View source for Constipation

{{Short description|Infrequent or difficult bowel movements}}
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{{Infobox medical condition (new)
| name            = Constipation
| image           = Constipation.JPG
| caption         = Constipation in a young child seen on X-ray. Circles represent areas of [[fecal matter]] (stool is white surrounded by black bowel gas).
| field           = [[Gastroenterology]]
| synonyms        = Costiveness,<ref>{{Cite web |url=http://www.merriam-webster.com/dictionary/costiveness |title=Costiveness&nbsp;– Definition and More from the Free Merriam-Webster Dictionary |url-status=live |archive-url=https://web.archive.org/web/20100411110846/http://www.merriam-webster.com/dictionary/costiveness |archive-date=11 April 2010 }}</ref> dyschezia<ref name=Review09/>
| symptoms        = Infrequent or hard to pass [[bowel movements]], abdominal pain, bloating<ref name=Review09/><ref name=AGA2013/>
| complications   = [[Hemorrhoids]], [[anal fissure]], [[fecal impaction]]<ref name=NIH2015/>
| onset           =
| duration        =
| types           =
| causes          = Slow movement of stool within the colon, [[irritable bowel syndrome]], [[celiac disease]], [[non-celiac gluten sensitivity]], [[pelvic floor]] disorders<ref name=NIH2015/><ref name=SymptomsCausesNIDDK/><ref name=MakhariaCatassi2015/>
| risks           = [[Hypothyroidism]], [[diabetes]], [[Parkinson's disease]], [[gluten-related disorders]], [[colon cancer]], [[ovarian cancer]], [[diverticulitis]], [[inflammatory bowel disease]], certain medications<ref name=NIH2015/><ref name=SymptomsCausesNIDDK/><ref name=MakhariaCatassi2015/>
| diagnosis       =
| differential    =
| prevention      =
| treatment       = Drinking enough fluids, eating more [[dietary fiber|fiber]], [[exercise]]<ref name=NIH2015/>
| medication      = [[Laxative]]s of the [[bulk forming agent]], [[Laxative#Hyperosmotic agents|osmotic agent]], [[stool softener]], or [[Laxative#Lubricant agents|lubricant type]]<ref name=NIH2015/>
| prognosis       =
| frequency       = 2–30%<ref name=And2006/>
| deaths          =
}}
<!-- Definition and symptoms -->
'''Constipation''' is a [[bowel]] dysfunction that makes [[bowel movement]]s infrequent or hard to pass.<ref name="Review09">{{cite journal |vauthors=Chatoor D, Emmnauel A | title = Constipation and evacuation disorders | journal = Best Pract Res Clin Gastroenterol |publisher=Baillière Tindall| volume = 23 | issue = 4 | pages = 517–30 | year = 2009 | pmid = 19647687 | doi = 10.1016/j.bpg.2009.05.001 }}</ref> The [[Human feces|stool]] is often hard and dry.<ref name="NIH2015" /> Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement.<ref name="AGA2013">{{cite journal|last1=Bharucha|first1=A. E.|last2=Dorn|first2=S. D.|last3=Lembo|first3=A.|last4=Pressman|first4=A.|date=January 2013|title=American Gastroenterological Association medical position statement on constipation|journal=Best Practice & Research: Clinical Gastroenterology|publisher=[[Bailliere Tindall|Baillière Tindall]]|type=Review|volume=144|issue=1|pages=211–217|doi=10.1053/j.gastro.2012.10.029|pmid=23261064|doi-access=free}}</ref> Complications from constipation may include [[hemorrhoids]], [[anal fissure]] or [[fecal impaction]].<ref name="NIH2015" /> The normal frequency of bowel movements in adults is between three per day and three per week.<ref name="NIH2015" /> Babies often have three to four bowel movements per day while young children typically have two to three per day.<ref name="Col2015">{{Cite journal|last1=Colombo|first1=Jennifer M.|last2=Wassom|first2=Matthew C.|last3=Rosen|first3=John M.|date=2015-09-01|title=Constipation and Encopresis in Childhood|journal=Pediatrics in Review|volume=36|issue=9|pages=392–401; quiz 402|doi=10.1542/pir.36-9-392|issn=1526-3347|pmid=26330473|s2cid=35482415 }}</ref>

<!-- Cause and diagnosis -->
Constipation has many causes.<ref name="NIH2015" /> Common causes include slow movement of stool within the colon, [[irritable bowel syndrome]], and [[pelvic floor]] disorders.<ref name="NIH2015" /> Underlying associated diseases include [[hypothyroidism]], [[diabetes]], [[Parkinson's disease]], [[celiac disease]], [[non-celiac gluten sensitivity]], [[Vitamin B12 deficiency|vitamin B<sub>12</sub> deficiency]], [[colon cancer]], [[diverticulitis]], and [[inflammatory bowel disease]].<ref name="NIH2015">{{cite web|url=https://www.niddk.nih.gov/health-information/digestive-diseases/constipation/all-content|title=Constipation|date=February 2015|website=National Institute of Diabetes and Digestive and Kidney Diseases|access-date=14 March 2017|archive-url=https://web.archive.org/web/20170315085221/https://www.niddk.nih.gov/health-information/digestive-diseases/constipation/all-content|archive-date=15 March 2017}}</ref><ref name="SymptomsCausesNIDDK">{{cite web|title=Symptoms & Causes of Celiac Disease {{!}} NIDDK|url=https://www.niddk.nih.gov/health-information/digestive-diseases/celiac-disease/symptoms-causes|website=National Institute of Diabetes and Digestive and Kidney Diseases|access-date=24 April 2017|date=June 2016|url-status=live|archive-url=https://web.archive.org/web/20170424175500/https://www.niddk.nih.gov/health-information/digestive-diseases/celiac-disease/symptoms-causes|archive-date=24 April 2017}}</ref><ref name="MakhariaCatassi2015" /><ref>{{cite journal|vauthors=Bharucha AE, Pemberton JH, Locke GR 3rd |title=American Gastroenterological Association technical review on constipation.|journal=Gastroenterology|date=January 2013|volume=144|issue=1|pages=218–38|pmid=23261065|doi=10.1053/j.gastro.2012.10.028|pmc=3531555}}</ref><ref>{{Cite web |title=Pernicious Anemia Clinical Presentation: History, Physical Examination |url=https://emedicine.medscape.com/article/204930-clinical |access-date=2023-04-06 |website=emedicine.medscape.com |language=en}}</ref> Medications associated with constipation include [[opioids]], certain [[antacids]], [[calcium channel blockers]], and [[anticholinergics]].<ref name="NIH2015" /> Of those taking [[opioids]] about 90% develop constipation.<ref name="Cad2014" /> Constipation is more concerning when there is weight loss or [[anemia]], [[hematochezia|blood is present in the stool]], there is a history of inflammatory bowel disease or colon cancer in a person's family, or it is of new onset in someone who is older.<ref name="Br2016">{{cite journal|last1=Brenner|first1=DM|last2=Shah|first2=M|title=Chronic Constipation.|journal=Gastroenterology Clinics of North America|date=June 2016|volume=45|issue=2|pages=205–16|pmid=27261894|doi=10.1016/j.gtc.2016.02.013}}</ref>

