rectocele [weakness in the posterior vaginal wall allowing the rectum to prolapse into the vagina upon straining]) may lead to functional outlet obstruction.

Clinical

History

Basing the diagnosis of constipation on simply asking the patients whether they are constipated is associated with the marked underreporting of the problem in patients who have physical evidence of constipation, such as the presence of hemorrhoidal disease.4

  • History should begin with a detailed inquiry into the patient's normal pattern of defecation, the frequency with which the current problem differs from the normal pattern (eg, "missing a day"), the perceived hardness of the stools, whether the patient strains in order to defecate, and any other symptoms the patient may be experiencing.
    • An inquiry concerning the amount of time spent on the toilet while waiting to defecate may also be illuminating. Patients should be asked to describe in detail what happens when they try to defecate and what maneuvers (pharmacological or physical) they have used to facilitate this process. These questions may suggest chronic laxative abuse or less common causes, such as colonic outlet obstruction.
    • The duration of the problem is important. In adolescents or young adults, the duration of the problem may differentiate congenital defects from acquired causes. Neoplastic obstruction is less likely in patients older than 50 years who have had symptoms for at least 2 years.
    • Questions regarding the onset of constipation may provide useful etiological information, either in terms of changes in diet, new medications, or associated psychosocial difficulties at that time.
  • In addition to defining the nature of the patient's bowel habit, the factors that are likely to be responsible for the abnormal bowel habit should be delineated. Most patients who are constipated consume either too little fiber or too little water; therefore, assessing the patient's diet is useful. For acute changes in the bowel habit, a parallel dietary change should be ascertained. Learning how much fluid and what types of fluids the patient drinks on an average day is important.
    • Epidemiological studies have clearly established a link between coffee consumption and worsening constipation.
    • The diuretic effects of coffee, tea, and alcohol are likely counterproductive.
    • Milk products may cause constipation in some individuals.
  • The state of patients' bowel motility represents a balance between factors that promote motility and those that inhibit it.
    • The most important influencing factor is exercise, which stimulates bowel motility. Conversely, the use of narcotics, antipsychotic agents, and other constipating medications reduce motility.
    • Diuretics or substantial amounts of coffee, tea, or alcohol decrease available water to the colon.
    • Chronic laxative abuse also causes refractory constipation.
  • If the patient shows evidence of diseases or symptoms associated with constipation, such as diverticular disease, hemorrhoids, anal fissures, or fistula-in-ano, delineating these conditions historically and determining the nature of any previous treatment for these conditions is appropriate. For instance, patients with hemorrhoids may neglect to mention that they were previously treated for this problem or that they have been receiving medications for constipation for several years.
  • Rectal bleeding should be taken seriously and evaluated carefully, particularly in patients older than 50 years or with a family history of colorectal disease.
    • Patients with hemorrhoids may also have rectosigmoid cancer. Both cancer and hemorrhoids can produce bright red blood from the rectum.
    • Most patients older than 50 years or with a family history of colorectal disease should be screened for colorectal cancer with at least a sigmoidoscopic examination.
  • Finally, the evaluation should include the patient's description of the act of defecation.
    • Pain during defecation might suggest a fissure or tenesmus from a rectal tumor.
    • Painless inability to pass an otherwise soft stool suggests a rectal outlet obstruction.
  • Neurological or endocrine disorders also can cause constipation.
    • Most notably, diabetes may be associated with chronic dysmotility.
    • Patients with hypothyroidism may exhibit decreased motility and slow transit times.5
    • Patients with panhypopituitarism, pheochromocytoma, or multiple endocrine neoplasia 2B are also at risk of developing constipation.
    • When no other cause can be determined, a careful endocrine review is particularly important for patients with a recent onset of constipation and for patients who are refractory to conservative treatment.
    • Similarly, central nervous system diseases, such as Parkinson disease, multiple sclerosis, stroke, CNS syphilis, and spinal injury or tumors, may cause constipation and should be considered in the patient's history and evaluation.
  • Some cases of constipation may have a psychogenic component because constipation is a frequent somatic expression of psychological distress. Alternately, constipation may result in psychological disturbances.
    • A history of sexual abuse is observed with unusual frequency in patients who are chronically constipated, particularly those with anismus.
    • A history of other psychological abnormalities is often found, particularly among patients who are refractory to medical treatment and have normal bowel transit times and normal results from anorectal studies. Such factors should be gently explored in patients in whom the first-line conservative treatment has failed.
    • Psychiatric referral may be appropriate in such patients after medical evaluation and therapy has been exhausted or if gentle questioning reveals some unexpected information.

