’Review article

Clinical practice guidelines from the French National

Society of Coloproctology in treating chronic
constipation
Véronique Vittona, Henri Damonc, Alban Benezecha, Dominique Bouchardd, Sarah Brardjanianb,
Charlène Brocharde, Benoit Coffing,h, Nadia Fathallahi, Thierry Higuerol, Pauline Jouëtj, Anne-Marie Leroim,
Laure Lucianob, Guillaume Meuretten, Thierry Picheo, Alain Ropertf, Jean-Marc Sabatek and Laurent Siproudhise;
for the SNFCP CONSTI Study Group

Chronic constipation is a common symptom that regularly affects the quality of life of adult patients. Its treatment is mainly based
on dietary rules, laxative drugs, perineal rehabilitation and surgical treatment. The French National Society of Coloproctology
offers clinical practice recommendations on the basis of the data in the current literature, including those on recently developed
treatments. Most are noninvasive, and the main concepts include the following: stimulant laxatives are now considered safe drugs
and can be more easily prescribed as a second-line treatment; biofeedback therapy remains the gold standard for the treatment
of anorectal dyssynergia that is resistant to medical treatment; transanal irrigation is the second-line treatment of choice in
patients with neurological diseases, but it may also be proposed for patients without neurological diseases; and although
interferential therapy may be a new promising treatment, it needs further evaluation. Eur J Gastroenterol Hepatol 00:000–000
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Introduction tools for treatment are dietary rules, laxative drugs, perineal
rehabilitation and surgical treatment. The first French
Chronic constipation (CC) is a frequent symptom, with an
recommendations were published in 2007 [6]. However, in
estimated prevalence of 10–15% of the population [1],
recent years, some new treatments, such as colokinetics,
and can significantly impact the quality of life [2]. CC is
transanal irrigation, botulinum toxin or sacral nerve mod-
usually classified into primary or secondary constipation.
ulation, have been developed, but no recent recommendation
Moreover, the mechanism of CC is of particular importance
has been published. Therefore, the French National Society
in clinical practice and primary constipation is, therefore,
of Coloproctology (SNFCP) took the initiative of establishing
classified into defaecation disorders (= distal constipation)
recommendations for clinical practice in this area.
and slow-transit constipation (STC) [3]. CC treatment is
often disappointing and different countries have published
their recommendations according to the cultural habits and Methods
the availability of the treatments and drugs [4,5]. The main
The organizing committee was appointed by the SNFCP. A
European Journal of Gastroenterology & Hepatology 2018, 00:000–000
list of questions was defined and a working group was chosen
to be representative of professional exercises. The working
Keywords: biofeedback therapy, chronic constipation, laxative drugs,
recommendations group analysed each selected item according to the principles
a
Gastroenterology Unit, North Hospital, AP-HM, Clinical Interface Unit CRN2M,
of critical reading of the literature, which allowed for assign-
UMR 7286, Aix-Marseille University, bGastroenterology Unit, Military Hospital of ment of a level of scientific evidence to each item. A systematic
Laveran, Marseille, cPhysiological Digestive Unit, Edouard Herriot Hospital, study was carried out of the MEDLINE, HealthSTAR,
Hospices Civils de Lyon, Lyon, dMedical and Surgical Unit of Coloproctology, EMBASE, PASCAL and Cochrane Library databases. At first,
Bagatelle Hospital, Talence, eGastroenterology Unit, Pontchaillou Hospital, Rennes
it identified, over a period of 10 years, the recommendations
1 University, fPhysiological Digestive Unit, Rennes, gAP-HP, Gastroenterology Unit,
Louis Mourier Hospital, Colombes, hDenis Diderot–Paris 7 University, for clinical practice, consensus conferences, articles in medical
i
Proctological Unit, Hospital Group Paris Saint-Joseph, Léopold Bellan Institute, decision-making, systematic reviews and meta-analyses on the
j
Gastroenterology Unit Ambroise Paré Hospital, kGastroenterology Service, subject to assess the relevance of keywords and their combi-
Avicenne Hospital, Paris, lGastroenterological Office, Beausoleil, mPhysiological nations. The literature obtained by automated search was also
Digestive Unit, Charles Nicolle Hospital, Rouen, nSurgical Digestive Clinic, CHU
Nantes, Nantes and oGastroenterology Unit, Nice, France
supplemented by a manual search performed by each member
of the working group.
