Version July 2025
INTRODUCTION —
Constipation is a common complaint that affects up to 15 percent of the population and may be due to a variety of causes. Initial management of chronic constipation includes dietary and lifestyle counseling, fiber supplementation, and laxative therapy.
This topic will discuss the initial management of chronic constipation. The etiology and evaluation of chronic constipation, as well as the management of persistent, unresponsive constipation and opioid-related constipation, are discussed elsewhere:
●(See "Etiology and evaluation of chronic constipation in adults".)
●(See "Management of persistent unresponsive constipation in adults".)
GENERAL APPROACH —
The initial management of chronic constipation includes dietary and lifestyle counseling for all patients (algorithm 1). Patients with mild constipation may improve with dietary and lifestyle modification alone or in conjunction with bulk-forming laxatives. Patients with ongoing symptoms may require additional treatment with osmotic or stimulant laxatives. For patients with persistent symptoms, treatment with secretagogues or other prescription agents may be appropriate. (See 'Subsequent referral or management' below.)
The initial management of chronic constipation also includes identifying and modifying any secondary contributors, including systemic conditions and medications (table 1). In some cases (eg, hypothyroidism, hypercalcemia), management of the underlying condition can lead to resolution of constipation, whereas in other cases (eg, Parkinson disease, diabetes mellitus), management of the underlying condition is less likely to improve constipation. When addressing the underlying etiology does not resolve constipation, we proceed with the same general management strategy described in this topic.
For patients on medications that are contributing to constipation, removal of medication may resolve constipation, but this may not always be possible or advisable based on the underlying condition being treated. When a medication cannot be discontinued, we proceed with the same management strategy described in this topic. In addition, for patients with opioid-induced constipation, peripherally acting mu-opioid receptor antagonists may be helpful. (See "Prevention and management of side effects in patients receiving opioids for chronic pain", section on 'Constipation'.)
Goal of treatment — When treating chronic constipation, it is important to emphasize that daily bowel movements are not necessary for health [1,2]. The goal of treatment is not to have a daily bowel movement, but rather to improve bowel-related symptoms that are bothersome to the patient (eg, incomplete evacuation or hard, lumpy stool).
INITIAL MEASURES FOR ALL PATIENTS —
The initial management of chronic constipation includes guidance to increase fiber and fluid intake, and to modify lifestyle factors, including optimizing physical activity, timing of defecation, and defecation posture (algorithm 1). (See "Patient education: Constipation in adults (Beyond the Basics)".)
Optimizing fiber and fluid intake — Initial guidance for patients with chronic constipation includes ensuring adequate fiber and fluid intake. There is a dose-response between fiber intake, water intake, and fecal output [3,4]. Fiber should be increased gradually. The effects of fiber on bowel movements may take several weeks.
●Gradual increase – We advise patients to modify their diet to increase their fiber intake to 20 to 35 g/day (table 2). However, a sudden increase in fiber intake can cause bloating and may worsen constipation. Fiber intake often worsens slow transit constipation, which should be suspected if symptoms are very long-standing and stool frequency is less than three times a week; in these cases, we avoid extra dietary fiber. We generally recommend starting with 5 g/day of additional fiber intake for the first week and increasing by 3 to 5 g/day every week thereafter as tolerated up to a maximum of 35 g/day. We also emphasize adequate fluid intake along with fiber supplementation. (See 'Fluid intake' below.)
●Mechanisms of action – Fiber increases stool bulk, which causes colonic distention and promotes stool propulsion. Cereal fibers generally possess cell walls that resist digestion and retain water within their cellular structures, enhancing fecal bulking effects. Fiber found in citrus fruits and legumes stimulates the growth of colonic flora, thereby increasing fecal mass [5].
●Adverse effects – For some patients (and especially almost all those with slow transit constipation), fiber (whether through diet or supplementation) increases bloating and distention, leading to poor compliance [6]. Patients should be warned that consuming large amounts of fiber can cause abdominal bloating or flatulence; this can be modulated by starting with small amounts and slowly increasing fiber intake according to tolerance and efficacy.
