Alimentary Pharmacology & Therapeutics

Review article: self-report measures to evaluate constipation

G. L. MCCREA*, C. MIASKOWSKI*, N. A. STOTTS*, L. MACERA*, S. A. HART   & M. G. VARMAà

*Department of Physiological Nursing, SUMMARY

University of California, San Fran-
cisco, CA, USA;  Department of Psy- Background
chology, Ryerson University, Toronto,
Constipation is a subjective phenomenon, and as such must be evalu-
ON, Canada; àDepartment of Surgery,
University of California, San Fran- ated using patient self-report. Valid and reliable measures of constipa-
cisco, CA, USA tion are essential to standardize the diagnosis, assess the severity and
evaluate the effectiveness of treatments.
Correspondence to:
Dr G. L. McCrea, 3185 Old Tunnel Aim
Road, Lafayette, CA 94549, USA.
E-mail: lindsay.mccrea@ucsf.edu
To compare and contrast published self-report measures of constipation
in terms of development, content, general characteristics, psychometric
properties and clinical utility.
Publication data
Submitted 5 November 2007
Methods
First decision 9 December 2007
Resubmitted 11 January 2008 MEDLINE (1966–2007), CINAHL (1980–2007), Cochrane (1993–2007)
Second decision 13 January 2008 and Web of Science (1995–2007) were searched to identify self-report
Resubmitted 16 January 2008 measures of constipation. Measures of constipation were selected if
Accepted 17 January 2008
they: (i) were self-report measures that measured only constipation; (ii)
Epub OnlineAccepted 22 January
2008 had undergone psychometric testing; (iii) were used in adults and (iv)
were written in English.

Results
Seven self-report measures of constipation were identified. The content
areas evaluated by these measures varied. Only two measures had ade-
quate validity and reliability, sensitivity to change, or were tested in
more than one sample.

Conclusions
Findings from this review suggest that the Chinese Constipation Ques-
tionnaire and the Patient Assessment of Constipation-Symptom Ques-
tionnaire demonstrate adequate psychometric properties for a
constipation measure. Additional research is warranted to refine or
develop a more comprehensive self-report measure to evaluate constipa-
tion in adults.

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on this initial screening and a review of the reference

INTRODUCTION
lists, 10 papers were reviewed and seven met the crite-
Constipation, a common problem that involves a con- ria for inclusion in this review. The seven studies6–12
stellation of symptoms, affects between 2% and 27% described the development and testing of seven differ-
of the general population.1–5 The severity of constipa- ent self-report measures of constipation. Table 1 pro-
tion can range from a mild acute event to a chronic vides a synthesis of the content of the seven self-
condition. Often it requires frequent interventions that report measures selected for this review. Table 2 sum-
may produce mixed or even unsatisfactory results. marizes their psychometric properties and Table 3
A key issue for clinical practice and research is the summarizes their characteristics and clinical utility.
assessment and measurement of constipation. Because
it is a subjective phenomenon, constipation must be
RESULTS
evaluated using patient self-report. Valid and reliable
measures of constipation are essential to standardize
Description of measures and reports of
the diagnosis, assess severity and evaluate the effec-
psychometric testing
tiveness of treatments. Such measures have only
recently been developed. Each measure, described below in chronologic order of
To date, no systematic evaluation has been made of development, is summarized in terms of its character-
the published measures of constipation. Therefore, the istics, scoring procedure and psychometric properties.
purpose of this review was to compare and contrast The criteria used to evaluate the measures consisted of
these measures of constipation in terms of their devel- established validity and reliability, ability to identify
opment, content, general characteristics, psychometric constipation and sensitivity to change over time.
properties and clinical utility. Understanding the
strengths and limitations of existing measures of con-
The Constipation Assessment Scale. The Constipation
stipation makes it possible to adapt existing tools or
Assessment Scale (CAS)11 is an eight-item self-report
develop new measures that can be used in clinical
measure designed to assess the presence and severity
practice and research.
of constipation in cancer patients taking opioids or
vinca alkaloids. The CAS was subsequently modified
METHODS and validated for use with women during pregnancy.13
Constipation was defined qualitatively as defecation
Selection of the constipation measures less than normal, amount of stool less than normal and
bowel movements that were painful or difficult. The
To identify the relevant measures of constipation, a
CAS was developed from a list of 22 defining character-
number of strategies were employed. A literature
istics for constipation proposed by McShane and
search was conducted using the following databases
McLane.14 Characteristics that appeared to be peripheral
and time periods: MEDLINE (1966–2007), CINAHL
to constipation (such as headache) were removed. Eight
(1980–2007), Cochrane (1993–2007) and Web of Sci-
characteristics were included in the initial evaluation of
ence (1995–2007). The following exploded MeSH
the CAS: abdominal distention or bloating, change in
terms were used: (constipation OR functional constipa-
the amount of gas passed rectally, less frequent bowel
tion) AND (instrument OR questionnaire OR inventory
movements, oozing liquid stool, rectal fullness or pres-
OR scale OR assessment).
sure, rectal pain with bowel movements, small volume
Criteria for inclusion of a measure were: (i) self-
of stool and inability to pass stool.
report measures that measured only constipation; (ii)
A three-point summated rating scale was con-
had undergone psychometric testing; (iii) were used in
structed (0 = ‘no problem’, 1 = ‘some problem’,
adults and (iv) were written in English. Measures were
2 = ‘severe problem’). A total score is calculated that
excluded, if they evaluated constipation in children
can range from 0 (no constipation) to 16 (severe con-
and ⁄ or measured other symptoms in addition to con-
stipation). Each item is rated based on the patients’
stipation.
experience with each characteristic in the previous
The abstracts of 900 citations were reviewed to
week. A score of ‡1 indicates constipation. No cut-off
determine if the paper described the development and
score was provided.
testing of a self-report measure for constipation. Based

