Constipation

Description of condition
Constipation is defaecation that is unsatisfactory because of infrequent
stools, difficult stool passage, or seemingly incomplete defaecation. It can
occur at any age and is commonly seen in women, the elderly, and during
pregnancy.

It is important for those who complain of constipation to understand that

bowel habit can vary considerably in frequency without doing harm. Some
people erroneously consider themselves constipated if they do not have a
bowel movement each day.

New onset constipation, especially in patients over 50 years of age, or

accompanying symptoms such as anaemia, abdominal pain, weight loss,
or overt or occult blood in the stool should provoke urgent investigation
because of the risk of malignancy or other serious bowel disorder. In
those patients with secondary constipation caused by a drug, the drug
should be reviewed.

Overview
In all patients with constipation, an increase in dietary fibre, adequate
fluid intake and exercise is advised. Diet should be balanced and contain
whole grains, fruits and vegetables. Fibre intake should be increased
gradually (to minimise flatulence and bloating). The effects of a high-fibre
diet may be seen in a few days although it can take as long as 4 weeks.
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Adequate fluid intake is important (particularly with a high-fibre dietPage
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fibre supplements), but can be difficult for some people (for example, the
frail or elderly). Fruits high in fibre and sorbitol, and fruit juices high in
sorbitol, can help prevent and treat constipation.

Misconceptions about bowel habits have led to excessive laxative use.

Laxative abuse may lead to hypokalaemia. Before prescribing laxatives it
is important to be sure that the patient is constipated and that the
constipation is not secondary to an underlying undiagnosed complaint.

Laxatives

Bulk-forming laxatives
 Bulk-forming laxatives
Bulk-forming laxatives include bran, ispaghula husk (/drugs/ispaghula-
husk/), methylcellulose and sterculia (/drugs/sterculia/). They are of
particular value in adults with small hard stools if fibre cannot be
increased in the diet. Onset of action is up to 72 hours. Symptoms of
flatulence, bloating, and cramping may be exacerbated. Adequate fluid
intake must be maintained to avoid intestinal obstruction.

Methylcellulose, ispaghula husk (/drugs/ispaghula-husk/) and sterculia

(/drugs/sterculia/) may be used in patients who cannot tolerate bran.
Methylcellulose also acts as a faecal softener.

Stimulant laxatives
Stimulant laxatives include bisacodyl (/drugs/bisacodyl/), sodium
picosulfate (/drugs/sodium-picosulfate/), and members of the
anthraquinone group (senna (/drugs/senna/), co-danthramer (/drugs/co-
danthramer/) and co-danthrusate (/drugs/co-danthrusate/)). Stimulant
laxatives increase intestinal motility and often cause abdominal cramp;
manufacturer advises they should be avoided in intestinal obstruction.

The use of co-danthramer (/drugs/co-danthramer/) and co-danthrusate

(/drugs/co-danthrusate/) is limited to constipation in terminally ill patients
because of potential carcinogenicity (based on animal studies) and
evidence of genotoxicity.

Docusate sodium (/drugs/docusate-sodium/) is believed to act as both a

stimulant laxative and as a faecal softener (below). Glycerol suppositories
act as a lubricant and as a rectal stimulant by virtue of the mildly irritant
action of glycerol.

Faecal softeners
Faecal softeners are claimed to act by decreasing surface tension and
increasing penetration of intestinal fluid into the faecal mass. Docusate
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sodium (/drugs/docusate-sodium/) and glycerol (/drugs/glycerol/)

suppositories have softening properties. Enemas containing arachis oil
(/drugs/arachis-oil/) (ground-nut oil, peanut oil) lubricate and soften
impacted faeces and promote a bowel movement. Liquid paraffin
(/drugs/liquid-paraffin/) has also been used as a lubricant for the passage

of stools but manufacturer advises that it should be used with caution

because of its adverse effects, which include anal seepage and the risks
of granulomatous disease of the gastro-intestinal tract or of lipoid
pneumonia on aspiration.

Osmotic laxatives
Osmotic laxatives increase the amount of water in the large bowel, either
by drawing fluid from the body into the bowel or by retaining the fluid
 they were administered with. Lactulose (/drugs/lactulose/) is a semi-
synthetic disaccharide which is not absorbed from the gastro-intestinal
BNF
tract. It produces an osmotic diarrhoea of low faecal pH, and discourages
the proliferation of ammonia-producing organisms. It is therefore useful in
the treatment of hepatic encephalopathy. Macrogols (such as macrogol
3350 with potassium chloride, sodium bicarbonate and sodium chloride
(/drugs/macrogol-3350-with-potassium-chloride-sodium-bicarbonate-
and-sodium-chloride/)) are inert polymers of ethylene glycol which
sequester fluid in the bowel; giving fluid with macrogols may reduce the
dehydrating effect sometimes seen with osmotic laxatives.