Strategies to increase fiber — We prefer to increase fiber intake through diet, when possible. Patients who are not able to achieve adequate fiber intake through diet alone can add supplementary dietary fiber or bulk-forming laxatives (ie, fiber supplements) to help achieve the recommended fiber intake.
High-fiber foods — Whole foods rich in fiber include fruits (particularly dates and prunes), vegetables (particularly pears and broccoli), legumes, whole grains, and some nuts (table 2).
The fiber in fruit, which is both soluble and insoluble fiber, may be more beneficial and have fewer side effects compared with other fiber sources. In addition, many fruits include sugar components (sorbitol or fructose) that can further improve bowel health through osmotic laxative effects. Common foods with these sugar components include prunes, apples, peaches, pears, and cherries. We counsel patients to be aware of the caloric and glycemic content of these foods, particularly for those with comorbidities such as obesity or diabetes mellitus.
Despite substantial clinical experience indicating benefit from dietary fiber, formal studies regarding their effectiveness are limited and inconsistent. Few natural foods have been studied in clinical trials; among those that have been studied, kiwifruit and prunes have demonstrated efficacy [7-9]. In one meta-analysis, kiwifruit (two to three per day) and prunes led to similar rates of constipation relief compared with psyllium, with approximately 35 to 45 percent of patients experiencing response to treatment in each group [9]. Those who ate kiwifruit demonstrated increased stool frequency compared with psyllium (mean difference of 0.36 bowel movements weekly, 95% CI 0.24-0.48). Prunes led to similar stool frequency compared with psyllium.
Fiber supplementation if needed — We suggest fiber supplementation for patients who are not able to achieve fiber goals with whole foods. We increase the dose gradually to minimize bloating and abdominal distension. Options for supplementation include concentrated dietary sources of fiber, such as bran, or bulk-forming laxatives, such as psyllium or methylcellulose.
●Bran – In addition to consuming high-fiber foods (table 2), patients may add raw bran (two to six tablespoons with each meal) followed by a glass of water or another beverage to achieve the fiber intake goal. This approach is effective for some patients, although the available evidence is limited and does not demonstrate a clear benefit compared with placebo [10].
●Bulk-forming laxatives – Bulk-forming laxatives include psyllium seed (sample brand name Metamucil), methylcellulose (sample brand name Citrucel), calcium polycarbophil (sample brand name FiberCon), and wheat dextrin (sample brand name Benefiber) (table 3). They are natural or synthetic polysaccharides or cellulose derivatives that primarily exert their laxative effect by absorbing water and increasing fecal mass. Bulk-forming laxatives are low cost, easy to use, and safe.
We avoid bulk-forming laxatives if there is a high suspicion for slow transit constipation (eg, severe constipation with bowel movements occurring once or twice a week), as they may aggravate the problem.
In one systematic review, psyllium increased stool frequency in patients with chronic constipation compared with placebo, but there was insufficient evidence to recommend other forms of fiber supplementation including calcium polycarbophil or methylcellulose [11]. In a subsequent randomized trial, a fruit-based mixed soluble fiber (sample brand name Suprafiber) was as effective as psyllium in relieving constipation and was also more palatable and caused less bloating [12]. However, this treatment is generally more expensive than psyllium.
Fluid intake — In patients with chronic constipation, we suggest ensuring adequate hydration, usually with a fluid intake goal of at least 1.5 liters daily. Although water intake alone has not been evaluated for constipation relief, water in combination with fiber intake appears to be helpful. In one randomized trial of adults with functional constipation on a high-fiber diet, those who drank two liters of mineral water daily reported improved symptoms and decreased laxative use compared with those with ad libitum fluid intake [4].
Mineral water rich in magnesium may have additional benefits compared with tap water due to increased osmotic effect. Although evidence is limited, several small studies have found an increase in bowel frequency and improvement in stool consistency with magnesium-rich water compared with low-mineral water, with minimal adverse events [13-16].