<!-- Treatment -->
Treatment of constipation depends on the underlying cause and the duration that it has been present.<ref name="NIH2015" /> Measures that may help include drinking enough fluids, eating more [[dietary fiber|fiber]], consumption of [[honey]]<ref>{{cite journal|title=Gut microbiota is involved in the alleviation of loperamide-induced constipation by honey supplementation in mice|last1=Li|first1=Yuyuan|last2=Long|first2=Shangqin|last3=Liu|first3=Qiaochu|last4=Ma|first4=Hong|last5=Li|first5=Jianxin|last6=Xiaoking|first6=Wei|last7=Yuan|first7=Jieli|last8=Li|first8=Ming|last9=Hou|first9=Minmin|journal=Food Science & Nutrition|publisher=[[National Institute of Health|NIH]]|quote=The results of this study suggested that honey can improve the symptoms of constipation by elevating fecal water content and intestinal transit rate in loperamide‐induced constipation model.|date=8 August 2020|volume=8|issue=8|pages=4388–4398|doi=10.1002/fsn3.1736|pmid=32884719|pmc=7455974}}</ref> and [[exercise]].<ref name="NIH2015" /> If this is not effective, [[laxative]]s of the [[bulk-forming agent]], [[Laxative#Hyperosmotic agents|osmotic agent]], [[stool softener]], or [[Laxative#Lubricant agents|lubricant type]] may be recommended.<ref name="NIH2015" /> [[Stimulant laxatives]] are generally reserved for when other types are not effective.<ref name="NIH2015" /> Other treatments may include [[biofeedback]] or in rare cases surgery.<ref name="NIH2015" />

<!-- Epidemiology and culture -->
In the general population rates of constipation are 2–30 percent.<ref name=And2006>{{cite journal |vauthors=Andromanakos N, Skandalakis P, Troupis T, Filippou D | title = Constipation of anorectal outlet obstruction: Pathophysiology, evaluation and management | journal = Journal of Gastroenterology and Hepatology | volume = 21 | issue = 4 | pages = 638–646 | year = 2006 | pmid = 16677147 | doi = 10.1111/j.1440-1746.2006.04333.x | s2cid = 30296908 | doi-access =  }}</ref> Among elderly people living in a care home the rate of constipation is 50–75 percent.<ref name=Cad2014>{{cite book |author1=Canadian Agency for Drugs and Technologies in Health|title=Dioctyl Sulfosuccinate or Docusate (Calcium or Sodium) for the Prevention or Management of Constipation: A Review of the Clinical Effectiveness|date=26 June 2014|pmid=25520993}}</ref> People in the United States spend more than {{US$|250{{nbsp}}million|link=yes}} on medications for constipation a year.<ref>{{cite book|last1=Avunduk|first1=Canan|title=Manual of gastroenterology: diagnosis and therapy|date=2008|publisher=Wolters Kluwer Health/Lippincott Williams & Wilkins|location=Philadelphia|isbn=978-0-7817-6974-7|page=240|edition=4th|url=https://books.google.com/books?id=PekixjgbRlcC&pg=PA240|url-status=live|archive-url=https://web.archive.org/web/20160911004050/https://books.google.com/books?id=PekixjgbRlcC&pg=PA240|archive-date=11 September 2016}}</ref>
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==Definition==
[[File:BristolStoolChart.png|thumb|upright=1.7|[[Bristol stool scale]]]]
Constipation is a symptom, not a disease. Most commonly, constipation is thought of as infrequent bowel movements, usually fewer than 3 stools per week.<ref name=Jam2011>{{Cite journal|last1=Jamshed|first1=Namirah|last2=Lee|first2=Zone-En|last3=Olden|first3=Kevin W.|date=2011-08-01|title=Diagnostic approach to chronic constipation in adults|journal=American Family Physician|volume=84|issue=3|pages=299–306|issn=1532-0650|pmid=21842777}}</ref><ref>[http://www.emedicine.com/med/topic2833.htm "Constipation"] {{webarchive|url=https://web.archive.org/web/20070329015509/http://www.emedicine.com/med/topic2833.htm |date=29 March 2007 }}. eMedicine.</ref> However, people may have other complaints as well including:<ref name=AGA2013/><ref name=walia>{{cite journal |vauthors=Walia R, Mahajan L, Steffen R | title = Recent advances in chronic constipation | journal = Curr Opin Pediatr | volume = 21 | issue = 5 | pages = 661–6 | date = October 2009 | pmid = 19606041 | doi = 10.1097/MOP.0b013e32832ff241 | s2cid = 11606786 }}</ref>
* Straining with bowel movements
* Excessive time needed to pass a bowel movement
* Hard stools
* Pain with bowel movements secondary to straining
* Abdominal pain
* Abdominal bloating.
* the sensation of incomplete bowel evacuation.