Other drugs used in constipation

Linaclotide (/drugs/linaclotide/) is a guanylate cyclase-C receptor agonist
that is licensed for the treatment of moderate to severe irritable bowel
syndrome associated with constipation. It increases intestinal fluid
secretion and transit, and decreases visceral pain.

Prucalopride (/drugs/prucalopride/) is a selective serotonin 5HT4-receptor

agonist with prokinetic properties. It is licensed for the treatment of
chronic constipation in adults, when other laxatives have failed to provide
an adequate response.

Bowel cleansing preparations

Bowel cleansing preparations are used before colonic surgery,
colonoscopy or radiological examination to ensure the bowel is free of
solid contents; examples include macrogol 3350 with anhydrous sodium
sulfate, potassium chloride, sodium bicarbonate and sodium chloride
(/drugs/macrogol-3350-with-anhydrous-sodium-sulfate-potassium-
chloride-sodium-bicarbonate-and-sodium-chloride/), citric acid with
magnesium carbonate (/drugs/citric-acid-with-magnesium-carbonate/),
magnesium citrate with sodium picosulfate (/drugs/magnesium-citrate-
with-sodium-picosulfate/) and sodium acid phosphate with sodium
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phosphate (/drugs/sodium-acid-phosphate-with-sodium-phosphate/).
Bowel cleansing treatments are not treatments for constipation.

Management
Short-duration constipation
In the management of short-duration constipation (where dietary
measures are ineffective) treatment should be started with a bulk-forming
laxative, ensuring adequate fluid intake. If stools remain hard, add or
switch to an osmotic laxative. If stools are soft but difficult to pass or the
person complains of inadequate emptying, a stimulant laxative should be
added.
 Opioid-induced constipation
For guidance on the management of constipation in palliative care, see
Prescribing in palliative care (/medicines-guidance/prescribing-in-
palliative-care/).

In patients with opioid-induced constipation, an osmotic laxative (or

docusate sodium (/drugs/docusate-sodium/) to soften the stools) and a
stimulant laxative is recommended. Bulk-forming laxatives should be
avoided.

Naloxegol (/drugs/naloxegol/) is recommended for the treatment of

opioid-induced constipation when response to other laxatives is
inadequate.

Methylnaltrexone bromide (/drugs/methylnaltrexone-bromide/) is licensed

for the treatment of opioid-induced constipation when response to other
laxatives is inadequate.

Faecal impaction
The treatment of faecal impaction depends on the stool consistency. In
patients with hard stools, a high dose of an oral macrogol (such as
macrogol 3350 with potassium chloride, sodium bicarbonate and sodium
chloride (/drugs/macrogol-3350-with-potassium-chloride-sodium-
bicarbonate-and-sodium-chloride/)) may be considered. In those with
soft stools, or with hard stools after a few days treatment with a
macrogol, an oral stimulant laxative should be started or added to the
previous treatment. If the response to oral laxatives is inadequate, for soft
stools consider rectal administration of bisacodyl (/drugs/bisacodyl/), and
for hard stools rectal administration of glycerol (/drugs/glycerol/) alone, or
glycerol (/drugs/glycerol/) plus bisacodyl (/drugs/bisacodyl/).
Alternatively, an enema of docusate sodium (/drugs/docusate-sodium/) or
sodium citrate (/drugs/sodium-citrate/) may be tried.
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If the response is still insufficient, a sodium acid phosphate with sodium

phosphate (/drugs/sodium-acid-phosphate-with-sodium-phosphate/) or
arachis oil (/drugs/arachis-oil/) retention enema may be necessary. For
hard faeces it can be helpful to give the enema of arachis oil
(/drugs/arachis-oil/) overnight before giving an enema of sodium acid
phosphate with sodium phosphate (/drugs/sodium-acid-phosphate-with-
sodium-phosphate/) or sodium citrate (/drugs/sodium-citrate/) the
following day. Enemas may need to be repeated several times to clear
hard impacted faeces.

Chronic constipation
In the management of chronic constipation, treatment should be started
with a bulk-forming laxative, whilst ensuring good hydration. If stools
 with a bulk-forming laxative, whilst ensuring good hydration. If stools
remain hard, add or change to an osmotic laxative such as a macrogol.
Lactulose (/drugs/lactulose/) is an alternative if macrogols are not
effective, or not tolerated. If the response is inadequate, a stimulant
laxative can be added. The dose of laxative should be adjusted gradually
to produce one or two soft, formed stools per day.

If at least two laxatives (from different classes) have been tried at the
highest tolerated recommended doses for at least 6 months, the use of
prucalopride (/drugs/prucalopride/) (in women only) should be
considered. If treatment with prucalopride (/drugs/prucalopride/) is not
effective after 4 weeks, the patient should be re-examined and the
benefit of continuing treatment reconsidered.