Correspondence to Veronique Vitton, MD, Gastroenterology Unit, North Hospital,
AP-HM, Clinical Interface Unit CRN2M, UMR 7286, Aix-Marseille University, The analysis was carried out on the basis of this search
Marseille 13915, France and, whenever possible, the proposed working group
Tel: + 33 491 965 598; fax: + 33 491 965 108; e-mail: vittonv@yahoo.com recommendations. Depending on the level of evidence of
Received 25 August 2017 Accepted 12 October 2017 the studies on which they are based, the recommendations
Supplemental Digital Content is available for this article. Direct URL citations
have a degree of variability, listed from A to C according
appear in the printed text and are provided in the HTML and PDF versions of this to the scale proposed by the Haute Autorité de Santé
article on the journal’s website, www.eurojgh.com. (HAS) (Table 1). In the absence of sufficient scientific data,

0954-691X Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/MEG.0000000000001080 1

Copyright r 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
2 European Journal of Gastroenterology & Hepatology
Table 1. Levels of evidence
Level of evidence A
Level of evidence B
Level of evidence C
the recommendation was based on a professional recom-
mendation (Expert Recommendation) of the working
group. References cited in the manuscript have contributed
towards the development of grade recommendations that
rely on all available references on the topic for analysis.
The reading group was consulted to advise on the content
and form of recommendations, particularly on their read-
ability and applicability according to Delphi methodology.
The comments of the reading group were considered
whenever possible in finalizing recommendations.
Behavioural and dietetic rules
Patients with CC should be asked about their behavioural
and dietary habits. First, it is recommended to stop, if
possible, any drug that can induce constipation (Expert
Recommendation).
In terms of behavioural rules, and despite the lack of studies,
the following is recommended (Expert Recommendation):
(a) to promote a regular gastrointestinal reflex with a daily
presentation to the toilet; (b) to recommend an optimal posi-
tion for defaecation, that is, foot up to open the anorectal
angulation and (c) to recommend an improvement in the
environmental conditions, that is, a calm environment with the
door closed [7–10].
For dietary rules, data from the literature confirm that it
is recommended to gradually increase the daily fibre intake
by dietary or pharmaceutical supplementation over 2 weeks
(to reduce the undesirable effects of bloating and digestive
discomfort) until reaching the recommended dose of at least
25 g/day to treat mild to moderate CC. It is important to
note that the fibre intake also includes dried plumes, which
has been shown to significantly improve stool consistency,
with a better efficacy than psyllium in patients with from
mild to moderate CC (Level II, Grade B) [10–13]. More
recent data have recommended water rich in minerals,
especially magnesium. Indeed, a recent randomized study
has reported a significant laxative effect of 1 l/day of water
rich in magnesium [14]. Therefore, this new rule can be
recommended with a sufficient level of scientific evidence
(Level II, Grade B).
In contrast, in the absence of studies with sufficient meth-
odology, no strong recommendations can be made on the
following (Expert Recommendation): (a) the consumption of
foods other than fibres, such as cheese, milk, meat, rice, eggs,
olive oil, sweet almond oil, etc. (Expert Recommendation);
(b) overeating, except in a targeted population (young women
dieting or with anorexia and elderly individuals with a loss of
appetite); (c) an increase in the daily water intake except in the
case of dehydration in elderly individuals or a normalization
of water intake (1.5–2 l/day) and (d) the recommendation of
regular physical activity.