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 Table 1. Summary of the content areas evaluated in seven self-report measures of constipation

Constipation measures

Chinese Patient Assessment Visual Scale

Constipation Constipation Constipation Knowles, Eccersley, of Constipation- Analog
Questionnaire Assessment Scoring Garrigues Scott Symptom Symptom Questionnaire
Content areas (7) Scale (11) System (6) Questionnaire (9) Score (10) Questionnaire (8) (12)
640 G . L . M C C R E A et al.

Stool frequency <3 per week* Less frequent 1–2 times per Number per week 1–2 times per <3 per week*
than normal 1–2 days 1–2 days
to <1 per month to <1 per 2 weeks
Length of time Length of time Length of time
per attempt per attempt per attempt
Stool consistency Hard ⁄ lumpy* Small ⁄ oozing Hard* or small Hard* to pellet like Hard* Hard* or pellety
Loose or watery Soft ⁄ loose ⁄ normal Small Watery
Rectal symptoms Incomplete Incomplete Incomplete Incomplete Incomplete Incomplete Incomplete
evacuation* evacuation* evacuation* evacuation* evacuation* evacuation* evacuation*
+urge to defecate +urge to defecate +urge to defecate Sensation of anorectal +urge to defecate +urge to defecate Strain*
Difficult Pain with BM blockage ⁄ obstruction* Strain*
to pass stools Pain with BM
Pain with BM Strain* Rectal bleeding
Rectal fullness
or pressure
Abdominal Bloating Distention ⁄ bloating Abdominal pain Pain, visits to Bloating Bloating
symptoms provider >6· Abdominal pain Abdominal pain
last year Discomfort in
abdomen stomach
cramps
Assistive measures Digital evacuation Digital evacuation Digital evacuation
of stool* of stool* of stool*
Support vagina
or perineum*
Medications Number of Laxatives ⁄ enemas Laxatives ⁄ enemas ⁄ Laxatives ⁄ enemas
laxatives suppositories
Number of items* Four items One item Two items Five items Three items Three items Four items
congruent
with Rome III
(X items of 6)

*Items congruent with Rome III.

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ª 2008 The Authors, Aliment Pharmacol Ther 27, 638–648
 Table 2. Summary of psychometric properties of the self-report measures for constipation assessment
Validity Reliability

Construct

Number of Sensitivity Divergent ⁄ Factor Discriminant Internal

Measure Participants items ⁄ dimensions Content Criterion to change convergent analysis consistency Test–retest

CCQ (7) N = 221; 111 constipated Six items, unidimensional, Literature review, NR Kendall’s DV: reported; Completed Present, sensitivity Cronbach’s ICC = 0.70
patients; derived from 30 items patient interview tau = 0.69, CV: NR and specificity = 91% alpha = 0.79 10–14 days
110 healthy controls P = 0.001
CAS (11) N = 64; 32 at-risk Nine items, Literature review NR NR NR NR Present between Cronbach’s r = 0.98
patients being treated unidimensional patients at risk and alpha = 0.70 1 h delay
for cancer; healthy controls