The [[Rome process|Rome III Criteria]] are a set of symptoms that help standardize the diagnosis of constipation in various age groups. These criteria help physicians to better define constipation in a standardized manner.

==Causes==
The causes of constipation can be divided into [[congenital]], primary, and secondary.<ref name=Review09/> The most common kind is primary and not life-threatening.<ref name=AGA2000/> It can also be divided by the age group affected such as children and adults.

Primary or [[functional constipation]] is defined by ongoing symptoms for greater than six months not due to an underlying cause such as medication [[side effects]] or an underlying medical condition.<ref name=Review09/><ref name=AFP05/> It is not associated with abdominal pain, thus distinguishing it from [[irritable bowel syndrome]].<ref name=Review09/> It is the most common kind of constipation, and is often multifactorial.<ref name="AGA2000"/><ref name=CC:CriticalReview>{{Cite journal|last1=Basilisco|first1=Guido|last2=Coletta|first2=Marina|title=Chronic constipation: A critical review|journal=Digestive and Liver Disease|volume=45|issue=11|pages=886–893|doi=10.1016/j.dld.2013.03.016|pmid=23639342|year=2013|doi-access=free}}</ref> In adults, such primary causes include: dietary choices such as insufficient dietary fiber or fluid intake, or behavioral causes such as decreased [[physical activity]]. In children, causes can include diets low in fiber and fluids, underlying medical conditions, and reluctance to go to the bathroom.<ref>{{Cite web |title=Pediatric Chronic Constipation {{!}} Children's National Hospital |url=https://www.childrensnational.org/get-care/health-library/chronic-constipation}}</ref> In the elderly, common causes have been attributed to insufficient dietary fiber intake, inadequate fluid intake, decreased [[physical activity]], side effects of medications, [[hypothyroidism]], and obstruction by [[colorectal cancer]].<ref name=Le2007/> Evidence to support these factors however is poor.<ref name=Le2007>{{cite journal | author = Leung FW | title = Etiologic factors of chronic constipation: review of the scientific evidence | journal = Dig. Dis. Sci. | volume = 52 | issue = 2 | pages = 313–6 | date = February 2007 | pmid = 17219073 | doi = 10.1007/s10620-006-9298-7 | s2cid = 608978 }}</ref>

Secondary causes include side effects of medications such as opiates, endocrine and metabolic disorders such as [[hypothyroidism]], and obstruction such as from [[colorectal cancer]]<ref name=CC:CriticalReview/> or [[ovarian cancer]].<ref name="CDCsep2016">{{cite web|url=https://www.cdc.gov/cancer/ovarian/pdf/ovarian_facts.pdf|title=Ovarian Cancer, Inside Knowledge, Get the Facts about Gynecological Cancer|date=September 2016|publisher=Centers for Disease Control and Prevention|access-date=17 June 2017|url-status=live|archive-url=https://web.archive.org/web/20170616220028/https://www.cdc.gov/cancer/ovarian/pdf/ovarian_facts.pdf|archive-date=16 June 2017}}{{CDC}}</ref> [[Celiac disease]] and [[non-celiac gluten sensitivity]] may also present with constipation.<ref name=SymptomsCausesNIDDK/><ref name=WGO2016>{{cite web|url=http://www.worldgastroenterology.org/guidelines/global-guidelines/celiac-disease/celiac-disease-english|title=Celiac disease|date=July 2016|publisher=[[World Gastroenterology Organisation]] Global Guidelines|access-date=23 April 2017|url-status=live|archive-url=https://web.archive.org/web/20170317123604/http://www.worldgastroenterology.org/guidelines/global-guidelines/celiac-disease/celiac-disease-english|archive-date=17 March 2017}}</ref><ref name=MakhariaCatassi2015>{{cite journal| vauthors = Makharia A, Catassi C, Makharia GK | title=The Overlap between Irritable Bowel Syndrome and Non-Celiac Gluten Sensitivity: A Clinical Dilemma | journal=Nutrients | year= 2015 | volume= 7 | issue= 12 | pages= 10417–26 | pmid=26690475 | doi=10.3390/nu7125541 | pmc=4690093 | type=Review | doi-access=free }}</ref> Cystocele can develop as a result of chronic constipation.<ref>{{Cite news|url=https://www.niddk.nih.gov/health-information/urologic-diseases/cystocele?dkrd=/health-information/urologic-diseases/bladder-control-problems-women/cystocele-prolapsed-bladder|title=Cystocele (Prolapsed Bladder) {{!}} NIDDK|work=National Institute of Diabetes and Digestive and Kidney Diseases|access-date=2017-12-02|language=en-US}}</ref>

===Diet===
Constipation can be caused or exacerbated by a low-fiber diet, low liquid intake, or dieting.<ref name="walia"/><ref name="mccallum">{{cite journal|year=2009|title=Chronic constipation in adults|journal=The BMJ|volume=338|pages=b831|doi=10.1136/bmj.b831|pmid=19304766|vauthors=McCallum IJ, Ong S, Mercer-Jones M|s2cid=8291767}}</ref> Dietary fiber helps to decrease colonic transport time, increases stool bulk but simultaneously softens stool. Therefore, diets low in fiber can lead to primary constipation.<ref name=CC:CriticalReview/>