For patients who enjoy caffeinated coffee, we advise one to two cups per day to help promote bowel movements. Caffeinated coffee has been shown to stimulate colon motility and increase intestinal secretion [17,18].
Physical activity — We typically advise increasing physical activity in the management of mild constipation. However, the data supporting this are limited [19,20]. In one meta-analysis, exercise (most commonly at least 140 minutes of aerobic exercise weekly) did improve symptoms related to constipation [21]. However, methodologic limitations including lack of blinding and lack of exercise supervision make it difficult to assess the effect reliably.
Timing of defecation — We counsel patients to try to establish a regular pattern of bowel movement, most commonly either in the morning after waking or after a meal. Colonic motility is maximal two hours after waking and after meals [22]. Most patients who have a normal bowel pattern usually empty stools at approximately the same time every day [23], suggesting that the initiation of defecation is in part a conditioned reflex.
Defecation posture modification — We encourage patients with constipation to consider a squat-like posture (ie, sitting up, leaning forward, and raising the feet 8 to 12 inches above the ground) to help defecation if they are physically able to do this, using a squat assist device if needed. These are commercially available. A squatting posture straightens the anorectal angle to help stool pass through the rectum and reduce straining [24]. In one small observational study, individuals who used a squat-assist device during bowel movements reported a subjective improvement in bowel emptiness and reduced straining, as well as a decreased duration of bowel movements [25].
ADDITIONAL LAXATIVES FOR PERSISTENT SYMPTOMS —
Patients who are not able to tolerate increased fiber, and those who have persistent symptoms, may require the addition of osmotic and/or stimulant laxatives (table 3). In our experience, optimizing these two types of agents is effective in relieving symptoms in most patients with chronic constipation.
Choice of laxative — There are limited data comparing various laxatives, and the choice among them is based on cost, ease of use, patient preference, and response to empiric treatment. The risk of side effects from these agents is minimal [10,26,27]. In general, we begin by ensuring the patient is getting sufficient fiber intake, and adding bulk-forming laxatives if this is inadequate. (See 'Strategies to increase fiber' above.)
We then start daily osmotic laxative therapy and titrate up to effective or maximum dosage. For the minority of patients with ongoing symptoms, we add a stimulant laxative every other day or every third day, and titrate up to maximum dosage if needed (algorithm 1).
Optimizing each type of agent — It is important to optimize dosing of each type of agent, as discussed below. Inconsistent medication use and underdosing of medication are common reasons for persistent constipation symptoms; optimizing the regimen and dosing can decrease the need for unnecessary testing and referral.
Osmotic laxatives — We typically start osmotic laxative treatment with polyethylene glycol without electrolytes (PEG 3350; sample brand name MiraLAX) at a dose of 17 g of powder dissolved in 8 oz of water once daily and titrate up or down (to a maximum of 34 g daily) to effect. We prefer PEG 3350 due to low cost, safety, and efficacy; other osmotic agents include synthetic disaccharides and magnesium-based saline laxatives. These agents all cause intestinal water secretion and thereby increase stool frequency. Excessive use of these agents may result in electrolyte and volume overload in patients with renal and cardiac dysfunction [6].
●Polyethylene glycol (PEG) – PEG is typically used as a powdered preparation without electrolytes and is effective in improving stool frequency and constipation symptoms [28-30]. In a meta-analysis of three randomized trials, PEG led to an increase in weekly spontaneous bowel movements compared with placebo (mean increase 2.3 bowel movements weekly, 95% CI 1.6-3.1) as well as an increase in global relief of constipation symptoms (risk ratio [RR] 2.6, 95% CI 1.6-4.3) [10]. In another meta-analysis evaluating PEG versus lactulose for patients with chronic constipation, those who received PEG had increased stool frequency and improved consistency compared with those who received lactulose [31]. Studies comparing PEG with other laxative agents are not available.