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32 controls healthy adults; (t = 6.3, P < 0.0001)
16 healthy adults in Present, differentiates

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the reliability arm between moderate
and severe intensity
(t = 2.5, P < 0.01)
CSS (6) N = 232; consecutive Eight items, unidimensional, Literature review CSS scores correlate NR DV: NR; CV: not NR Present NR NR
patients with derived from 100 items with findings of performed
constipation with 12 dimensions physiology tests, PPV
96% (P < 0.05)
GQ (9) N = 349; community 21 items of which 13 are Rome I and II SR and Rome 1 good NR DV: NR; CV: partial test NR Present NR NR
dwelling adults; related to bowel habits, (kappa: 0.68, CI: Rome I and II
systematic unidimensional 0.59–0.77) Rome I
population based and Rome II gold
standard good (kappa:
0.71, CI: 0.61–0.81), SR
and Rome II moderate
(kappa: 0.55, CI: 0.44–0.65)
KESS (10) N = 91; 11 items, unidimensional Literature review, Discriminated between NR DV: NR; CV: NR Present, Mann– NR NR
71 chronically Rome II and CSS three pathophysiological correlation with Whitney U-test
constipated patients; 20 questionnaire subgroups (ROC 55%, CSS tool P < 0.0001
asymptomatic controls CI: 43–67%), median (Pearson r = 0.90) Sensitivity CI 95–100%
total KESS scores by and Specificity
subgroup N.S. (P = 0.13) CI 63–100%
PAC-SYM (8) N = 216; chronically 12 items, unidimensional Literature review Correlation of Change from DV: correlation with Completed Present, t = )6.1, Cronbach’s ICC = 0.75
constipated patients 3 subscales: stool and 5 focus groups subjects and visit 1 to SF-36 (physical P < 0.001 alpha = 0.89
symptoms (a), rectal of constipated patients investigator global visit 3 noted and mental 0.80 (a)
symptoms (b), severity ratings component summary 0.84 (b)
abdominal symptoms (c), (r = 0.72 and 0.68, scores) and PGWB 0.87 (c)
derived from 44 items P < 0.001) (r = 0.36, 0.49, 0.54
P < 0.0001); CV:
correlation indicated
between items and
bowel diaries,
though no r
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642 G . L . M C C R E A et al.

Content validity was established through a review

tau = 0.47–0.97,

NR, not reported; DV, divergent validity; CV, convergent validity; SR, self-report; PPV, positive predictive value; N.S., nonsignificant; ICC, Intra Class Coefficient; PGWB, Patient Global Well Being; SF-36, Medical Outcomes Study-
7-day delay
of the literature. Construct validity was evaluated

Test–retest

Kendall’s
by comparing 32 patients (69% female; mean
age = 53.9 years) who were at risk for developing con-
stipation from cancer treatments to 32 healthy adults

consistency
(94% female; mean age = 37.9). Significantly higher
Reliability

Internal
constipation scores were reported by the cancer

NR
patients than by the control group (t = 6.3,
Discriminates only P < 0.0001). In addition, symptom severity was evalu-
subjects without ated in two subgroups of the 32 cancer patients. Sig-
constipation
Discriminant

nificantly higher CAS scores were reported by patients

who received morphine than those who received vinca
alkaloids (t = 2.5, P < 0.01).11
Test–retest reliability of the CAS with 1-h delay was
analysis

high in a sample of 32 healthy controls (r = 0.98,

Factor

P = 0.000).11 The internal consistency of the CAS was

NR

found to be acceptable (a = 0.70 and 0.78) in a single

r = )0.68 stool consistency,

study. The findings from this single, small study, led

DV: NR; CV: correlated

evacuation P < 0.001

the authors to conclude that the CAS had acceptable

with items on daily

r = 0.56 incomplete
r = 0.52 straining,

psychometric properties to measure the severity of

bowel diaries

constipation.
convergent
Divergent ⁄
Construct

The CAS was modified and validated to assess con-

stipation in pregnant women.13 The original eight-item
measure was revised from a three-point to a five-point
Sensitivity