===Medications===
Many medications have constipation as a side effect. Some include (but are not limited to) [[opioid]]s, [[diuretics]], [[antidepressant]]s, [[antihistamine]]s, [[antispasmodic]]s, [[anticonvulsant]]s, [[tricyclic antidepressant]]s, [[antiarrythmics]], [[Beta blocker|beta-adrenoceptor antagonists]], [[anti-diarrheal]]s, 5-HT3 receptor antagonists such as [[ondansetron]], and aluminum [[antacid]]s.<ref name=walia/><ref name="ap01">{{Cite journal|date=August 2010|title=Managing constipation in adults|journal=Australian Prescriber|volume=33|issue=4|pages=116–9|author=Selby, Warwick|author2=Corte, Crispin|doi=10.18773/austprescr.2010.058|doi-access=free}}</ref> Certain [[calcium channel blocker]]s such as [[nifedipine]] and [[verapamil]] can cause severe constipation due to dysfunction of motility in the [[rectosigmoid colon]].<ref>{{cite journal|vauthors=Gallegos-Orozco JF, Foxx-Orenstein AE, Sterler SM, Stoa JM |title=Chronic constipation in the elderly|journal=The American Journal of Gastroenterology|volume=107|issue=1|pages=18–25|date=January 2012|pmid=21989145|doi=10.1038/ajg.2011.349|s2cid=205099253|type=Review}}</ref> Supplements such as calcium and iron supplements can also have constipation as a notable side effect.<ref>{{cite journal|first1=Kelvin|last1=Li|first2=Xia-Fang|last2=Wang|first3=Ding-You|last3=Li|first4=Yuan-Cheng|last4=Chen|title=The good, the bad, and the ugly of calcium supplementation: a review of calcium intake on human health|journal=Clinical Interventions in Aging|date=28 November 2018|issn=1176-9092|pages=2443–2452|volume=13|pmid=30568435|pmc=6276611|doi=10.2147/CIA.S157523|first5=Lan-Juan|last5=Zhao|first6=Xiao-Gang|last6=Liu|first7=Yan-Fang|last7=Guo|first8=Jie|last8=Shen|first9=Xu|last9=Lin|first10=Jeffrey|last10=Deng|first11=Rou|last11=Zhou|first12=Hong-Wen|last12=Deng|doi-access=free }}</ref><ref name="q220">{{cite journal | last1=Parvataneni | first1=Swetha | last2=Maw | first2=Min | title=Ileus Due to Iron Pills: A Case Report and Literature Report on the Importance of Stool Softeners | journal=Cureus | publisher=Cureus Inc. | volume=12 | issue=6 | date=2024-03-14 | article-number=e8392 | pmid=32637274 | doi=10.7759/cureus.8392 | doi-access=free | pmc=7331903 }}</ref>

===Medical conditions===
Metabolic and endocrine problems which may lead to constipation include: [[pheochromocytoma]], [[hypercalcemia]], [[hypothyroidism]], [[hyperparathyroidism]], [[porphyria]], [[chronic kidney disease]], [[pan-hypopituitarism]], [[diabetes mellitus]], and [[cystic fibrosis]].<ref name=walia/><ref name=AGA2000/> Constipation is also common in individuals with muscular and myotonic dystrophy.<ref name=walia/>

[[Systemic disease]]s that may present with constipation include [[celiac disease]] and [[systemic sclerosis]].<ref name=SymptomsCausesNIDDK/><ref name=WGO2016/><ref name=GygerBaron2015>{{cite journal| author=Gyger G, Baron M| title=Systemic Sclerosis: Gastrointestinal Disease and Its Management. | journal=Rheum Dis Clin North Am | year= 2015 | volume= 41 | issue= 3 | pages= 459–73 | pmid=26210129 | doi=10.1016/j.rdc.2015.04.007 |type=Review }}</ref>

Constipation has a number of structural (mechanical, morphological, anatomical) causes, namely through creating space-occupying lesions within the colon that stop the passage of stool, such as [[colorectal cancer]], [[Stenosis|strictures]], [[Rectocele|rectocoles]], [[Human anus|anal sphincter]] damage or malformation and post-surgical changes. Extra-intestinal masses such as other malignancies can also lead to constipation from external compression.<ref>{{Cite journal|last1=Rao|first1=Satish S. C.|last2=Rattanakovit|first2=Kulthep|last3=Patcharatrakul|first3=Tanisa|title=Diagnosis and management of chronic constipation in adults|journal=Nature Reviews Gastroenterology & Hepatology|volume=13|issue=5|pages=295–305|doi=10.1038/nrgastro.2016.53|pmid=27033126|year=2016|s2cid=19608417}}</ref>

Constipation also has neurological causes, including [[anismus]], [[descending perineum syndrome]], [[desmosis]] and [[Hirschsprung's disease]].<ref name="And2006"/> In infants, Hirschsprung's disease is the most common medical disorder associated with constipation. Anismus occurs in a small minority of persons with chronic constipation or obstructed defecation.<ref>{{cite journal|year=1997|title=Anismus: fact or fiction?|journal=Diseases of the Colon and Rectum|volume=40|issue=9|pages=1033–1041|doi=10.1007/BF02050925|pmid=9293931|vauthors=Schouten WR, Briel JW, Auwerda JJ, van Dam JH, Gosselink MJ, Ginai AZ, Hop WC|s2cid=23587867}}</ref>

Spinal cord lesions and neurological disorders such as [[Parkinson's disease]] and [[pelvic floor dysfunction]]<ref name="AGA2000"/> can also lead to constipation.

[[Chagas disease]] may cause constipation through the destruction of the [[myenteric plexus]].<ref>{{cite journal |last1=Pérez-Molina |first1=José A. |last2=Molina |first2=Israel |title=Chagas disease |journal=The Lancet |date=6 January 2018 |volume=391 |issue=10115 |pages=82–94 |doi=10.1016/S0140-6736(17)31612-4 |pmid=28673423 |s2cid=4514617 }}</ref><ref>{{cite journal |last1=Nguyen |first1=Tina |last2=Waseem |first2=Muhammad |title=Chagas Disease |journal=StatPearls |date=2022 |url=https://www.ncbi.nlm.nih.gov/books/NBK459272/ |publisher=StatPearls Publishing|pmid=29083573 }}</ref>