Laxative drugs
There are currently six categories of laxatives available in
France: osmotics (macrogol, polyethylene glycol, etc.), bulk
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Month 2018 • Volume 00 • Number 00
Data derived from multiple randomized clinical trials or meta-analyses
Data derived from a single randomized clinical trial or large nonrandomized studies
Consensus of the expert and/or small studies, retrospective studies and registries
laxatives (psyllium, ispaghul, sterculia, wheat bran, etc.),
lubricants (paraffin oil, etc.), stimulants (bisacodyl, docusate
sodium, sennosides, etc.), colokinetics (prucalopride) and local
laxatives (suppositories of sodium bicarbonate + potassium
acid tartrate and enemas of sorbitol + sodium citrate).
Despite the lack of scientific data, it is possible to
recommend an association of different classes of laxatives
(Expert Recommendation).
First-line laxatives
Osmotic and bulk laxatives remain the first-line laxative
treatment for treating CC, including during pregnancy
(Expert Recommendation).
Osmotic laxatives are recommended as a first-line treat-
ment for constipation on the basis of their efficacy and good
tolerance with the dietetic rules or as a complement to them
(Level II, Grade B). They are more effective than a placebo
with an increase of 2–3 stools per week and a two-fold
higher success (≥3 stools/week) (Level I, Grade A). Among
osmotic laxatives, polyethylene glycol is more effective than
lactulose in improving the stool frequency and consistency as
well as for abdominal pain (Level I, Grade A) [15–20].
Bulk laxatives can be soluble (psyllium, ispaghule, etc.) or
insoluble fibres (wheat bran). These are organic polysaccharides
that retain water in the intestinal lumen. They should be
ingested with sufficient quantities of water [13,21,22]. They are
also a first-line laxative option (Level II, Grade B). Moreover,
they can improve the frequency and consistency of faeces as
well as the symptoms of dyschesia. Their main side effects are
meteorism and flatulence. Bulk laxatives are contraindicated in
cases of intestinal stenosis, faecal impaction or inflammatory
colitis.
Second-line laxatives
Lubricating laxatives include paraffin oils. Paraffin oils
have a mechanical action in lubricating and softening the
colonic content. They may be offered as a second-line
therapeutic agent in the event of failure of bulk laxatives or
osmotics (Level III, Grade C). Their use is contraindicated
in the case of swallowing disorders and oesogastric motor
function, particularly in the elderly, because of the risk of
lipoid pneumonitis, and its main side effect is the loss of
lipid-soluble vitamins [23–26].
Stimulant laxatives, such as bisacodyl, may be proposed
as a second-line option in case of failure of osmotic and/or
bulk laxatives (Level II, Grade B). They inhibit the
absorption of water and electrolytes, stimulate colonic
motility by direct action on the myenteric nerve plexuses
and accelerate colonic transit [27]. Their efficacy (on the
symptoms and quality of life) has been reported in two
randomized studies [28,29]. Until the 2000s, it was
recommended to reserve the use of stimulant laxatives to
special situations (elderly, constipation refractory to other
treatments) over short periods as a second-line treatment
(Level III, Grade C) [6,30]. More recently, the intermittent
use of stimulant laxatives as a recourse treatment in
 CC Vitton et al.
constipation resistant to commonly recommended treat-
ments has been proposed by several experts (Level II,
Grade B) [31,32]. In a recent technical review, the American
Gastroenterological Association recommended using sti-
mulant laxatives for recourse treatment (if patients did not
have a stool for 2 days) or more regularly, if necessary [16].
In another review, a group of European experts proposed
empiric treatment by osmotic laxatives and/or stimulants as
a first-line treatment [15] (Level III, Grade C).
With respect to the available literature data, the current
French recommendations are that stimulant laxatives can
be proposed if patients have not had stools for several days
(Level III, Grade C). Moreover, (a) their short-term
adverse effects are acceptable and dominated by diar-
rhoea (Level II, Grade B) and (b) in the long term, their
side effects have long been overestimated and are limited
(Expert Recommendation).