PEG is generally very well tolerated. However, it can be associated with abdominal bloating, cramping, and flatulence, particularly at high doses [11].
PEG is also available as an electrolyte solution (eg, PEG-electrolyte solution; sample brand name GoLYTELY). This formulation is rarely used in the routine management of constipation but can be used in selected situations when colon evacuation is required (eg, prior to a colonoscopy or after fecal impaction). In a noninferiority study, PEG-electrolyte solution was not inferior to prucalopride (a prokinetic agent usually reserved for the treatment of severe nonresponsive constipation) [32]. (See "Management of persistent unresponsive constipation in adults", section on 'Prucalopride (prokinetic agent)'.)
●Synthetic disaccharides – Lactulose (sample brand name Enulose) is a synthetic disaccharide. It is less effective than PEG in relieving constipation [31]. It is not metabolized by intestinal enzymes; thus, water and electrolytes remain within the intestinal lumen due to the osmotic effect of the undigested sugar. Lactulose improves stool frequency and consistency [10]. It typically requires 24 to 48 hours to achieve its effect. The most common side effects are abdominal bloating and flatulence.
Another disaccharide is sorbitol, which is the major ingredient in prunes. It is available in powder and liquid forms but is less commonly used than lactulose.
●Magnesium-based laxatives – Magnesium-based laxatives such as milk of magnesia, magnesium citrate, or water containing high amounts of magnesium sulfate are poorly absorbed and act as hyperosmolar solutions [13]. Hypermagnesemia, seen primarily in patients with renal failure, is the major complication.
Stimulant laxatives — For patients with ongoing constipation despite fiber supplementation and a daily osmotic laxative, we add a stimulant laxative every other day to every third day and titrate up to maximum dosage if needed. They work in part by increasing endogenous prostaglandin from intestinal mucosa, largely in the colon, leading to increased colonic fluid and electrolyte secretion. They also increase intestinal motor activity.
Several studies have compared stimulant laxatives with placebo, although not with bulk-forming or osmotic laxatives:
●Bisacodyl – In one randomized trial of patients with chronic constipation, patients who received bisacodyl (10 mg daily) had more complete spontaneous bowel movements per week compared with those who received placebo (5.2 versus 1.9) [33].
●Senna – In one randomized trial of patients with chronic idiopathic constipation, senna 1 g daily improved the frequency of bowel movements and quality of life scores compared with placebo [34]. There were no serious adverse effects.
●Sodium picosulfate – In a small, randomized trial of patients with chronic constipation, sodium picosulfate 10 mg improved bowel function as well as quality of life scores compared with placebo [35].
Chronic use — While stimulant laxatives are generally used for short-term and rescue therapy, they can be used daily if needed and are likely safe for chronic use. We advise patients to attempt to gradually taper these as tolerated as new measures to improve bowel function are introduced, but we do not discontinue them in patients for whom they are effective. There is no convincing evidence that chronic use of stimulant laxatives causes structural or functional impairment of the colon, nor does it increase the risk for colorectal cancer or other tumors [36,37]. Prescriber reluctance to use these laxatives long term often leads to the use of newer agents that have never been shown to be safer or more effective than stimulant agents.
Therapies for limited use — We do not routinely recommend surfactants, enemas, or suppositories because there is limited evidence to support their use [27].
Surfactants (stool softeners) — We generally do not suggest using surfactants (ie, stool softeners) in the treatment of constipation, as there is little evidence to support their use. Surfactants such as docusate sodium (sample brand name Colace) are intended to lower the surface tension of stool, thereby allowing water to more easily enter the stool. Although these agents have few side effects, they are less effective than other laxatives. In one randomized trial, docusate was inferior to psyllium in the treatment of chronic idiopathic constipation [38].
Enemas and suppositories — We generally reserve use of suppositories for patients with severe symptoms, particularly those with defecatory dysfunction. We reserve use of enemas for patients with prior fecal impaction to prevent a recurrence. (See 'Fecal impaction' below.)
