Constipation is an unpleasant problem, that, like many other conditions, can occur at any age, but has a higher incidence among older adults, with elderly females more likely to suffer from severe constipation (Vazquez Roque and Bouras, 2015). There are a number of definitions but the condition is generally defined as defecation that is unsatisfactory because of infrequent stools, difficulty passing stools, or the sensation of incomplete emptying (National Institute for Health and Care Excellence [NICE], 2021a). Statistics indicate that each GP will see approximately 6.3 people for the problem per week (Bowel Interest Group, 2019). Given the prevalence of this condition, it is highly likely nurses will be asked for advice by their patients. This article therefore hopes to give an insight into causes, treatment and management, with the aim of increasing confidence among general practice nurses who treat patients affected by this common problem.
Prevalence rates
Prevalence rates for constipation are difficult to determine as it is likely that some of those affected may try self-help measures or over the counter (OTC) remedies and therefore never consult a health professional. A recent report found that 35% of people affected would search online for self-help remedies, and 1 in 10 people would wait at least 2 weeks to see if their problem resolved before seeking advice, thought to be due to embarrassment (Bowel Interest Group, 2020). The study indicated as many as 1 in 7 may suffer with the condition, and approximately 2 million people in the UK may be living with chronic constipation (Bowel Interest Group, 2020). Vazquez Roque and Bouras (2015) indicated a prevalence of approximately 20% in the general population, but among the elderly rates of constipation were found to be two to three times higher among females than seen in their male counterparts, with rates as high as 50% among elderly nursing home residents (Mounsey et al, 2015). Constipation is also commonly seen in pregnant women, with approximately 1 in 5 in this patient group affected (Harding, 2019).
Constipation types
The condition is usually divided into two categories (Basson, 2020a).
Primary constipation
This is generally subdivided into:
- Normal transit constipation (NTC): this is the most common type, and occurs when the patient has difficulty emptying their bowels, despite stool passing through the bowel at a normal rate. This type can occur with irritable bowel syndrome (IBS) but can usually be differentiated from chronic constipation because patients with IBS will usually have abdominal discomfort or pain, which is less common in those with NTC
- Slow transit constipation (STC): this type of constipation is associated with less frequent bowel motions and the patient may complain of straining to open their bowels. More frequently seen in females, they may also give a history of feeling bloated and clinicians may be able to feel stool in the colon on examination of the patient
- Pelvic floor dysfunction: characterised by dysfunction of the pelvic floor. Patients will report excessive straining to open their bowels but will feel they have not emptied their bowel properly and, in some cases, may resort to manual evacuation.
Secondary constipation
There are many causes of secondary constipation. Poor diet is a frequent finding when taking the history and those with diets low in fibre or inadequate fluid intake may be affected. Other common causes include a change to usual diet or daily routine, inactivity (limited exercise or sedentary lifestyle) and ignoring the need to open the bowels (NHS, 2020). Patients with diabetes are also prone to constipation and it is reported to be the most common gastrointestinal problem affecting people living with diabetes (Bassan, 2020a). Mechanical causes of constipation include colon, rectal, or anal strictures, injured tissues, diverticular disease or abnormal narrowing of the intestine or rectum, and, in addition, anal fissures, and haemorrhoids are diseases that delay the removal of stool and exacerbate chronic constipation due to pain during defaecation (Forootan et al, 2018). Table 1 shows other causes of secondary constipation.
Table 1. Other causes of secondary constipation
| Cause | Additional information |
|---|---|
| Medications | |
| Iron therapy | Frequently causes constipation |
| Antihypertensives | Calcium antagonists reduce smooth muscle contractility and can cause constipation. These can be replaced by beta-blockers, angiotensin-converting enzyme inhibitors, or angiotensin II receptor antagonists if this is the case |
| Antidepressants | Tricyclic antidepressants (eg, amitriptyline). Selective 5HT reuptake inhibitors and 5HT norepinephrine reuptake inhibitors are alternatives that are less associated with constipation |
| Antacids | Some types of antacids may cause constipation |
| Analgesia | Codeine and codeine-containing analgesia (eg co-codamol) are associated with constipation |
| Neurological disorders | Diseases affecting the neurological system, such as autonomic neuropathy, can be a cause of constipation |
| Multiple sclerosis, spinal cord injuries, Parkinson's disease | The cause of constipation in patients with these conditions is complex and includes disease-related autonomic and pelvic nerve dysfunction, as well as an altered diet of solids and liquid, impaired mobility and psychological disturbances. In addition, drugs used to treat these conditions may also play a part |
Patient history
It is important when the patient presents to get an idea of what they mean by constipation and what would be a normal pattern for them. Some patients deny previous constipation but, when questioned specifically, admit to spending 15 to 20 minutes per bowel movement (Gotfried, 2020). The history should also include any changes to their diet or lifestyle, current medications, and if they have suffered with the problem before, and if so, how did they resolve it. In the elderly population, particularly nursing home residents, constipation may present as confusion and sometimes urinary retention (Singh, 2019). It may be useful if care home staff keep a stool chart to give clinicians a better indication of the severity of the problem (Singh, 2019). Frail older patients may also present with other non-specific symptoms such as delirium, anorexia, and functional decline (an impairment in ability to maintain independence) (Jani and Marsicano, 2018).
