Treatments for

constipation
CJ Lau
26 Aug 2009
 Outline
 Definition of constipation
 Etiology and pathophysiology of
constipation
 Rationale for drug use
 Pharmacological and non pharmacological
treatments
 Patient education/counselling
 Definition
 Constipation has varied meaning for
different people
 Rome II criteria define constipation as >2
of the following in a 12 weeks period:
1. Straining at defecation at least a quarter
of the time
2. Lumpy or hard stools at least a quarter of
the time
3. Sensation of incomplete evacuation at
least a quarter of the time
4. 3 or fewer bowel movements/week
 Types of constipation
 Acute constipation
1. Use suppositories or enema to clear the rectum and
followed by simple non drug measure
2. Use lactulose or sorbitol if dietary fibre cannot be
adequately increased
 Fecal impaction
1. Occurs when dry hard stool become compacted into large
hard stool which cannot be expelled from rectum
 Fecal impaction
continues..
2. Should initially be disimpacted by manual disimpaction
3. An enema with mineral oil can then be used to soften
the stool
4. Sometimes impacted fecal must be accomplished using
sigmoidoscopy with instrumentation
5. Regular laxative use in addition to lifestyle and diet
changes
 Types of constipation
 Chronic constipation
1. Normal colonic transit- exhibit psychosocial
distress
2. Colonic inertia/slow colonic transit- have
delayed passage of radiopaque markers
through proximal colon, have little or no
increase in motor activity following a meal
3. Dyssynergic defecation- inappropriate
contraction of pelvic floor muscle, can be only
diagnosed with anorectal manometry
 Etiology
 The slowing of colonic transit may be
idiopathic or due to motor disorders
associated with many diseases
 Due to side effects of many drugs- opiods,
calcium supplements, verapamil,
anticholinergics, aluminium antacids
 Medical conditions (secondary causes)-
hypothyroidism, pregnancy, irritable
bowel syndrome, Parkinson disease, colon
cancer & Hirschprung’s disease
 Pathophysiology
 Defecation involves the coordinated relaxation
of puborectalis and external anal sphincter
muscles, together with increased in
intraabdominal pressure and inhibition of colonic
segmenting activity.
 Slow transit constipation- possibly related to
decreased numbers of high-amplitude
propagated contractions
 Pelvic floor dysfunction- features normal or
slightly slowed colonic transit, leads to inability
to evacuate adequately the content from the
rectum.
 Hirschsprung’s disease
 Incidence of 1 in 5000 patients, commonly due to
trisomy 21
 A rare cause of intractable constipation in toddler
and children
 Absence of ganglion cells in the myenteric &
subcutaneous plexures of the distal colon resulting
sustained contraction of the aganglionic segment.
 Bowel above the constricted area dilates
(megacolon) due to stool trapping
 Commonly occurs near rectum region
 May require surgery to remove the aganglion
segment
 Evaluation/diagnosis
 Careful history taking- defining the
nature and duration of constipation and
identify secondary causes
 Physical examination- rectal examination
may be helpful. It can identify fissures
and heamorrhoids
 Endoscopy/colonoscopy
 Radiography/imaging
 Dietary and lifestyle
changes
 Is the mainstay treatment for constipation, it should
be continued even when laxatives are used
 Ensure adequate dietary fibre intake (25-30g/daily).
Increase intake gradually to avoid bloating &
flatulence
 Ensure adequate fluid intake
 Increase exercise, avoid sedentary lifestyle
 Behaviour changes- do not hold urge to defecate
When to start treatment
 Symptoms do not resolve after
treating reversible causes (eg.
Hypothyroidism, depression etc)
 Dietary changes are ineffective
 Fecal impaction
 When starting on opioid analgesia
 Onset of effect of
Group of laxatives
Examples Onset of
laxatives action
Bulking pysllium Oral: 48-
agents 72hours
Osmotic Glycerol, Oral: 24-
laxatives lactulose, 72hours
sorbitol Rectal: 5-
30min
Polyethylene Oral: 0.5-
glycol, saline 3hours
laxatives Rectal: 2-
30min
Stool softener Docusate, Oral: 24-
 Bulking agent (eg.