===Psychological===
Voluntary withholding of the stool is a common cause of constipation.<ref name=walia/> The choice to withhold can be due to factors such as fear of pain, fear of public restrooms, or laziness.<ref name=walia/> When a child holds in the stool a combination of encouragement, [[drink|fluids]], [[dietary fiber|fiber]], and [[laxative]]s may be useful to overcome the problem.<ref>{{cite journal | author = Cohn A | title = Stool withholding | journal = Journal of Pediatric Neurology | year = 2010 | volume = 8 | issue = 1 | pages = 29–30 | doi = 10.3233/JPN-2010-0350 | url = http://www.anthonycohnpaediatrics.co.uk/jpn.pdf | access-date = 7 September 2011 | pmid = <!-- none--> | s2cid = 257155678 | url-status = live | archive-url = https://web.archive.org/web/20110907082744/http://www.anthonycohnpaediatrics.co.uk/jpn.pdf | archive-date = 7 September 2011 }}</ref> Early intervention with withholding is important as this can lead to [[anal fissure]]s.<ref name=AmericanGATReview/>

=== Congenital ===
[[Congenital disorder|A number of diseases present at birth]] can result in [[constipation in children]]. They are as a group uncommon with Hirschsprung's disease (HD) being the most common.<ref>{{Cite book|title=Constipation: etiology, evaluation and management|last=Wexner|first=Steven|publisher=Springer|year=2006|location=New York}}</ref> There are also congenital structural anomalies that can lead to constipation, including anterior displacement of the anus, [[imperforate anus]], strictures, and small left colon syndrome.<ref name =JournalOPGAN/>

==Pathophysiology==

{{empty section|date=July 2019}}

==Diagnosis==
[[File:Constipation(lots).png|thumb|Significant constipation in the plain X-ray of an 8-year-old]]
The diagnosis is typically made based on a person's description of the symptoms. Bowel movements that are difficult to pass, very firm, or made up of small hard pellets (like those excreted by rabbits) qualify as constipation, even if they occur every day. Constipation is traditionally defined as three or fewer bowel movements per week.<ref name=Jam2011/> Other symptoms related to constipation can include bloating, [[Abdominal distension|distension]], abdominal pain, headaches, a feeling of fatigue and nervous exhaustion, or a sense of incomplete emptying.<ref>[http://www.medicinenet.com/constipation/article.htm "Constipation"] {{webarchive|url=https://web.archive.org/web/20071130041024/http://www.medicinenet.com/constipation/article.htm |date=30 November 2007 }} MedicineNet</ref> Although constipation may be a diagnosis, it is typically viewed as a symptom that requires evaluation to discern a cause.

=== Description ===
Distinguish between acute (days to weeks) or chronic (months to years) onset of constipation because this information changes the [[differential diagnosis]]. This in the context of accompanied symptoms helps physicians discover the cause of constipation. People often describe their constipation as bowel movements that are difficult to pass, firm stool with lumpy or hard consistency, and excessive straining during bowel movements. Bloating, abdominal [[Abdominal distension|distension]], and abdominal pain often accompany constipation.<ref name=LTierneyBook>{{cite book|vauthors = Tierney LM, Henderson MC, Smetana GW|title=The patient history: an evidence-based approach to differential diagnosis|date=2012|publisher=McGraw-Hill Medical|location=New York|isbn=978-0-07-162494-7|page=Chapter 32|edition=2nd}}</ref> Chronic constipation (symptoms present at least three days per month for more than three months) associated with abdominal discomfort is often diagnosed as irritable bowel syndrome (IBS) when no obvious cause is found.<ref>{{cite journal|year=2006|title=Functional bowel disorders|journal=Gastroenterology|volume=130|issue=5|pages=1480–91|doi=10.1053/j.gastro.2005.11.061|pmid=16678561|vauthors=Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC}}</ref>

Poor dietary habits, previous abdominal surgeries, and certain medical conditions can contribute to constipation. Diseases associated with constipation include [[hypothyroidism]], certain types of [[cancer]], and [[irritable bowel syndrome]]. Low fiber intake, inadequate amounts of fluids, poor ambulation or immobility, or medications can contribute to constipation.<ref name="walia"/><ref name="mccallum"/> Once the presence of constipation is identified based on a culmination of the symptoms described above, then the cause of constipation should be figured out.

Separating non-life-threatening from serious causes may be partly based on symptoms. For example, colon cancer may be suspected if a person has a family history of colon cancer, fever, weight loss, and rectal bleeding.<ref name=Jam2011/> Other alarming signs and symptoms include family or personal history of inflammatory bowel disease, age of onset over 50, change in stool caliber, nausea, vomiting, and neurological symptoms like weakness, numbness and difficulty urinating.<ref name=LTierneyBook/>

=== Examination ===
A physical examination should involve at least an abdominal exam and rectal exam. Abdominal exam may reveal an abdominal mass if there is significant stool burden and may reveal abdominal discomfort. [[Rectal examination]] gives an impression of the anal sphincter [[muscle tone|tone]] and whether the lower rectum contains any feces or not. Rectal examination also gives information on the consistency of the stool, the presence of hemorrhoids, blood and whether any [[perineum|perineal]] irregularities are present including skin tags, fissures, anal warts.<ref name="mccallum"/><ref name="walia"/><ref name=Jam2011/> Physical examination is done manually by a physician and is used to guide which diagnostic tests to order.