summated rating scale. A total score can range from 0

to change

to 32, with 0 to 8 indicating no to minimal problem

NR

with constipation during pregnancy; 9 to 16, indicat-

ing some problems; 17 to 24, indicating some to mod-
Criterion

erately severe problems and 25 to 32, indicating

NR

moderately severe to severe problems. The revised

scale was tested in a sample of 30 pregnant women
Rome I and II and SR

(15 who had low-risk pregnancies and 15 who had

Literature review,

high-risk pregnancies) and 16 nonpregnant women of

child-bearing age. The revised measure was found by
Validity

Content

an expert panel to have a high calculated percentage

of agreement of 0.75 and a Cohen’s kappa of 0.71.
Test–retest and internal consistency estimates for the
items ⁄ dimensions

unidimensional

revised measure were also high (r = 0.84, a = 0.82,

respectively).
Five items,
Number of

Constipation Scoring System. The Constipation Scor-

ing System (CSS)6 is an eight-item self-report measure
hospital employees,
prospective study
N = 369; healthy

designed to assess the prevalence and severity of con-

stipation. The authors used a pathophysiological defi-
Table 2. Continued

Participants

nition of constipation. The scoring system is based on

eight variables (frequency of bowel movements; diffi-
Short Form 36.

cult or painful evacuation; completeness of evacua-

VSAQ (12)

tion; abdominal pain; time per attempt; type of

Measure

assistance including laxatives; digitations or enemas;

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 Table 3. Summary of constipation measures: characteristics and clinical utility

Time to administer. Country of origin

Ease of use, Populations in which
Number Response mode of the instrument has
Measure of items format Scoring Time frame administration been used How often cited

CCQ(7) 6 0–4 Likert scale, Total score 0–24; Preceding 2 weeks Not reported Hong Kong 0
0 = asymptomatic, cut-off score ‡5 and preceding Patient sample reported
4 = very severe symptoms 3 months easy to understand
Questionnaire

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CAS(11) 8 0–2 Likert scale, Total score 0–16; Preceding week 2 min USA 8