Glycerin or bisacodyl suppositories can be helpful in the treatment of defecatory dysfunction. They stimulate colon motility as their primary mechanism of action and also have an osmotic effect. Suppositories can be effective in liquifying stool and thereby help overcome obstructive defecation.
Enemas can be helpful for patients with a prior fecal impaction to prevent recurrence. When using enemas, we favor tap water. We avoid soapsud enemas, which can cause rectal mucosal damage (ie, soap colitis). We also advise against sodium phosphate enemas for the treatment of constipation due to serious adverse effects, especially in older adults. In a retrospective series, the use of sodium phosphate enemas in older adults was associated with complications including hypotension and volume depletion, hyperphosphatemia, hypo- or hyperkalemia, metabolic acidosis, severe hypocalcemia, renal failure, and electrocardiogram changes (prolonged QT interval) [39]. In January 2014, the US Food and Drug Administration (FDA) issued a safety announcement regarding electrolyte abnormalities and severe dehydration with the use of a single dose of over-the-counter sodium phosphate that was larger than recommended or with more than one dose in 24 hours, particularly in adults older than 55 years, patients with dehydration, bowel obstruction, or inflammation, and patients with kidney disease or on medication that may affect renal function older adults [40,41].
SUBSEQUENT REFERRAL OR MANAGEMENT
Clinical re-evaluation — Most patients with chronic constipation who do not improve with osmotic or stimulant laxatives can be treated with a secretagogue or other prescription agent. However, it is important to first clinically re-evaluate these patients with a history and physical examination, particularly if this was not done at time of diagnosis (algorithm 1).
Important considerations during clinical re-evaluation include:
●Evaluating whether the patient has developed any alarm symptoms – Patients with alarm symptoms warrant gastrointestinal evaluation and colonoscopy to evaluate for malignancy. (See 'Alarm symptoms or age ≥45 years old' below.)
●Evaluating for signs or symptoms of defecatory disorder – Patients with consistent symptoms or findings may also benefit from early gastrointestinal evaluation (table 4). (See 'High clinical suspicion for defecatory dysfunction' below.)
●Ensuring the patient is adhering to fiber intake goals and lifestyle measures described above – Patients should be consistent with these recommendations prior to escalating therapy. (See 'Initial measures for all patients' above.)
●Ensuring that osmotic and stimulant therapy dosing is optimized, and that the patient is adherent to these therapies – Optimizing dosing and ensuring adherence can resolve constipation and avoid the need to escalate therapy for some patients. (See 'Optimizing each type of agent' above.)
Considerations for gastrointestinal referral — Gastrointestinal evaluation is necessary for patients with alarm symptoms and those ≥45 years old, as these patients require colonoscopy to evaluate for malignancy. Most other patients can be started on secretagogue agents without a specialty referral. For patients in whom there is a high clinical suspicion for defecatory dysfunction (based on history or examination), gastrointestinal evaluation can be helpful in establishing the diagnosis and coordinating specialized treatment (biofeedback therapy).
Alarm symptoms or age ≥45 years old — Patients with alarm symptoms require gastrointestinal evaluation and colonoscopy. Alarm symptoms include hematochezia or heme-positive stool, iron deficiency anemia, unexplained weight loss of ≥10 pounds, new onset of unexplained constipation, new obstructive symptoms (eg, bloating, distension, abdominal pain during stool passage), rectal pain or tenesmus, and family history of colon cancer or inflammatory bowel disease (table 5).
Patients aged ≥45 years with new constipation also warrant colonoscopy for colon cancer evaluation. We generally do not consider stool-based testing sufficient screening for patients with constipation unless they have had a prior colonoscopy without a subsequent change in symptoms. (See "Etiology and evaluation of chronic constipation in adults", section on 'Colonoscopy for patients with alarm features or age ≥45 years old'.)