=== Diagnostic tests ===
Functional constipation is common and does not warrant diagnostic testing. Imaging and laboratory tests are typically recommended for those with alarm signs or symptoms.<ref name=Jam2011/>

The laboratory tests performed depends on the suspected underlying cause of the constipation. Tests may include CBC ([[complete blood count]]), thyroid function tests, serum calcium, serum potassium, etc.<ref name="walia"/><ref name=Jam2011/>

[[Abdominal radiography|Abdominal X-rays]] are generally only performed if bowel obstruction is suspected, may reveal extensive impacted fecal matter in the colon, and may confirm or rule out other causes of similar symptoms.<ref name="mccallum"/><ref name="walia"/>

Colonoscopy may be performed if an abnormality in the colon like a tumor is suspected.<ref name=Jam2011/> Other tests rarely ordered include [[anorectal manometry]], anal sphincter electromyography, and [[defecography]].<ref name="walia"/>

Colonic propagating pressure wave sequences (PSs) are responsible for discrete movements of the bowel contents and are vital for normal defecation. Deficiencies in PS frequency, amplitude, and extent of propagation are all implicated in severe defecatory dysfunction (SDD). Mechanisms that can normalize these aberrant motor patterns may help rectify the problem. Recently the novel therapy of [[sacral nerve stimulation]] (SNS) has been utilized for the treatment of severe constipation.<ref>{{Cite journal |author=Dinning PG |title=Colonic manometry and sacral nerve stimulation in patients with severe constipation |journal=Pelviperineology |volume=26 |issue=3 |pages=114–116 |date=September 2007 |url=http://www.pelviperineology.com/pelvis/severe_constipation_colonic_manometry_sacral_nerve_stimulation.html |archive-url=https://web.archive.org/web/20080212124726/http://www.pelviperineology.com/pelvis/severe_constipation_colonic_manometry_sacral_nerve_stimulation.html |archive-date=12 February 2008 }}</ref>

===Criteria===
The Rome III Criteria for functional constipation must include two or more of the following and present for the past three months, with symptoms starting for at least 6 months prior to diagnosis.<ref name=Jam2011/>
* Straining during defecation for at least 25% of bowel movements
* Lumpy or hard stools in at least 25% of defecations
* Sensation of incomplete evacuation for at least 25% of defecations
* Sensation of anorectal obstruction/blockage for at least 25% of defecations
* Manual maneuvers to facilitate at least 25% of defecations
* Fewer than 3 defecations per week
* Loose stools are rarely present without the use of laxatives
* There are insufficient criteria for irritable bowel syndrome

==Prevention==
Constipation is usually easier to prevent than to treat. Following the relief of constipation, maintenance with adequate exercise, fluid intake, and high-fiber diet is recommended.<ref name=walia/>

==Treatment==
A limited number of cases require urgent medical intervention or will result in severe consequences.<ref name=AGA2013/>

The treatment of constipation should focus on the underlying cause if known. The National Institute of Health and Care Excellence (NICE) break constipation in adults into two categories: chronic constipation of unknown cause, and constipation due to opiates.<ref>{{cite web|title=Constipation overview|url=http://pathways.nice.org.uk/pathways/constipation|publisher=National Institute for Health and Care Excellence|access-date=10 October 2015|url-status=live|archive-url=https://web.archive.org/web/20150908041215/http://pathways.nice.org.uk/pathways/constipation|archive-date=8 September 2015}}</ref>

In chronic constipation of unknown cause, the main treatment involves the increased intake of water and fiber (either dietary or as supplements).<ref name=AGA2000/> The routine use of laxatives or enemas is discouraged, as having bowel movements may come to be dependent upon their use.<ref>{{cite web |url=https://www.lecturio.com/concepts/constipation/| title=Constipation|website=The Lecturio Medical Concept Library |access-date= 10 July 2021}}</ref>

=== Fiber supplements ===
Soluble fiber supplements such as [[psyllium]] are generally considered first-line treatment for chronic constipation, compared to insoluble fibers such as wheat bran. Side effects of fiber supplements include bloating, flatulence, diarrhea, and possible [[malabsorption]] of iron, calcium, and some medications. However, patients with opiate-induced constipation will likely not benefit from fiber supplements.<ref name=AmericanGATReview>{{Cite journal|last1=Bharucha|first1=Adil E.|last2=Pemberton|first2=John H.|last3=Locke|first3=G. Richard|title=American Gastroenterological Association Technical Review on Constipation|journal=Gastroenterology|volume=144|issue=1|pages=218–238|doi=10.1053/j.gastro.2012.10.028|pmc=3531555|pmid=23261065|year=2013}}</ref>

===Laxatives===
If [[laxatives]] are used, [[milk of magnesia]] or [[polyethylene glycol]] are recommended as first-line agents due to their low cost and safety.<ref name=AGA2013/> Stimulants should only be used if this is not effective.<ref name=AGA2000/> In cases of chronic constipation, polyethylene glycol appears superior to [[lactulose]].<ref>{{cite journal |vauthors=Lee-Robichaud H, Thomas K, Morgan J, Nelson RL | title = Lactulose versus Polyethylene Glycol for Chronic Constipation. | journal = Cochrane Database of Systematic Reviews | issue = 7 | article-number = CD007570 | date = 7 July 2010 | pmid = 20614462 | doi=10.1002/14651858.CD007570.pub2}}</ref> [[Prokinetic agent|Prokinetic]]s may be used to improve gastrointestinal motility. A number of new agents have shown positive outcomes in chronic constipation; these include [[prucalopride]]<ref>{{cite journal |vauthors=Camilleri M, Deiteren A | title = Prucalopride for constipation | journal = Expert Opin Pharmacother | volume = 11 | issue = 3 | pages = 451–61 | date = February 2010 | pmid = 20102308 | doi = 10.1517/14656560903567057 | s2cid = 207478370 }}</ref> and [[lubiprostone]].<ref>{{cite journal |vauthors=Barish CF, Drossman D, Johanson JF, Ueno R | title = Efficacy and safety of lubiprostone in patients with chronic constipation | journal = Dig. Dis. Sci. | volume = 55 | issue = 4 | pages = 1090–7 | date = April 2010 | pmid = 20012484 | doi = 10.1007/s10620-009-1068-x | s2cid = 23450010 }}</ref> [[Cisapride]] is widely available in third world countries, but has been withdrawn in most of the west. It has not been shown to have a benefit on constipation, while potentially causing cardiac arrhythmias and deaths.<ref>{{Cite journal|issue = 1|article-number = CD007780|last1=Aboumarzouk|first1=Omar M|last2=Agarwal|first2=Trisha|last3=Antakia|first3=Ramez|last4=Shariff|first4=Umar|last5=Nelson|first5=Richard L|date=2011-01-19|language=en|doi=10.1002/14651858.cd007780.pub2|pmid = 21249695|title = Cisapride for Intestinal Constipation|journal = Cochrane Database of Systematic Reviews}}</ref>