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0 = no problem, >0 = problem with Readability of the Pregnancy, opioid
2 = severe problem constipation instrument sixth constipation in
grade level questionnaire patients with cancer
CSS(6) 8 0–4 Likert scale for Total score 0–30; Not reported Not reported USA 57 (5 times by
seven items; 0–2 Likert cut-off for constipation Not reported Constipated patients the authors)
scale for one item >15 Interview format
GQ(9) 21 (13 related to Never, sometimes, often, Not reported Preceding Not reported Spain 7
bowel habits) always; never, <1 per week, 12 months Pilot study concluded
‡1 per week, every day easy to understand
and to complete
Mailed questionnaire
KESS(10) 11 0–4 Likert scale for six items; Total score 0–39; Not reported <5 min UK 11
0–3 Likert scale for five items; cut-off score ‡11 Not reported
lower scores = symptom free, questionnaire
increased scores = increased
symptom severity
PAC-SYM(8) 12 0–4 Likert scale, Total score 0–48; Preceding Not reported US (42 translations; 9
frequency: cut-off score 2 weeks Pilot study concluded not all have been validated)
0 = none of the time, 4 = all not reported comprehensive and Opioid Constipation,
of the time; severity: understandable constipation in older
0 = absent, 4 = very severe Questionnaire adults in long-term care
VSAQ(12) 5 0–10 Likert for three items; Total score Preceding Not reported Turkey 2
1–5 Likert scale for two items not reported; 12 months Not reported
cut-off scores >3 Questionnaire
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644 G . L . M C C R E A et al.
number of unsuccessful attempts at evacuation in a
24-h period and duration of constipation). The CSS
consists of seven items that are scored using a five-
point Likert scale that ranges from 0 (none of the time)
to 4 (all of the time) and one item that is rated on a
0–2 scale. A total score can range from 0 (normal) to
30 (severe constipation). A cut-off score of 15 suggests
constipation.
The measure was tested in a sample of 232 patients
with constipation referred for an anorectal physiology
evaluation (79% female; mean age = 64.9). Significant
correlations, between CSS scores and objective findings
from anorectal physiology tests, provide evidence of
criterion validity (r not reported, P < 0.05). In addition,
CSS scores differentiated between patients who were
constipated and those who were not; both groups were
confirmed by physiological testing, with 96% accuracy.
Additional evidence to support the discriminant validity
of the CSS comes from its ability to distinguish between
subgroups of constipated patients and not constipated
patients whose condition was confirmed by physiologi-
cal tests. Physiological tests in this validation study
were used to establish convergent validity. However,
no data were reported on the reliability of the CSS, its
responsiveness, or its sensitivity to change.
Patient Assessment of Constipation – Symptom. The
Patient Assessment of Constipation – Symptom (PAC-
SYM)8 was developed as a brief, easily administered tool
to assess symptom frequency and severity of chronic
constipation. The authors used a definition for constipa-
tion based on the Rome II criteria.15 This 12-item self-
report measure is divided into three symptom subscales
(i.e. abdominal, rectal and stool). Items are scored on a
four-point Likert scale, with 4 indicating the worst
symptom severity. A total score for the PAC-SYM can
range from 0 to 48. No cut-off score was reported.
The initial psychometric evaluation of the PAC-SYM
involved patients (n = 216; 94% female; mean
age = 42.2) from nine sites.8 Subsequently, the validity
of the PAC-SYM was evaluated for use in older adults
in long-term care facilities16 and in patients with low
back pain and opioid-induced constipation.17
Criterion or concurrent validity was established based
on the high correlations between patient and investiga-
tor global severity ratings. Construct validity of the
PAC-SYM was established using exploratory factor and
multi-trait analyses. Six factors were retained based on
eigen values of >1 and factor loadings of >0.3 on at
least for items. The factor matrices were used to identify
a five-factor solution or five subscales: stool symptoms,
rectal symptoms, abdominal symptoms, systemic symp-
toms and urgency symptoms. Systemic symptoms and
urgency symptoms were found to be separate from the
constipation symptom domain and were deleted. The
final 12 items were assigned to three subscales: stool,
rectal and abdominal symptoms.8
Positive correlations between three items recorded in
a bowel diary (straining, incomplete evacuation and
stool consistency) and corresponding symptoms on the
PAC-SYM provide evidence of convergent validity.
Additional evidence of the PAC-SYM’s validity comes
from moderate positive correlations between items on
the Medical Outcomes Study-Short Form 36 (SF-36)
scale18 and the Patient Global Well Being (PGWB)
scale.19 Participants who received interventions for con-
stipation were assessed at three different times using the
PAC-SYM, to assess for both sensitivity to change and
discriminant validity. The PAC-SYM distinguished
between responders (those who reported improvement
in symptoms) and nonresponders (those who reported
no change or worse symptoms) (t = 6.1, P < 0.001).8
Estimates of test–retest reliability of the initial mea-
sure were high [r = 0.74, intraclass correlation coeffi-
cient (ICC) = 0.72, P < 0.01]. The Cronbach’s alpha for
the total PAC-SYM score was 0.98. Test–retest and
internal consistency estimates for the final measure
were high (a = 0.89, ICC 0.75). Subscale Cronbach’s
alphas were 0.80 for stool symptoms, 0.84 for abdomi-
nal symptoms and 0.87 for rectal symptoms.8
Knowles Eccersley Scott Symptom Score. The Know-
les Eccersley Scott Symptom (KESS)10 is an 11-item
measure that was developed to help diagnose constipa-
tion and to discriminate among pathophysiological
subgroups. The authors acknowledged that constipa-
tion is a poorly defined clinical symptom, but did not
provide a definition of constipation. This omission
makes evaluation of content validity nearly impossi-
ble. Items on the KESS are based on a review of the
literature, items from the CSS questionnaire,6 as well
as the Rome II criteria.15 The KESS uses four- to five-
point Likert scales that are scored on an unweighted
linear integer scale. Total scores can range from 0 (no
symptoms) to 39 (high symptom severity). A cut-off
score of ‡11 indicates constipation.
The KESS was tested in a sample of patients with
chronic constipation (n = 71; 93% female) and healthy
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controls (n = 20; 90% female) with a similar, unspeci-
fied age distribution in each group.10 Content validity
was established through a review of the literature and
incorporation of elements from the Rome II criteria
and the CSS into the KESS. In a sample of patients
with constipation, convergent validity was established
based on significant correlations between KESS and
CSS scores (r = 0.90). In addition, the KESS was able
to discriminate between constipated patients, whose
diagnosis was confirmed with physiological tests, and
healthy controls. KESS scores predicted which patients
had pure slow-transit constipation or rectal evacuatory
disorder better than patients with a mixed aetiology
(ROC 55%, CI: 43–67%). However, no significant dif-
ferences were found in median total KESS scores by
subgroup (P = 0.13). No data are available on the
reliability of the KESS or on its responsiveness or sen-
sitivity to change.
Visual Scale Analog Questionnaire. The Visual Scale
Analog Questionnaire (VSAQ)12 is a five-item tool
designed to assess the frequency and severity of con-
stipation symptoms in healthy individuals. The Rome
II definition of constipation was used to create the
items. Two of the five VSAQ items, stool consistency
and straining, are rated on a Likert scale that ranges
from 1 to 5. Three items, presence of constipation,
duration of constipation, incomplete evacuation, are
rated on a 0–10 scale. Methods for scoring the VSAQ
are not reported, although a score of ‡3 on the 0–10
scale is the cut-off score for constipation.