These data are important because, for many years, the
use of stimulant laxatives has been discouraged on the
basis of more or less justified fears of complications
[33,34]. In the middle of the last century, it was recognized
that the prolonged use of these molecules led to peripheral
neuropathies with a loss of neurons, especially in animal
models [35]. However, these data have never been con-
firmed, and the neurological impairment reported in the
first studies seems to be the cause of constipation rather
than the consequence of the treatment [36]. Anatomical
changes were also induced with luminal distension and a
loss of colonic haustrations, but the physiopathological
and clinical impacts of these changes have never been
established [37]. A role in stimulating carcinogenesis has
also been suggested [38], but this has not been confirmed
by recent studies, especially prospective studies [39,40]. In
a prospective study on a large cohort of 84 555 women,
there was no association between the use of laxatives and
colonic cancer [40]. Therefore, in its latest technical
review, the American Gastroenterological Association
considered these molecules to be ‘safe’, even in long-term
use [16]. Finally, the use of bisacodyl is authorized in
pregnant women [41,42].
Prucalopride, the only representative of the class of
colokinetics, has proven its efficacy in treating CC with a
high level of scientific evidence (Level I, Grade A). Three
pivotal studies were published until marketing authoriza-
tion in Europe and, more recently, in France at the
beginning of December 2009. Camilleri et al.’s [43] ran-
domized, placebo-controlled study included 620 patients
with severe CC with less than two complete spontaneous
evacuations per week. In this study, the proportions of
patients with more than three spontaneous stools per week
with a complete evacuation sensation were 30.9 and
28.4%, respectively, of patients treated with 2 and 4 mg of
prucalopride compared with 12% treated with placebo.
The most common side effects included headache, nausea
and diarrhoea. In the study by Tack et al. [44], 713
patients were included and received 2 or 4 mg of pruca-
lopride daily or placebo for 12 weeks. The number of
patients with more than three spontaneous stools per week
was 19.6% at 2 mg and 23.6% at 4 mg compared with
9.6% with placebo. Quigley et al. [45] obtained similar
results in another study carried out on 641 patients treated
with 2 or 4 mg of prucalopride versus placebo for 12 weeks.
The authors observed that 23.9 and 23.5%, respectively, of
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www.eurojgh.com 3
patients treated with 2 or 4 mg of prucalopride had more
than three spontaneous and complete stools per week com-
pared with 12.1% for placebo. The three pivotal studies
concluded that compared with placebo, treatment with pru-
calopride for 12 weeks at a dose of 2 or 4 mg/day significantly
improved the symptoms of CC, irrespective of the assessment
criteria (Level 1, Grade of Recommendation A).
Prucalopride (2 mg/day) is currently indicated in the
second intention after the failure of hygienodietetic rules
and osmotic and/or bulk laxatives (Level I, Grade A). After
only initially being authorized in women, its use has, since
27 May 2015, also been authorized in men in France.
Nevertheless, in France, its high, unreimbursed cost has
largely curbed its prescription.
‘Local’ laxatives
‘Local’ laxatives include suppositories and enemas. They
may be prescribed in the case of defaecation disorders (distal
constipation) alone or associated with constipation of transit.
The new French recommendations confirm that CO2-releasing
suppositories are recommended as a first-line approach in
distal constipation (Level I, Grade A) [46]. Moreover, as
shown by a randomized study, the combination of their use
with biofeedback rehabilitation is recommended because of a
synergistic and lasting effect with a high level of scientific
evidence (Level I, Grade A) [47].
New prosecretory compounds
Lubiprostone, linaclotide, plecanatide and other drugs
available in other American or European countries are still
not currently available in France. Therefore, no practical
recommendations may be made on their use.
Probiotics
At present, despite many publications on probiotics, the
level of scientific evidence remains poor. Therefore, the use
of probiotics for treating CC cannot be recommended
(Expert Recommendation) [48].
Transanal irrigation
Transanal irrigation is recommended in patients with
faecal incontinence and constipation related to a neuro-
logical disease (Level I, Grade A) [49–51]. It aims to obtain
a colonic cleansing to reduce faecal incontinence episodes.
This treatment is recommended as a second-line treatment
for constipation in neurological patients after failure of
conservative treatment (Level I, Grade A). Despite the lack
of sufficient level of evidence studies and according to
clinical practices, transanal irrigation may be proposed in
the treatment of CC in the absence of neurological
pathology (Expert Recommendation) [52].