High clinical suspicion for defecatory dysfunction — We also consider a gastrointestinal referral for patients in whom there is a high suspicion for defecatory dysfunction based on clinical history and examination. However, a trial of secretagogue therapy is also reasonable for these patients, taking into account factors such as specialist availability and patient preference.
Symptoms suggestive of defecatory dysfunction include excessive straining, prolonged defecation time, feelings of incomplete evacuation, and use of digital maneuvers to defecate. Signs suggestive of defecatory dysfunction on digital rectal examination include a high anal resting pressure, an impaired push effort, or a paradoxical contraction of the anal sphincter or puborectalis muscles during simulated evacuation [42]. Details about how to perform the digital rectal examination are discussed elsewhere. (See "Etiology and evaluation of chronic constipation in adults", section on 'History and physical examination'.)
For clinicians inexperienced in the rectal examination who are not able to confidently evaluate for defecatory dysfunction, the decision to refer can be based on suggestive symptoms by history.
Patients in whom there is a high clinical suspicion for defecatory dysfunction warrant anorectal manometry and balloon expulsion testing, which is typically done through a gastrointestinal specialist, and, if the diagnosis is confirmed, they can be treated with biofeedback therapy rather than additional laxatives. (See "Management of persistent unresponsive constipation in adults", section on 'Defecatory dysfunction'.)
Secretagogue therapy for most patients — We initiate treatment with secretagogues in patients with chronic constipation for whom lifestyle changes, fiber supplements, and osmotic and stimulant laxatives are not effective, and who do not require gastrointestinal referral for specialized testing (algorithm 1). In addition, most patients with alarm symptoms who have a normal colonoscopy can be initiated on secretagogues.
Choice of agent — We prefer linaclotide or plecanatide for initial secretagogue treatment in patients with persistent chronic constipation (table 3). These agents may cause less nausea than lubiprostone, although there are no direct comparison studies between the available agents. All secretagogues (ie, linaclotide, plecanatide, and lubiprostone) are effective and well tolerated; they are typically not used as first-line therapy because they are more costly than traditional laxatives.
●Dose titration – Secretagogues are typically initiated once daily and titrated to effect. Dose titration is guided by symptoms. Some patients take the medication daily, while others use it every other day or as needed. There are no known concerns with long-term use. If the initial agent is not effective, options include switching to another secretagogue or adding or switching to a prokinetic agent (ie, prucalopride).
●Efficacy – Linaclotide and plecanatide are both effective and safe in the treatment of constipation. In one meta-analysis, patients receiving linaclotide (72 mcg or 145 mcg) were more likely to achieve a composite constipation endpoint (improvement in complete spontaneous bowel movements [CSBMs] ≥1 per week with ≥3 CSBM per week for at least 75 percent of weeks in a 12-week trial of therapy) compared with placebo (odds ratio [OR] for 72 mcg 3.1; 95% CI 1.8-5.3; OR for 145 mcg 3.3; 95% CI 2.2-4.9) [43]. Patients who received plecanatide (3 mg and 6 mg) were also more likely to achieve a similar composite endpoint compared with placebo (OR for 3 mg 2.0, 95% CI 1.6-2.5; OR for 6 mg 1.9, 95% CI 1.5-2.5). The most common side effect for each agent was diarrhea.
These agents, as well as additional options for the treatment of persistent, unresponsive constipation, are reviewed in detail separately. (See "Management of persistent unresponsive constipation in adults", section on 'Pharmacologic therapy'.)
ADDITIONAL CONSIDERATIONS —
Additional considerations in the initial management of constipation include management of fecal impaction, tailoring treatment for older adults, and additional treatment options with limited data.
Fecal impaction — Patients with fecal impaction (a solid immobile bulk of stool in the rectum) typically require manual disimpaction followed by colon evacuation. We also implement a maintenance bowel regimen to prevent recurrence.
Management — Initial management includes manual disimpaction to fragment a large fecal bolus and facilitate its passage through the anal canal. After this is accomplished, the colon should be evacuated with enemas and/or polyethylene glycol (PEG)-electrolyte solution.