The VSAQ was tested in a sample of healthy hospital
employees (n = 369; 54% female; mean age = 31.6).
Participants were asked to rate each bowel movement
for 7 days. Significant correlations were found
between items on the VSAQ and bowel diaries (i.e.
straining and incomplete evacuation). The VSAQ was
found to be discriminative only for those participants
without constipation, not for those with constipation.
Estimates of test–retest reliability were high in healthy
participants (kappa = 0.97). However, no data were
reported on criterion validity, internal consistency or
sensitivity to change.
Garrigues Questionnaire. The Garrigues Questionnaire
(GQ)9 is a 21-item self-report measure that was devel-
oped to define the presence of chronic constipation.
Only 13 of the 21 items are related to bowel habits.
The Rome I20 and Rome II15 criteria were used to
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define constipation. A pilot study of 10 people deter-
mined that the GQ was easy to understand and to
complete. The items are scored using two different
four-point Likert scales. The first consisted of ‘never’,
‘sometimes’ (<25% of the time), ‘often’ (‡25% of the
time) and ‘always’. The second consisted of ‘never’,
‘fewer than once a week’, ‘one or more times a week’
and ‘every day’. Total and cut-off scores were not
reported.
The measure was tested in a sample of 349 partici-
pants (52% female; age range 18–65 years). Content
validity was established through having included the
Rome criteria in the development of the measure. Con-
vergent validity was reported through partial testing of
the Rome I and II criteria. The GQ was able to discrimi-
nate between participants with constipation and those
without it. However, the low, positive likelihood ratios
limit the clinical usefulness of the GQ to identify indi-
viduals with constipation. No data were reported on the
reliability of the GQ or on its sensitivity to change.
Chinese Constipation Questionnaire. The Chinese
Constipation Questionnaire (CCQ)7 is a six-item self-
report measure designed to diagnose functional consti-
pation in Chinese participants. The Rome II criteria15
were used as the definition of constipation.
A sample of 111 patients (95% female; mean
age = 38.5) with constipation and 110 healthy con-
trols (64% female; mean age = 34.2) participated in a
4-week psychometric evaluation of the CCQ. The
initial version of the CCQ consisted of 24 items that
were scored using a five-point Likert scale. Principal
components analysis was used to create the final
version of the CCQ that consisted of six items with
four subscales: bowel function, stool and rectal symp-
toms, laxative use and abdominal symptoms. A com-
posite score was generated by principal components
analysis with a cut-off score of ‡5 being able to dis-
criminate between controls and constipated patients
with both a sensitivity and specificity of 91%.
Content validity of the CCQ was established through
interviews with patients and a review of the literature.
Evidence of construct validity was provided by nega-
tive correlations between CCQ scores and seven
domains on the SF-36 scale18 (physical functioning,
role physical, bodily pain, general health, social func-
tioning, role emotional and mental health), but not
vitality. In addition, the CCQ was able to discriminate
between constipated patients and healthy controls.
646 G . L . M C C R E A et al.
Estimates of test–retest reliability were high
(ICC = 0.70, P < 0.01), with patients rating themselves
unchanged from baseline and at a second retesting
10–14 days later. Cronbach’s alpha for the total CCQ
score was 0.79.
Critique of the seven constipation measures
Definition of constipation. Defining a construct is an
important first step in the development of a measure.
Historically, measurement of stool frequency was used
to define constipation. ‘Normal’ frequency of stool
evacuation comprises a narrow to a broad range of
time that has large intraindividual and interindividual
variability. This self-report criterion does not describe
the entire symptom experience of constipation. The
definition of constipation has evolved to now include
abdominal and rectal symptoms.
Wide variations exist in the definition of constipa-
tion used in the development of measures included in
this review. The CSS and KESS utilized a purely path-
ophysiological definition based on the underlying aeti-
ology of constipation (e.g. slow transit and pelvic
outlet obstruction). Interestingly, developers of the
CSS and KESS attempted to identify the subtypes of
constipation more from a clinical than a mechanistic
perspective. In contrast, the developers of the CAS
provided a clear definition of constipation and used it
to develop the instrument. The CCQ, PAC-SYM and
VSAQ were developed using the Rome II criteria,15
whereas the developers of the GQ used both the Rome
I20 and Rome II15 criteria.
Content of the measures. How a construct is opera-
tionalized is represented by the content included in
the measure. Table 1 provides a synthesis of the
content evaluated by each measure. We compared
each measure with the others in terms of its specific
content. We also compared the content of each mea-
sure with the symptoms of functional constipation
found in the most recent version of the Rome crite-
ria21 (i.e. at least two or more of the following
symptoms at least 25% of the time: straining, lumpy
or hard stools, sensation of incomplete evacuation,
sensation of anorectal obstruction, manual manoeu-
vres to facilitate evacuation, fewer than three defe-
cations per week). As no gold standard exists for
the evaluation of the symptoms of constipation, we
compared the content of these measures to the Rome
III criteria because these criteria are a diagnostic
standard.22
All but one8 of the seven measures evaluate some
aspect of stool frequency. However, only the CCQ and
VSAQ assess frequency of bowel movements using the
Rome III format of <3 bowel movements per week.
The remaining measures assess stool frequency in a
variety of ways and three measures6, 9, 10 include an
evaluation of the length of time per attempt.
Stool consistency is evaluated in all but one6 of the
measures. In five of the measures,7–10, 12 hard stool is
one of the descriptors and is consistent with the Rome
III criteria. At the other end of the continuum, the
descriptors of stool consistency are not consistent (e.g.
oozing and watery).
In terms of rectal symptoms, all seven measures
include a rating of incomplete evacuation, which is
one of the Rome III criteria. Five measures6–11 have
‘urge to defecate present, unable to defecate’ as one of
the items in this content area. Three measures6, 8, 11
include a rating of ‘pain with defecation’. Only three
measures8, 9, 12 contain the other Rome criterion,
namely straining.
Six of the seven measures include abdominal symp-
toms. The two most common symptoms assessed are
bloating and abdominal pain. These symptoms do not
appear in the Rome III criteria for functional constipa-
tion, but are descriptors for irritable bowel syndrome.
Only three6, 9, 10 of the seven measures assess for
the use of assistive measures, which is part of the
Rome III criteria. Only three of the measures6, 10, 12
evaluate the duration of constipation.
None of the seven measures includes all of the Rome
III criteria for functional constipation. The total num-
ber of items matching the Rome III criteria ranges
from only 111 to 59 of the 6, in addition to a range of
other symptoms described above and in Table 1. Our
review of the content in all of the measures suggests
that the assessment of constipation using self-report
measures is complex.
Psychometric properties: validity. The psychometric
properties of the seven measures are summarized in
Table 2. All of the measures provide some evidence of
content validity. Most of the measures were developed
based on a review of the literature, but the CCQ and
the PAC-SYM were based on patient interviews and
clinical opinions. Four measures provided evidence of
good-to-moderate criterion validity by demonstrating
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 R E V I E W : S E L F - R E P O R T M E A S U R E S T O E V A L U A T E C O N S T I P A T I O N 647

