Constipation

Constipation is a heterogeneous, symptom-based disorder in which people have infrequent and/or hard stools, difficulty passing stools or sensation of incomplete emptying or anorectal blockage (National Institute for Health and Care Excellence (NICE), 2023). The Rome IV diagnostic criteria for constipation include spontaneous bowel movements occurring less than three times a week (Aziz et al, 2020; NICE, 2023). In clinical practice, constipation is often defined as a passage of stools less frequently than the person’s normal pattern (NICE, 2023) and often categorised by using the Bristol stool chart (Figure 1).

Women are more likely to experience constipation than men, especially during pregnancy, and it is also more common in older people (Bowel Interest Group, 2020).

There are many causes for constipation. The most common risk factors are related to social (ie diet and lifestyle), psychological and physical factors (Table 1).

Sometimes there is no obvious reason or known cause for constipation. This

According to NICE (2023), a diagnosis of constipation can be made if an adult present with defecation which is unsatisfactory because of infrequent stools (less than 3 times a week), difficulties passing stools (ie there may be daily bowel movements but associated symptoms such as excessive straining), or a sensation of incomplete emptying or anorectal blockage.

If a diagnosis of constipation is suspected, the following should be considered:

• any symptoms or signs that may suggest a serious underlying cause, such as colorectal cancer
• the person's perception of a normal bowel habit may influence the diagnosis of constipation
• the duration of constipation, and the frequency and consistency of stools
• associated symptoms such as rectal discomfort, excessive straining, feeling of incomplete evacuation, rectal bleeding, abdominal pain or distension
• associated fever, nausea, vomiting, loss of appetite and/or weight
• associated urinary symptoms, urinary incontinence or retention, dyspareunia
• any family history of colorectal cancer or

The management of constipation depends on the primary cause. For example, if the cause of constipation is secondary to drug treatment, a full review of the patient current medications will be needed. Before advising on constipation, it is essential that a full clinical history, physical assessment, sign and symptoms, drugs (including over the counter preparations) and diet histories are undertaken. Stress anxiety and depression should also be considered.

Furthermore, the management of constipation will vary depending on its presentation and clinical scenario:

• short duration constipation
• chronic constipation
• faecal loading and/or impaction
• constipation in pregnancy and breast feeding

In acute medicine, constipation should no be overlooked. In the critical care setting, the incidence of constipation can occur at 83% and has been associated with an increased length of stay and increased duration of mechanical ventilation (Prat et al 2018). Laxative prophylaxis can be used successfully to prevent constipation in the critically

When considering treatment for constipation, people can often request over-the-counter preparations or drugs to be prescribed without full consideration of diet and lifestyle measures. The treatments for constipation should always include diet and lifestyle measure, and laxative when appropriate.

Diet and lifestyle measures

Dietary changes should be introduced gradually, and the effect should be seen at least after 4-6 weeks of their implementation.