Diagnosis
There is no test to confirm a diagnosis of constipation and the problem is usually apparent from the patient's history and symptoms. Bassan (2020b) suggests using the Rome IV criteria to help clinicians differentiate between IBS and constipation, and to determine how troublesome the symptoms may be (see Table 2for further information).
Table 2. Rome IV criteria for diagnosis of constipation and IBS
| Constipation | IBS |
|---|---|
| Less than 3 spontaneous bowel movements per week | Recurrent abdominal pain on average at least 1 day per week during the previous 3 months that is associated with two or more of the symptoms below |
| Straining for more than 25% of defaecation attempts | Abdominal pain must be related to defaecation (may be increased or unchanged by opening the bowels) |
| Lumpy or hard stools for at least 25% of defaecation attempts | Pain associated with a change in stool form or appearance |
| Sensation of an anorectal obstruction or blockage for at least 25% of defaecation attempts | Straining or urgency to open the bowels |
| Sensation of incomplete emptying of the bowels for at least 25% of defaecation attempts | Bloating |
| Manual evacuation needed to defaecate for at 25% of attempts to open the bowels | Mucorrhoea |
Physical examination
A general examination is recommended to exclude symptoms such as fever and weight loss. An abdominal examination should be undertaken to exclude masses, and a rectal examination should be done to check for fissures, strictures, blood, or masses, including impacted faeces (Gotfried, 2020).
After red flag symptoms (discussed below) have been ruled out, other investigations may include the following depending on the circumstances (Singh, 2019):
- Full blood count (FBC) to check for anaemia
- Faecal immunochemical test (FIT) if iron deficiency anaemia is found (NHS, 2019)
- Ferritin
- Urea and electrolytes (U&Es)
- Calcium
- Thyroid stimulating hormone (TSH) (if the history dictates)
- HbA1c to exclude diabetes
- Liver function test (LFT)
- Coeliac screen.
Further investigations are rarely needed, but an abdominal X-ray may be helpful if faecal loading or obstruction is suspected (BPAC New Zealand, 2019).
Red flags
Constipation alone is thought to be a poor predictor of colorectal cancer (Best Practice Advocacy Centre [BPAC] New Zealand, 2019); however, any patient with signs or symptoms (shown below) which may be suggestive of an alternative cause, found on history or clinical examination, should be referred on a 2-week wait (2ww) as per NICE guidelines to exclude malignancy or another serious bowel disease (NICE, 2021b). These red flags include (NICE, 2021b):
- New onset constipation, especially in patients over 60 years of age
- Change in bowel habit persistent for more than 6 weeks
- Anaemia
- Abdominal pain
- Bloating
- Weight loss
- Rectal bleeding.
Endoscopy – either flexible sigmoidoscopy or colonoscopy – is the usual initial investigation for red flag symptoms. Ca125 may be tested if ovarian cancer is suspected.
Treatment and management
In some cases, increasing fluid and fibre intake may be sufficient to resolve the problem. Patients should be advised to increase fibre gradually (to minimise flatulence and bloating) and improvements in symptoms should be seen in a few days, although it can sometimes take 4 weeks (NICE, 2021a). However, despite changes to diet and lifestyle, some people will require pharmacological treatment to achieve symptom resolution and this may be the case for frail elderly patients who have a limited ability to make significant changes in these areas (BPAC New Zealand, 2019). If laxatives are needed there are several to choose from and many can be purchased OTC.
Laxatives
There are many laxative options available and patients may try more than one before they find something that suits them and eases their symptoms. Options are discussed below and prescribing drugs within each category, and factors affecting choices and adverse effects are shown in Table 3.