Laxatives can be slowly withdrawn when regular bowel movements occur

without difficulty, according to the frequency and consistency of the
stools. If a combination of laxatives has been used, reduce and stop one
laxative at a time; if possible, the stimulant laxative should be reduced
first. However, it may be necessary to also adjust the dose of the osmotic
laxative to compensate.

Constipation in pregnancy and

breast-feeding
If dietary and lifestyle changes fail to control constipation in pregnancy,
fibre supplements in the form of bran or wheat are likely to help women
experiencing constipation in pregnancy, and raise no serious concerns
about side-effects to the mother or fetus.

A bulk-forming laxative is the first choice during pregnancy if fibre

supplements fail. An osmotic laxative, such as lactulose
(/drugs/lactulose/), can also be used. Bisacodyl (/drugs/bisacodyl/) or
senna (/drugs/senna/) may be suitable if a stimulant effect is necessary
but use of senna (/drugs/senna/) should be avoided near term or07/10/23,
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is a history of unstable pregnancy. Stimulant laxatives are more effective
than bulk-forming laxatives but are more likely to cause side-effects
(diarrhoea and abdominal discomfort), reducing their acceptability to
patients. Docusate sodium (/drugs/docusate-sodium/) and glycerol
(/drugs/glycerol/) suppositories can also be used.

A bulk-forming laxative is the first choice during breast-feeding, if dietary

measures fail. Lactulose (/drugs/lactulose/) or a macrogol may be used if
stools remain hard. As an alternative, a short course of a stimulant
laxative such as bisacodyl (/drugs/bisacodyl/) or senna (/drugs/senna/)
can be considered.

Constipation in children
Early identification of constipation and effective treatment can improve
 Early identification of constipation and effective treatment can improve
outcomes for children. Without early diagnosis and treatment, an acute
episode of constipation can lead to anal fissure and become chronic.

The first-line treatment for children with constipation requires the use of a
laxative in combination with dietary modification and behavioural
interventions. Diet modification alone is not recommended as first-line
treatment.

In children, an increase in dietary fibre, adequate fluid intake, and exercise

is advised. Diet should be balanced and contain fruits, vegetables, high-
fibre bread, baked beans, and wholegrain breakfast cereals. Unprocessed
bran (which may cause bloating and flatulence and reduces the
absorption of micronutrients) is not recommended.

If faecal impaction is not present (or has been treated), the child should
be treated promptly with a laxative. A macrogol (such as macrogol 3350
with potassium chloride, sodium bicarbonate and sodium chloride
(/drugs/macrogol-3350-with-potassium-chloride-sodium-bicarbonate-
and-sodium-chloride/)) is preferred as first-line management, with the
dose adjusted according to symptoms and response. If the response is
inadequate add a stimulant laxative, or change to a stimulant laxative if
the first-line therapy is not tolerated. If stools remain hard, lactulose
(/drugs/lactulose/) or another laxative with softening effects, such as
docusate sodium (/drugs/docusate-sodium/) should be added.

In children with chronic constipation, laxatives should be continued for

several weeks after a regular pattern of bowel movements or toilet
training is established. The dose of laxatives should then be tapered
gradually, over a period of months, according to response. Some children
may require laxative therapy for several years.

A shorter duration of laxative treatment may be possible in some children

with a very short history of constipation, but they should be carefully
monitored for a relapse of constipation.
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likely to fit in with the child's toilet routine.

Faecal impaction in children

Treatment of faecal impaction may initially increase symptoms of soiling

and abdominal pain. An oral preparation containing a macrogol (such as
macrogol 3350 with potassium chloride, sodium bicarbonate and sodium
chloride (/drugs/macrogol-3350-with-potassium-chloride-sodium-
bicarbonate-and-sodium-chloride/)) is used first-line for all children to
clear faecal mass and to establish and maintain soft well-formed stools. In
children over 1 year of age with faecal impaction, an escalating dose
regimen should be used. If disimpaction does not occur after 2 weeks of
macrogol treatment, a stimulant laxative should be added. If macrogol
 therapy is not tolerated, change to a stimulant laxative alone or, if stools
are hard, use in combination with an osmotic laxative such as lactulose
(/drugs/lactulose/). Long-term regular use of laxatives is essential to
maintain well-formed stools and prevent recurrence of faecal impaction;
intermittent use may provoke relapses.

Related drugs

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Arachis oil (/drugs/arachis-oil/) Bisacodyl (/drugs/bisacodyl/)

Citric acid with magnesium carbonate (/drugs/citric-acid-with-

magnesium-carbonate/)

Co-danthramer (/drugs/co-danthramer/)

Co-danthrusate (/drugs/co-danthrusate/)

Docusate sodium (/drugs/docusate-sodium/)