Physical

In addition to the general evaluation, the abdomen, pelvis, and rectum, specifically, should be physically examined. Both the cause of constipation and its effects should be sought.4

  • Abdominal examination
    • Abdominal distention or masses may indicate the presence of colonic stools or tumors.
    • Large abdominal wall hernias, especially ventral hernias, may interfere with the generation of adequate intra-abdominal pressure that is required for the initiation of defecation.
    • Rarely, a left-sided sliding inguinal hernia with an incarcerated sigmoid colon may cause difficulties in bowel movements.
    • Conversely, the once-held belief was that elderly patients with new inguinal hernias should be assumed to have occult constipation due to partially obstructing colonic neoplasms and that those patients required colorectal cancer screening. The requirement for colorectal cancer screening in such patients remains controversial, and the pathophysiology underlying a link between colonic neoplasms and hernias is unknown because the lesions detected on screening are early lesions and are unlikely to have caused constipation.
  • Pelvic examinations in women should specifically address the posterior vaginal wall, with attention to any evidence of internal prolapse or rectocele.
    • This region should be palpated while the patient is at rest and then while she is straining to defecate.
    • Many women with rectocele do not experience constipation. Good surgical results are not guaranteed, and a thorough preoperative workup to rule out other potential causes of constipation should always be performed.
  • Perform a complete anorectal examination to determine the cause of constipation and to assess its effects.
  • Causes of constipation that may be defined on rectal examination include the following:
    • Anal fissure, particularly in children who retain their feces in order to avoid painful defecation
    • Anal stenosis
    • Partially obstructing rectal masses
    • Rectal prolapse: The rectal prolapse may be either external or internal. The anus should be carefully examined for prolapse at rest and during a Valsalva maneuver. Care should be taken to distinguish a true full-thickness rectal prolapse from a mucosal prolapse, which is unlikely to cause constipation. Asking the patient to perform a Valsalva with the examining finger in the rectum in order to seek evidence of an internal prolapse may be worthwhile, although this is a relatively insensitive way to diagnose a prolapse. In contrast to inguinal hernias, rectal prolapses are typically related to constipation. At least 1 retrospective study has demonstrated a strong association between rectal prolapse and rectosigmoid neoplasms in patients older than 50 years. Sigmoidoscopy is probably indicated for these patients.
  • In addition to delineating the cause of constipation, an anorectal examination should be used to determine the effects of the constipation.
    • The presence of fissures or fistulae, evidence of scars from previous perirectal abscess drainages or other surgeries, and the nature of the patient's hemorrhoidal columns should be characterized.
    • Enlarged hemorrhoids do not require treatment unless they cause symptoms.
  • Although the effectiveness of fecal occult blood testing has been hotly debated, performing such a test following a rectal examination in patients older than 50 years is probably worthwhile.
    • The presence of blood in the stool requires further evaluation.
    • Never assume that the patient is bleeding from hemorrhoids or fissures until other sources of bleeding have been ruled out.
  • A component of a complete physical evaluation of the patient should be to look for evidence of systemic diseases contributing to constipation. Such systemic diseases include the following:
    • Endocrine dysfunctions, such as hypothyroidism, hypopituitarism, or diabetes mellitus
    • Neurologic abnormalities, such as brain or spinal cord injury, peripheral neuropathy, multiple sclerosis, or Parkinson disease

Causes

Constipation may originate primarily from within the colon and rectum or may originate externally.

  • Causes of constipation directly attributable to the colon or rectum
  • Outlet obstruction may be anatomical or functional. Characteristics of outlet obstruction include the following:
    • Patients have difficulty evacuating bowels despite straining, often even with soft stools.
    • Anatomic outlet obstruction may be due to intussusception of the anterior wall of the rectum on straining, rectal prolapse, and rectocele.
    • Functional causes of outlet obstruction include puborectalis and/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.
  • Causes of constipation outside the colon
    • Poor dietary habit (most common)
    • Medications
    • Systemic endocrine or neurologic diseases
    • Psychological factors
  • Dietary issues
    • Inadequate water intake
    • Inadequate fiber intake
    • Overuse of coffee, tea, or alcohol
    • Recent change in bowel habit paralleled with changes in the diet
  • Medications that may contribute to constipation include the following:
    • Narcotics
    • Iron supplements
    • Nonmagnesium antacids
    • Calcium-channel blockers
    • Inadequate thyroid hormone supplementation
    • Many psychotropic drugs6
    • Anticholinergic agents
    • 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 requires increasing laxative use with decreasing efficacy.
  • Systemic diseases
    • Endocrine dysfunctions, most commonly hypothyroidism
    • Neurologic dysfunction, including diabetic autonomic neuropathy, spinal cord injury, head injury, cerebrovascular accident, multiple sclerosis, and Parkinson 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.