Table 3. Laxative choices
| Laxative option | Factors affecting use of this option | Adverse effects |
|---|---|---|
| Faecal softeners (eg, docusate, co-danthramer) | Manufacturer advises against use in breastfeeding women as drug is present in the breast milkCo-danthramer and co-danthrusate use is limited to constipation in terminally ill patients because of potential carcinogenicity | Can cause nausea, rashes and abdominal cramps, although side effects are rare |
| Bulk forming (eg, Ispaghula husk, methylcellulose, sterculia) | Should not be given if faecal impaction or intestinal obstruction is suspected | May cause flatulence and bloating and if taken with inadequate fluid intake can cause obstruction |
| Stimulant laxatives (eg, bisacodyl, senna, co-danthrusate) | Do not use if patient has undiagnosed abdominal pain or intestinal obstruction is suspected | Nausea, vomiting, diarrhoea and abdominal cramps. Senna may give the urine a yellowish-brown colour |
| Osmotic laxatives (eg, lactulose and macrogels) | Do not use lactulose in patients with galactosaemia or intestinal obstructionMacrogels should not be prescribed in intestinal obstruction or in those with inflammatory bowel disease such as Crohn's disease or ulcerative colitis | Rarely causes electrolyte imbalance but this is more common in those with inadequate fluid intake. May cause nausea and vomiting, bloating, flatulence and abdominal cramps |
| Prokinetic laxatives (Prucalopride) | Should only be prescribed when other laxatives have failed to provide an adequate response, but may be an option if other choices have failed. Should only be prescribed by an experienced physician | Common side effects include diarrhoea and abdominal pain. Rarely the drug may cause headaches, palpitations and frequent urination |
| Rectal laxatives (eg, enemas and suppositories) | Patient may find these unpleasant to use | Side effects of suppositories are usually mild but may include irritation and loose stoolsEnemas are generally safe but can occasionally cause irritation to the rectal mucosa or tissue damage if inserted incorrectly |
Laxative options include (NICE, 2021a):
Faecal softeners
Faecal softeners are thought to achieve their effect by increasing uptake of fluid into the faecal mass.
Bulk-forming laxatives
Options in this category stimulate peristalsis and retain fluid within the stool, which increases faecal mass.
Stimulant laxatives
Drugs of this type increase the motility of the intestines and can cause stomach cramps.
Osmotic laxatives
Osmotic laxatives increase the amount of water in the large bowel, either by encouraging the fluid they were administered with to be retained or by drawing fluid into the bowel.
Prokinetic laxatives (Prucalopride)
Prucalopride is a selective serotonin receptor agonist, which works by stimulating intestinal motility.
Rectal laxatives
Options for rectal laxatives include suppositories and enema preparations.
Some patients with severe symptoms may need more than one laxative to solve their problem. There are no studies assessing a step-wise approach to laxative therapy, although a bulk-forming agent is recommended with the addition of an osmotic laxative, followed by a stimulant laxative if needed (Schuster et al, 2015).
Complications
Although complications of constipation are rare, they do still occur in some people. The most common of these include (Harding, 2019; Basson, 2020a):
- Haemorrhoids and rectal bleeding
- Anal fissure
- Faecal impaction and overflow diarrhoea
- Bowel obstruction
- Rectal prolapse
- Urinary incontinence.
Prognosis
The outlook for constipation is highly unpredictable, but for some patients it may take weeks to years of adjustments to lifestyle and laxative treatments to return bowel function to a more acceptable pattern (NICE, 2021a).
Conclusion
Constipation is a condition which at best is easily resolved, and at worst can be a long-term chronic condition requiring ongoing medication. Although seen in all age groups, older people are more frequently affected and may require more than one laxative to improve the problem. This article has given an overview of the condition and hopes to have provided nurses and non-medical prescribers with an understanding of advice and treatment options and give them more confidence when advising and treating patients who present with this condition.
KEY POINTS:
- Constipation is a very common condition, that is variable in its severity, and in some cases can significantly impact on quality of life
- Prevalence of constipation is increased among older adults, and it affects females more commonly than males
- In some cases, increasing fluid and fibre intake may be sufficient to resolve the problem
- Several treatments are available for constipation and some patients may need more than one medication to manage their symptoms
CPD reflective practice:
- What topics should be covered when taking a good history when patients present with constipation?
- How can lifestyle changes help with constipation?
- Are you confident that you can choose an appropriate laxative? Where could you get more information to help you decide?