psyllium)
 Useful for mild constipation,small hard stool
and long term control
 Not to be used in acute constipation
 Absorb water into colon to increase fecal
bulk which stimulates peristaltic activity
 Ensure adequate fluid intake to avoid
intestinal obstruction
 Pregnancy risk factor B & excretion in breast
milk unknown
 S/E: flatulence, bloating, abdominal
discomfort
 Osmotic laxatives
 Glycerol (suppository)- can be used for acute relief of
constipation, onset of action (5-30minutes)
1. Ravin enema (List C item) is available in hospital,
contains glycerin 25% and NaCl 15%
 Lactulose (List B item, available as 3.35g/5ml in hospital)
1. not suitable for acute relief (onset of action-1 to 3 days),
need to be taken regularly
2. Poorly absorbed, metabolised by colonic bacteria, exert
osmotic effect on colon
3. CI- lactose and galactose intolerance
4. Dose- adult: 15-30ml/day, increase to 60ml/day in 1-2
divided dose, paed: 0.5ml/kg 12-24hourly
5. Pregnancy risk factor B and excretion in breast milk
unknown
6. Can be mixed with water, fruit juice or milk for better
taste
 Osmotic laxatives
 Sorbitol 70%
1. non absorbable sugar, produce osmotic effect at the colon
2. Dose: 2-11yo – 2ml/kg , >12yo- 30-150ml
3. Precaution- use with caution with patients with severe
cardiopulmonary or renal impairment, large volume may
cause fluid overload or electrolytes imbalance
4. S/E: oedema, abdominal discomfort, diarrhea, fluid and
electrolytes disturbances
 Osmotic laxatives
 Polyethylene glycol
1. Used for bowel cleansing prior to GI
examination or occasional treatment of
constipation
2. Dose for constipation: adult- 17g of
powder dissolves in 8oz(240ml) of water
for Miralax, not to be used for > 2 weeks
3. Do not add flavouring agent to the
solution, chilled solution is more palatable
4. Many commercial dosage forms available,
dose depends on each product (eg.
Movicol, Movicol half, Colonlytelly)
 Osmotic laxatives
 Saline laxatives
1. Contains poorly absorbed irons eg magnesium sulfate,
phosphate, and citrate which retain water in colon by
osmotic effect and stimulates peristalsis
2. Onset of action- 30min to 3hours
3. Sodium phosphate laxatives are CI in heart failure and
renal impairment
4. Dosage- depending on each product
5. S/E: nausea, bloating, electrolyte imbalance
6. Eg- Fleet Ready-to-use Enema®, Micolette®, Microlax®,
 Stool softener
 Have little value used as single agent in chronic
constipation or opiod induced constipation
 Liquid paraffin (List C item)
1. Lubricates fecal material to facilitate passage
2. CI in children <3yo, pregnancy, bed ridden patients
3. Dose- 10-30ml in adults, 1ml/kg daily
4. S/E: rectal leakage and anal irritation
5. Do not take a dose immediately before lying down to
prevent aspiration
 Stool softener
 Docusate
1. Used for constipation associated with dry hard stools and for avoiding
straining
2. Facilitate admixture of fat and water to soften stool
3. Onset of action- 24-72hours
4. Dosage (oral):
-children 3-6 yo, 10-40mg/day in 1-4 divided dose
-children 6-12yo, 40-150mg/day in 1-4 divided dose
-adults, 50-500mg/day in 1-4 divided dose
5. Available in capsule, syrup, enema form
 Stimulant laxatives
 Act by direct stimulation at nerve ending in colonic
mucosa to increase intestinal motility
 CI in intestinal obstruction or inflammatory bowel
syndrome as it often causes abdominal cramp
 S/E: abdominal discomfort, cramp, nausea, diarrhoea,
fluid & electrolyte imbalance with prolonged use
 May be use in long term for constipation associated with
spinal damage, chronic neuromuscular disease and in
people taking opioid
 Stimulant laxatives
 Bisacodyl
1. Available in hospital as 5mg tablet and 5mg & 10mg
suppository
2. Onset of action- 15min to 1 hr (suppository), 6 to
12hr (oral)
3. Dose (Oral): >10yo, 10mg at night
children 4-10yo, 5mg at night
4. Dose (supp): <10yo, 5mg morning
>10yo, 10mg morning
 Senna
1. Onset of action- 6-12hr
2. S/E: discolouration of urine to yellowish brown or red.
3. Dose: 7.5-30mg at bedtime for adults
4. Available in market as tablet, granule
 Non pharmacological
treatment
 Biofeedback
1. Behavioral approach that is used to correct
inappropriate contraction of the pelvic floor
muscles and external anal sphincter during
defecation
2. Train patients to relax pelvic floor muscles
during straining and to correlate relaxation and
pushing during defecation
3. Does not appear to benefit patients with slow
transit constipation
4. Evidence quality is moderate
 Overall Management
 Normal or slow transit constipation-
patient education, dietary changes,
drug therapy, behavioral therapy
 Severe intractable slow transit
constipation- surgery in extreme
condition
 Dyssynergic defecation- biofeedback
 References
 Tramonte, SM, Brand, MB, Mulrow, CD, et al. The treatment
of chronic constipation in adults. A systematic review. J Gen
Intern Med 1997; 12:15.
 Floch, MH, Wald, A. Clinical evaluation and treatment of
constipation. Gastroenterologist 1994; 2:50
 Longstreth, GF, Thompson, G, Chey, WD, et al. Functional
bowel disorders Gastroenterology 2006; 130:1480
 An Evidence-Based Approach to the Management of Chronic
Constipation in North America. Am J Gastroenterol 2005;
100:S1
 Chiarioni, G, Whitehead, WE, Pezza, V, et al. Biofeedback is
superior to laxatives for normal transit constipation due to
pelvic floor dyssynergia. Gastroenterology 2006; 130:657.
 Lexi-comps drug information handbook 13th ed
 Australian medicine handbook 2008
 BNF and BNF for children online
 Frank Shann 14th ed