●Unsuccessful disimpaction – If manual disimpaction is unsuccessful or only partially successful, we order a water-soluble contrast enema (Gastrografin or Hypaque) administered under fluoroscopy to ensure absence of any obstruction and to eliminate more proximal impactions. Occasionally, fractionation of impacted stool beyond the reach of the finger must be accomplished using flexible or rigid sigmoidoscopy with instrumentation.
●Colon evacuation – After initial disimpaction, the colon should be thoroughly evacuated. This can be accomplished with daily warm water enemas for up to three days, or by drinking a balanced electrolyte solution containing PEG until cleansing is complete. We use warm water enemas (3 to 6 oz) rather than sodium phosphate enemas in older adults because of the potential dangers of sodium phosphate enemas in this age group, as described above. (See 'Enemas and suppositories' above.)
Prevention of recurrence — We advise sorbitol, lactulose, or polyethylene glycol without electrolytes (PEG 3350) after bowel cleansing to produce one stool at least every other day. We instruct the patient to use the bathroom after meals to take advantage of meal-stimulated increases in colonic motility. If the patient does not have a bowel movement for two days, we administer a bisacodyl or glycerin suppository to prevent recurrence of fecal impaction. Alternatively, enemas may be administered. Similar approaches have achieved success rates of up to 78 percent, although relapses are not uncommon [44]. Treatment failures have been attributed to noncompliance; underlying disturbances of bowel function may also have a role.
A modified preventative program may be used in patients with fecal impaction who are bedridden or have dementia. After disimpaction and bowel cleansing with enemas or PEG-electrolyte solution, a fiber-restricted diet can be useful to decrease the buildup of stool. In addition, cleansing enemas once or twice per week can prevent recurrence of fecal impaction.
Older adults — Older adults may be particularly susceptible to constipation. The prevalence of constipation in the older adult ranges from 24 to 50 percent [45-53]. In addition to age, risk factors for chronic constipation in older adults include consuming less food, comorbid illness, and nursing home residence [54]. Laxatives are used daily by up to 20 percent of community-dwelling older adults and 74 percent of nursing home residents [50,55-58].
When treating an older adult with constipation, we review common comorbid issues such as decreased mobility, chronic medical problems, and medication side effects (table 1). We also address concurrent psychosocial problems such as social isolation, poor nutrition, and lack of independence, as these factors may contribute to constipation [59,60].
Laxative usage in older adults should be individualized keeping in mind the patient's history (cardiac and renal comorbidities), drug interactions, cost, and side effects (table 3) [61]. Similar to younger patients, we initiate therapy with bulk-forming laxatives followed by daily osmotic agents and stimulant laxatives if needed. However, magnesium-based saline laxatives such as magnesium hydroxide have not been examined in older adults and should be used with caution because of the risk of hypermagnesemia. In addition, as described above, we avoid sodium phosphate enemas in older adults. (See 'Enemas and suppositories' above.)
Opioid-induced constipation — Constipation in patients receiving opioids is discussed in detail elsewhere. (See "Prevention and management of side effects in patients receiving opioids for chronic pain", section on 'Opioid bowel dysfunction'.)
Other nonpharmacologic approaches
●Acupuncture – We do not routinely recommend acupuncture in the treatment of constipation because the benefit is uncertain and there are barriers to successful treatment, including availability, cost, and variability in skill among acupuncturists. However, for patients who are interested, this may be a helpful adjunctive to standard therapy.
In a randomized trial of over 1000 patients with chronic severe functional constipation, electroacupuncture increased weekly complete spontaneous bowel movements (CSBMs) compared with sham acupuncture at nonacupoints [62]. It also improved stool consistency and reduced straining. However, long-term follow-up was not assessed in this trial and acupuncturists were not blinded. Additional studies are needed to confirm these findings and identify the optimal patient population who would benefit before acupuncture can be routinely recommended.