===Enemas===

[[Enema]]s can be used to provide a form of mechanical stimulation. A large volume or high enema<ref>{{cite web |url=https://www.merriam-webster.com/medical/high%20enema|title=high enema |work=Medical Dictionary |publisher=Merriam-Webster |access-date=17 February 2018}}</ref> can be given to cleanse as much of the colon as possible of feces,<ref>{{cite web |url=http://intranet.tdmu.edu.ua/data/kafedra/internal/meds/prac_skills_alg/Care%20of%20patients/Administering%20an%20Enema.htm |title=Administering an Enema |work=Care of patients |date=14 July 2015 |publisher=Ternopil State Medical University |access-date=17 February 2018 |archive-date=23 February 2018 |archive-url=https://web.archive.org/web/20180223111015/http://intranet.tdmu.edu.ua/data/kafedra/internal/meds/prac_skills_alg/Care%20of%20patients/Administering%20an%20Enema.htm }}</ref><ref>{{cite web |url=http://www.peoi.org/Courses/Coursesen/nursepractice/ch/ch12e1.html |title=Types of Enemas |work=Fundamentals of Nursing Practice |publisher=Professional Education, Testing and Certification Organization International |author= Rhodora Cruz |access-date=17 February 2018}}</ref> and the solution administered commonly contains [[castile soap]] which irritates the colon's lining resulting in increased urgency to defecate.<ref name=Safety_and_effectiveness>{{cite journal|title=Safety and effectiveness of large-volume enema solutions |author=Marilee Schmelzer |author2=Lawrence R.Schiller |author3=Richard Meyer |author4=Susan M.Rugari |author5=PattiCase |date=November 2004 |journal=Applied Nursing Research |doi=10.1016/j.apnr.2004.09.010 |volume=17 |issue=4 |pages=265–274|pmid= 15573335}}</ref> However, a low enema is generally useful only for stool in the rectum, not in the intestinal tract.<ref>{{cite web |url=https://www.merriam-webster.com/medical/low%20enema|title=low enema |work=Medical Dictionary |publisher=Merriam-Webster |access-date=17 February 2018}}</ref>

===Physical intervention===
Constipation that resists the above measures may require physical intervention such as manual disimpaction (the physical removal of impacted stool using the hands; see [[fecal impaction]]).

===Regular exercise===
Regular [[exercise]] can help improve chronic constipation.<ref>{{cite web|author=Canberra Hospital – Gastroenterology Unit|title=constipation|url=http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Constipation|url-status=live|archive-url=https://web.archive.org/web/20130717074139/http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Constipation|archive-date=17 July 2013}}</ref>

=== Surgical intervention ===
In refractory cases, procedures can be performed to help relieve constipation. [[Sacral nerve stimulation]] has been demonstrated to be effective in a minority of cases. [[Colectomy]] with ileorectal [[anastomosis]] is another intervention performed only in patients known to have a slow colonic transit time and in whom a defecation disorder has either been treated or is not present.<ref name="AGA2013"/> Because this is a major operation, side effects can include considerable abdominal pain, small bowel obstruction, and post-surgical infections. Furthermore, it has a very variable rate of success and is very case dependent.<ref name=AmericanGATReview/>

==Prognosis==
Complications that can arise from constipation include [[hemorrhoids]], [[anal fissures]], [[rectal prolapse]], and fecal impaction.<ref name=walia/><ref name=mccallum/><ref name=bharucha>{{cite journal | author = Bharucha AE | title = Constipation | journal = Best Practice & Research Clinical Gastroenterology | volume = 21 | issue = 4 | pages = 709–31 | year = 2007 | pmid = 17643910 | doi = 10.1016/j.bpg.2007.07.001 }}</ref><ref name=niddk>National Digestive Diseases Information Clearinghouse. (2007) NIH Publication No. 07–2754. [https://web.archive.org/web/20041020005801/http://digestive.niddk.nih.gov/ddiseases/pubs/constipation/#treatment] , Retrieved 7-18-2010.</ref> Straining to pass stool may lead to hemorrhoids. In later stages of constipation, the abdomen may become distended, hard and diffusely tender. Severe cases ("fecal impaction" or ''malignant constipation'') may exhibit symptoms of bowel obstruction (nausea, [[vomiting]], tender abdomen) and [[encopresis]], where soft stool from the small intestine bypasses the mass of impacted fecal matter in the [[colon (anatomy)|colon]].