Botulinum toxin
Injection of botulinum toxin may be proposed in distal
constipation (Level II, Grade B), especially as adverse
effects are minor (Expert Recommendation). The objec-
tives of these injections are to reduce resting anal pressure
and to improve puborectalis relaxation during straining
[53]. In clinical practice, the use of botulinum toxin
injection and biofeedback is recommended in case of failure
4 European Journal of Gastroenterology & Hepatology
of biofeedback alone (Expert Recommendation) [54–56].
However, the modalities for injecting botulinum toxin are
still not defined and should be evaluated in further studies
(Expert Recommendation).
Perineal rehabilitation
In patients with CC with only anorectal dyssynergia persistent
after dietetic changes and laxative drugs, perineal rehabilita-
tion remains the mainstay treatment. It aims to improve the
coordination of abdominal and anorectal muscles, has to be
comprehensive and is associated with perineal sphincters
and abdominal retraining. Perineal rehabilitation should be
preceded by anorectal manometry to clarify the symptom’s
mechanisms. Moreover, to confirm the diagnosis of functional
daefecation disorder, two concordant tests are necessary:
anorectal manometry and/or balloon expulsion test and/or
pelvic floor imaging. Various techniques have been described,
but biofeedback is the most effective method of rehabilitation.
Therefore, data from the literature confirm that biofeedback
therapy must be recommended for treating CC with asyn-
chronism with a high scientific level of evidence (Level I,
Grade A) [57–59].
Predictive factors identified for a good response to
rehabilitation are the presence of hard stools, the high
resting pressure measured with anorectal manometry, long
balloon expulsion time and patient motivation (Expert
Recommendation). Conversely, psychological disorders
(eating disorders, depression and anxiety) associated with
Fig. 1. Decision algorithm in chronic constipation.
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Month 2018 • Volume 00 • Number 00
anorectal disorders are associated with a worse response to
rehabilitation (Expert Recommendation) [60,61].
Stimulation techniques
Sacral nerve stimulation
Sacral nerve stimulation (SNS) is an effective method to
treat faecal incontinence, whereas its mechanism of action
remains unclear. Some studies have assessed its effective-
ness in treating CC, including four randomized studies
[62–65]. However, because of contradictory results and
the cost of the technique, SNS cannot currently be
recommended in CC treatment (Level II, Grade B).
Nevertheless, in certain special cases and after consultation
in expert centres, an SNS test may possibly be proposed on
a case-by-case basis (Expert Recommendation).
Interferential therapy
Three interesting studies from the same Australian team
and including a randomized trial have reported the success
of interferential therapy in the treatment of CC in children
[66–68]. The treatment consists of the use of a 6-V battery-
operated interferential stimulating machine through four
adhesive surface electrodes. Despite encouraging results,
data in the literature remain insufficient and the use of
interference current cannot be recommended at present
(Expert Recommendation) because further data from an
on-going randomized study are pending [69].
 CC Vitton et al.
Alternative and complementary medicines
Alternative and complementary medicines are mainly based
on the scientific level of evidence with numerous biases.
However, their use might be considered in patients who fail
conventional treatments (or who refuse them) according to
the context or their ‘sensitivity’ and ‘confidence’ in one or
another approach (Level II, Grade B) [70–72].
Surgical treatment
CC treatment is mainly based on conservative measures;
therefore, surgery will only be used for a limited number of
patients. In clinical practice, surgery will only be considered
when all conservative strategies have failed, such as in STC
and distal constipation. The proposed surgical approaches
include correctional interventions for pelvic floor disorders,
colectomies (segmental and total), coloproctectomy and,
more anecdotally, miniostomies (Malone procedure) and
derivative stoma.
Distal constipation and pelvic floor disorders
The surgical correction of a pelvic floor disorder may be a
factor in improving distal constipation when radiologically
significant imaging is related to the patient’s symptomatology
(Expert Recommendation). In this case, both abdominal
and transanal approaches have been shown to be effective
(Evidence Level III for ventral mesh rectopexy, Level of
Evidence I for STARR intervention). Depending on the ana-
tomical findings, one or the other approach can be proposed
(Level II, Grade B). Ventral mesh rectopexy will mainly be
proposed in patients with rectal prolapse, whereas the
STARR intervention will mainly be proposed in patients with
rectal intussusception and/or rectocele [73–76].
