Tis the Season for Good Laxation: How to More Effectively Treat Individuals with Chronic Constipation

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This document discusses chronic constipation (CC), emphasizing the importance of accurate diagnosis and tailored treatment. It opens with a challenging case of a young woman with severe constipation and comorbidities who underwent a total colectomy with worsening symptoms, highlighting the dangers of surgery without thorough pelvic floor evaluation.<br /><br />Functional constipation is diagnosed through criteria including fewer than three spontaneous bowel movements (SBMs) per week, straining, hard stools, and incomplete evacuation sensations, with symptoms lasting over six months per Rome IV guidelines. A large US study confirms normal bowel frequency ranges from 3 per week to 3 per day, with stool consistency defined by the Bristol Stool Form Scale.<br /><br />Constipation subtypes include normal transit, slow transit (STC), and evacuation disorders such as dyssynergic defecation (DD). History alone cannot accurately distinguish these. Many patients have overlapping conditions, and a history of abuse correlates with higher dyssynergia risk. Patient symptom recall is often unreliable, underscoring the need for objective testing.<br /><br />Diagnostic tools include anorectal manometry (ARM), balloon expulsion test (BET), and defecography, with the London Classification aiding pattern recognition. Biofeedback therapy is first-line for DD, showing 60-80% efficacy superior to laxatives, and pelvic floor retraining combined with proper toileting posture improves outcomes.<br /><br />Over-the-counter treatments vary in efficacy; polyethylene glycol (PEG 3350) is preferred as 1st-line laxative, outperforming soluble fibers like psyllium. Natural fibers (kiwi, prunes) provide symptom relief with better tolerance in some cases. Prescription agents include secretagogues (linaclotide, lubiprostone, plecanatide) and prokinetics (prucalopride), effectively improving both bowel and abdominal symptoms.<br /><br />Treatment challenges include inadequate response, poor adherence, and lack of guidelines. Comprehensive management often requires a multimodal approach addressing psychological factors, diet, pelvic floor dysfunction, and pharmacotherapy.<br /><br />The key clinical message is never to perform colectomy without prior pelvic floor assessment, as functional defecation disorders must be ruled out first. Effective constipation care demands individualized evaluation and treatment to "slay the demon within."

Keywords

chronic constipation

functional constipation

Rome IV criteria

Bristol Stool Form Scale

slow transit constipation

dyssynergic defecation

anorectal manometry

balloon expulsion test

biofeedback therapy

polyethylene glycol