significant correlations between the measure’s scores over time. Of these two measures, only the PAC-SYM
and Rome I and II criteria,9 anorectal physiological has undergone psychometric evaluation in more than
tests6–10 or patient and investigator global severity one patient sample.16-17
ratings.8
Evidence of convergent validity was established in
General characteristics of the seven constipation
five measures6, 8–10, 12 through significant correlations
measures. Table 3 summarizes the general character-
between constipation symptoms and a variety of con-
istics and clinical utility of the seven measures. Three
stipation measures such as bowel diaries, Rome criteria
measures (43%) were developed in the United
and self-report measures. However, the authors of the
States,6, 8, 11 one in Hong Kong,7 one in Spain,9 one in
CSS did not identify the measures used to support
Turkey12 and one in the United Kingdom.10 Only the
their assertion of convergent validity.
PAC-SYM has been translated into several languages,
Only the CCQ and the PAC-SYM provided evidence
though validation studies of the translations have not
of divergent validity. Both these measures were associ-
been published.
ated with changes in QOL. Patients with higher consti-
The target population was identified in all seven of
pation scores on the CCQ reported lower scores on
the measures. For two of the measures,9–12 the target
seven domains of the SF-36.18 The PAC-SYM had
population was the general population, which consisted
moderate positive correlations with items on both the
of healthy individuals. Four measures6–8, 10 identified
SF-36 and PGWB,19 showing a relationship between
patients with constipation as the target population. Only
symptoms and QOL. The authors of the PAC-SYM con-
one measure11 was constructed as a risk assessment
cluded that their tool measured a construct distinct
measure for patients undergoing cancer treatment.
from QOL.
Participant and administrator burden are minimal
Although discriminant validity was tested in all
for all seven of the measures. Time to completion
seven of the measures, only four of them6, 7, 10, 11 pro-
ranges from 5 to 15 min because the number of items
vided evidence to support their measure’s ability to
ranges from 5 to 21. Six measures have <12 items.
discriminate between patients with and without consti-
While short measures are clinically useful, they may
pation, and only one of them8 provided evidence to
lack sensitivity and specificity.
support their measure’s ability to discriminate between
All of the measures used some form of a Likert
responders and nonresponders. The two other mea-
scale, with 3–5 points to rate items. While the Likert
sures9, 12 were only able to identify patients who did
scale is a widely used scaling technique, the require-
not have constipation, which limits the utility of these
ments for a ‘good’ scale include a minimum number
measures.
of items (usually >10 items) and an adequate number
A validity test essential for measures with evaluative
of response alternatives (usually ‡5 points) to ensure
purpose is sensitivity to change. This test, frequently
the scale’s reliability.23 Only the PAC-SYM meets both
mistaken for test–retest, analyses the sensitivity of the
these criteria.
tool to measure changes in a symptom over time. Only
A cut-off score is an important aspect of the clinical
the PAC-SYM and the CCQ provided evidence of the
utility of a measure. Without a cut-off score, it is diffi-
measure’s ability to detect changes in constipation
cult to use a measure for treatment decisions and out-
over time.
come evaluation. Five of the measures6, 7, 10–12
reported a cut-off score for the presence of constipa-
Psychometric properties: reliability. Reliability esti- tion. The scoring system for the KESS is rather compli-
mates were reported for only four7, 8, 11, 12 of the cated, which may limit its clinical utility.
seven scales. All four have Cronbach’s alphas in the
acceptable range of ‡0.70. In addition, adequate esti-
CONCLUSIONS
mates of test–retest reliability were reported for the
same four measures.7, 8, 11, 12 Only the CCQ7 meets all of our prespecified criteria for
Our analysis of their psychometric properties found a constipation self-report measure. It underwent rigor-
that only the CCQ and the PAC-SYM provide robust ous development and testing; provided robust esti-
evidence of validity and reliability. Both measures also mates of validity and reliability; described a cut-off
provide evidence of their sensitivity to detect change score that discriminated for constipation and provided