More on Constipation

Overview: Constipation
Differential Diagnoses & Workup: Constipation
Treatment & Medication: Constipation
Follow-up: Constipation
References
Further Reading

References

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  2. Amselem C, Puigdollers A, Azpiroz F, Sala C, Videla S, Fernández-Fraga X, et al. Constipation: a potential cause of pelvic floor damage?. Neurogastroenterol Motil. Sep 17 2009;[Medline].

  3. Bouras EP, Tangalos EG. Chronic constipation in the elderly. Gastroenterol Clin North Am. Sep 2009;38(3):463-80. [Medline].

  4. Noguera A, Centeno C, Librada S, Nabal M. Screening for Constipation in Palliative Care Patients. J Palliat Med. Sep 11 2009;[Medline].

  5. Taghavi SA, Shabani S, Mehramiri A, Eshraghian A, Kazemi SM, Moeini M, et al. Colchicine is effective for short-term treatment of slow transit constipation: a double-blind placebo-controlled clinical trial. Int J Colorectal Dis. Aug 25 2009;[Medline].

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Further Reading

Clinical guidelines

Functional constipation and soiling in children.
University of Michigan Health System - Academic Institution. 1997 Sep (revised 2008 Sep). 15 pages. NGC:006843

ASGE guideline: guideline on the use of endoscopy in the management of constipation.
American Society for Gastrointestinal Endoscopy - Medical Specialty Society. 2005 Aug. 3 pages. NGC:004485

Prevention of constipation in the older adult population.
Registered Nurses' Association of Ontario - Professional Association. 2002 Jan (revised 2005 Mar). 56 pages. NGC:004213

Practice parameters for the evaluation and management of constipation.
American Society of Colon and Rectal Surgeons - Medical Specialty Society. 2007 Dec. 10 pages. NGC:006460

Clinical trials

An Open-Label, Long-Term Safety Study of Linaclotide in Patients With Chronic Constipation or Irritable Bowel Syndrome With Constipation

Intestinal Microecology in Chronic Constipation

Lubiprostone (Amitiza®) Vs. Standard Care in Opioid-Induced Constipation After Surgery in Inpatient Rehabilitation

Effectiveness of Docusate in Preventing/Treating Constipation in Palliative Care Patients

Related eMedicine topics

Constipation (Pediatrics: General Medicine)

Constipation (Emergency Medicine)

Constipation and Bowel Management

Hirschsprung Disease

Rectal Prolapse

Keywords

constipation, bowel movement, diverticular disease, defecation, anorectal manometry, hemorrhoid, anal fissure, hemorrhoidal disease, thrombosis hemorrhoid, rectal tumor, bowel motility, laxative abuse, colonic tumor, rectal prolapse, colonic ileus, obstipation, defecography, anismus, large bowel obstruction, ischemic bowel

Contributor Information and Disclosures

Author

Marc D Basson, MD, PhD, MBA, Professor, Chair, Department of Surgery, Michigan State University
Marc D Basson, MD, PhD, MBA is a member of the following medical societies: American College of Surgeons and American Gastroenterological Association
Disclosure: Nothing to disclose.

Medical Editor

Ronnie Fass, MD, Chief of Gastroenterology, Southern Arizona VA Health Care System; Professor of Medicine, Division of Gastroenterology, University of Arizona School of Medicine
Ronnie Fass, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians-American Society of Internal Medicine, American Gastroenterological Association, American Motility Society, American Society for Gastrointestinal Endoscopy, and Israel Medical Association
Disclosure: Takeda Pharmaceuticals Grant/research funds Conducting research; Takeda Pharmaceuticals Consulting fee Consulting; Takeda Pharmaceuticals Honoraria Speaking and teaching; Vecta Consulting fee Consulting; XenoPort Consulting fee Consulting; Eisai Honoraria Speaking and teaching; Wyeth Pharmaceuticals  Conducting research; AstraZeneca Grant/research funds Conducting research; Eisai Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

BS Anand, MD, Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine
BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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