Slow-transit constipation and colectomy
When an operative approach is discussed for a patient with
STC, total colectomy is the recommended reference inter-
vention. Segmental colectomy cannot be recommended as a
reference surgical treatment for transit constipation because of
the insufficient results in the literature. Given an unproven
long-term benefit and series reporting selected cases, it is
recommended that such patients be placed in an expert centre,
as a last resort, after failure of other medical and minimally
invasive alternatives (Expert Recommendation) [77–81].
Colonic irrigations
Antegrade irrigation, Malone antegrade continence enema,
may be proposed in case of failure of transanal irrigation
(Expert Recommendation). It is an alternative option for
patients with STC. In this case, it is recommended that
patient information be obtained and follow-up be performed
in conjunction with a paramedical team (stomatologists).
For 25 years, experience and patient follow-up have
enabled the assessment of long-term results. Most of the
series report satisfactory results, with good quality of life
for patients selected for this approach. However, in studies
targeting patients with constipation, the results are often
more mixed [82–85]. The literature is nevertheless very
poor in the series, and the studies on this topic generally
include a low number. An endoscopic variant has been
studied recently, with interesting results that are
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www.eurojgh.com 5
functionally equivalent to the surgical technique [86].
However, the current literature data do not support an
endoscopic approach more than a surgical one (Expert
Recommendation).
Conclusion
Numerous data are currently available in the literature on
the treatment of CC in adults with various success rates.
Clinical guidelines are useful data to help practitioners in
their daily practice in the context of the high number of
studies. The treatment of CC is mainly conservative.
Figure 1 shows the current guidelines of the French
National Society of Coloproctology, including the level of
scientific evidence and expert consensus.
Acknowledgements
The collaborators of the SNFCP CONSTI Study Group are
listed in the Online Supplementary Appendix (Supplemental
digital content 1, http://links.lww.com/EJGH/A261).
Organizing committee: Veronique Vitton, Henri Damon
and Laurent Siproudhis.
Working Group: Laurent Abramowitz, Alban
Benezech, Dominique Bouchard, Sarah Brardjanian,
Charlène Brochard, Benoit Coffin, Henri Damon, Michel
Dapoigny, Emilie Duchalais, Marianne Eleouet-Kaplan,
Nadia Fathallah, Charlotte Favreau-Weltzer, Aurélien
Garros, Thierry Higuero, Pauline Jouet, Anne-Marie
Leroi, Laure Luciano, Guillaume Meurette, Vincent de
Parades, Thierry Piche, François Pigot, Elise Pomaret,
Guillaume Portier, Alain Ropert, Pauline Roumeguère,
Jean-Marc Sabate, Laurent Siproudhis, Thomas Uguen,
Aurélien Vénara, Béatrice Vinson-Bonnet, Thimothée
Wallenhorst, Camille Zallot and Frank Zerbib.
Reading group: Laurent Abramowitz, Alban Benezech,
Dominique Bouchard, Sarah Brardjanian, Charlène Brochard,
Benoit Coffin, Henri Damon, Michel Dapoigny, Emilie
Duchalais, Marianne Eleout-Kaplan, Nadia Fathallah,
Charlotte Favreau-Weltzer, Aurélien Garros, Thierry Higuero,
Pauline Jouet, Anne-Marie Leroi, Laure Luciano, Guillaume
Meurette, Vincent de Parades, Thierry Piche, François Pigot,
Elise Pomaret, Guillaume Portier, Alain Ropert, Pauline
Roumeguère, Jean-Marc Sabate, Laurent Siproudhis, Thomas
Uguen, Aurélien Vénara, Béatrice Vinson-Bonnet, Thimothée
Wallenhorst, Camille Zallot and Frank Zerbib.
Conflicts of interest
There are no conflicts of interest.
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