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Journal compilation ª 2008 Blackwell Publishing Ltd
648 G . L . M C C R E A et al.

evidence of the measure’s sensitivity to detect change
over time. The major limitation of the CCQ is that it
was designed for a Chinese-speaking population and
no published reports in English-speaking populations
were identified, which suggests that it is not widely
used. The PAC-SYM8 is an acceptable alternative.
Although a cut-off score and its ability to discriminate
between healthy and symptomatic patients have not
been determined, other positive aspects of this measure
include the degree of rigor used in its development,
robust validity and reliability estimates, its sensitivity
to detect change, and use in English-speaking popula-
tions.
The results of this summary and critique suggest that
additional research is warranted to refine or develop a
more comprehensive self-report measure to evaluate
constipation in adults. As this review highlights, no one
perfect measure is currently available. A measure is
needed that evaluates the complex constellation of
symptoms that constipation encompasses. Using the
findings from this review, more comprehensive mea-
sures can be developed and tested in a variety of clini-
cal populations, as well as in the general population.
The development of more valid, reliable and compre-
hensive self-report measures of constipation will facili-
tate research on its epidemiology and management.
ACKNOWLEDGEMENTS
Declaration of personal interests: None. Declaration of
funding interests: The writing of this paper was funded
in part by the Betty Irene Moore Fellowship.

questionnaire. Scand J Gastroenterol 16 Frank L, Flynn J, Rothman M. Use of a

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