●Habit training — Habit training has been used successfully in children with severe constipation. A modified program may also be helpful in adults with neurogenic constipation, dementia, or those with physical impairments. We advise patients to attempt a bowel movement at least twice a day, usually 30 minutes after meals, and to strain for no more than five minutes [63].
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Constipation".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Constipation in adults (The Basics)" and "Patient education: High-fiber diet (The Basics)")
●Beyond the Basics topics (see "Patient education: Constipation in adults (Beyond the Basics)" and "Patient education: High-fiber diet (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●General approach – The general approach to the initial management of chronic constipation includes initiating dietary and lifestyle measures for all patients, adding daily osmotic laxatives if needed, and then adding an as-needed stimulant laxative for those with persistent symptoms (algorithm 1). In addition, it is important to identify secondary contributors to constipation and optimize these when possible. (See 'General approach' above.)
●Initial dietary and lifestyle measures for all patients – For most adults with chronic constipation, we suggest initial treatment with increased oral fiber intake (Grade 2C). This can be achieved by increasing dietary fiber (table 2) and using bulk-forming laxatives (ie, fiber supplements) as necessary for a goal of 20 to 35 g daily. Fiber should be increased gradually to avoid bloating and worsening of constipation. We also ensure adequate hydration with an increase in fiber, with a goal of 1.5 L of water intake daily. Mineral water with magnesium may offer additional benefits compared with low-mineral water. Additional lifestyle measures include regular physical activity, timing defecation either in the morning or after meals when colonic motility is highest, and modifying defecation posture to a squat-like position when possible. (See 'Initial measures for all patients' above.)
●Laxative therapy for patients with persistent symptoms – For patients who have optimized fiber intake and lifestyle measures but have ongoing constipation symptoms, we suggest adding an osmotic laxative (table 3) (Grade 2C). As an example, we use electrolyte-free polyethylene glycol (sample brand name Miralax), titrating to efficacy or a maximum of 34 g daily. For patients with ongoing symptoms after the addition of an osmotic laxative, we suggest adding a stimulant laxative (Grade 2C). In most cases this can be used every other day or every third day as needed; however, it can be used daily if needed without any known long-term health effects. (See 'Additional laxatives for persistent symptoms' above.)
●Clinical re-evaluation and considerations for specialty referral – We re-evaluate patients who have ongoing constipation symptoms despite increased fiber intake, lifestyle optimization, and osmotic and stimulant laxatives. Patients who have developed alarm symptoms require colonoscopy to evaluate for malignancy and should be referred to a gastrointestinal specialist. In addition, we evaluate for signs or symptoms suggestive of defecatory dysfunction; patients with consistent symptoms and/or examination findings may benefit from early gastrointestinal referral to establish the diagnosis and undergo biofeedback therapy, although these patients may also reasonably be managed with a trial of secretagogue therapy. (See 'Subsequent referral or management' above.)
●Secretagogue therapy for most patients – For patients with persistent constipation who do not have modifiable secondary contributors, are adherent with initial therapy, and do not have alarm symptoms, we suggest adding linaclotide or plecanatide (Grade 2C). Dosing guidance is provided in the table. (table 3). (See 'Secretagogue therapy for most patients' above.)
●Fecal impaction – Fecal impaction requires manual disimpaction followed by colon evacuation and a maintenance regimen to prevent recurrence. (See 'Fecal impaction' above.)
●Older adults – Laxative use in older adults should be individualized keeping in mind the patient's comorbidities, medication interactions, cost, and side effects (table 3). We use caution with magnesium-based laxatives because of the risk of hypermagnesemia. In addition, we avoid sodium phosphate enemas in older adults because they have been associated with complications in this population, including hypotension and volume depletion, hyperphosphatemia, hypo- or hyperkalemia, metabolic acidosis, severe hypocalcemia, renal failure, and electrocardiogram changes (prolonged QT interval). (See 'Older adults' above.)