==Epidemiology==
Constipation is the most common chronic gastrointestinal disorder in adults. Depending on the definition employed, it occurs in 2% to 20% of the population.<ref name=AGA2000>{{cite journal |vauthors=Locke GR, Pemberton JH, Phillips SF | title = American Gastroenterological Association Medical Position Statement: guidelines on constipation | journal = Gastroenterology | volume = 119 | issue = 6 | pages = 1761–6 | date = December 2000 | pmid = 11113098 | doi = 10.1053/gast.2000.20390 }}</ref><ref name=Epi89>{{cite journal |vauthors=Sonnenberg A, Koch TR | title = Epidemiology of constipation in the United States | journal = Dis Colon Rectum | volume = 32 | issue = 1 | pages = 1–8 | year = 1989 | pmid = 2910654 | doi = 10.1007/BF02554713 | s2cid = 3161661 }}</ref> It is more common in women, the elderly and children.<ref name=Epi89/> Specifically constipation with no known cause affects females more often affected than males.<ref name="chang">{{cite journal |vauthors=Chang L, Toner BB, Fukudo S, Guthrie E, Locke GR, Norton NJ, Sperber AD | s2cid = 8876455 | title = Gender, age, society, culture, and the patient's perspective in the functional gastrointestinal disorders | journal = Gastroenterology | volume = 130 | issue = 5 | pages = 1435–46 | year = 2006 | pmid = 16678557 | doi = 10.1053/j.gastro.2005.09.071 | doi-access = free }}</ref> The reasons it occurs more frequently in the elderly is felt to be due to an increasing number of health problems as humans age and decreased physical activity.<ref name=AFP05>{{cite journal | author = Hsieh C | title = Treatment of constipation in older adults | journal = Am Fam Physician | volume = 72 | issue = 11 | pages = 2277–84 | date = December 2005 | pmid = 16342852 | url = http://www.aafp.org/afp/2005/1201/p2277.html | url-status = live | archive-url = https://web.archive.org/web/20120410083631/http://www.aafp.org/afp/2005/1201/p2277.html | archive-date = 10 April 2012 }}</ref>
* 12% of the population worldwide reports having constipation.<ref>{{Cite journal|last1=Wald|first1=A.|last2=Scarpignato|first2=C.|last3=Mueller-Lissner|first3=S.|last4=Kamm|first4=M. A.|last5=Hinkel|first5=U.|last6=Helfrich|first6=I.|last7=Schuijt|first7=C.|last8=Mandel|first8=K. G.|date=2008-10-01|title=A multinational survey of prevalence and patterns of laxative use among adults with self-defined constipation|journal=Alimentary Pharmacology & Therapeutics|language=en|volume=28|issue=7|pages=917–930|doi=10.1111/j.1365-2036.2008.03806.x|pmid=18644012|s2cid=33659161|issn=1365-2036|doi-access=free}}</ref>
* Chronic constipation accounts for 3% of all visits annually to pediatric outpatient clinics.<ref name=walia/>
* Constipation-related health care costs total $6.9 billion in the US annually.<ref name=AGA2000/>
* More than four million Americans have frequent constipation, accounting for 2.5 million physician visits a year.<ref name=niddk/>
* Around $725 million is spent on laxative products each year in America.<ref name=niddk/>

==History==
[[File:A monkey rejects the old style clyster for his new 'clyso-pompe', which he fills with opium and marshmallow Wellcome V0011775.jpg|thumb|19th century satirical cartoon of a monkey rejecting an old style clyster for a new design, filled with marshmallow and opium]]

Since ancient times different societies have published medical opinions about how health care providers should respond to constipation in patients.<ref name="inner hygiene">{{cite book|last1=Whorton|first1=James C.|title=Inner hygiene: constipation and the pursuit of health in modern society|date=2000|publisher=Oxford University Press|location=New York|isbn=978-0-19-513581-7|url-access=registration|url=https://archive.org/details/innerhygiene00jame_0}}</ref> In various times and places, doctors have made claims that constipation has all sorts of medical or social causes.<ref name="inner hygiene"/> Doctors in history have treated constipation in reasonable and unreasonable ways, including use of a [[Spatula Mundani|spatula mundani]].<ref name="inner hygiene"/>

After the advent of the [[germ theory of disease]] then the idea of "auto-intoxication" entered popular Western thought in a fresh way.<ref name="inner hygiene"/> [[Enema]] as a scientific medical treatment and [[colon cleansing]] as alternative medical treatment became more common in medical practice.<ref name="inner hygiene"/>

Since the 1700s in the West there has been some popular thought that people with constipation have some moral failing with [[gluttony]] or [[laziness]].<ref>{{cite book|last1=Hornibrook|first1=F. A.|title=The culture of the abdomen;: The cure of obesity and constipation|date=1929|publisher=[[Heinemann (publisher)|Heinemann]]}}</ref>

==Special populations==
===Children===
{{main|Constipation in children}}
Approximately 3% of children have constipation, with girls and boys being equally affected.<ref name =JournalOPGAN>{{Cite journal|last1=Tabbers|first1=M.M.|last2=DiLorenzo|first2=C.|last3=Berger|first3=M.Y.|last4=Faure|first4=C.|last5=Langendam|first5=M.W.|last6=Nurko|first6=S.|last7=Staiano|first7=A.|last8=Vandenplas|first8=Y.|last9=Benninga|first9=M.A.|title=Evaluation and Treatment of Functional Constipation in Infants and Children|journal=Journal of Pediatric Gastroenterology and Nutrition|volume=58|issue=2|pages=265–281|doi=10.1097/mpg.0000000000000266|pmid=24345831|year=2014|s2cid=13834963|doi-access=free}}</ref> With constipation accounting for approximately 5% of general pediatrician visits and 25% of pediatric gastroenterologist visits, the symptom carries a significant financial impact upon the healthcare system.<ref name=Col2015/> While it is difficult to assess an exact age at which constipation most commonly arises, children frequently experience constipation in conjunction with life-changes. Examples include: toilet training, starting or transferring to a new school, and changes in diet.<ref name=Col2015/> Especially in infants, changes in formula or transitioning from breast milk to formula can cause constipation. The majority of constipation cases are not tied to a medical disease, and treatment can be focused on simply relieving the symptoms.<ref name =JournalOPGAN/>

===Postpartum women===
The six-week period after pregnancy is called the [[postpartum]] stage.<ref name=CochraneDatabase>{{Cite journal|issue = 9|article-number = CD010273|last1=Turawa|first1=Eunice B|last2=Musekiwa|first2=Alfred|last3=Rohwer|first3=Anke C|date=2014-09-23|language=en|doi=10.1002/14651858.cd010273.pub2|pmid = 25246307|title = Interventions for treating postpartum constipation|journal = Cochrane Database of Systematic Reviews| volume=2014 |pmc=10823348}}</ref> During this time, women are at increased risk of being constipated. Multiple studies estimate the prevalence of constipation to be around 25% during the first 3 months.<ref>Drossman DA, Corazziari E, Talley NJ, Grant Thompson W, Whitehead WE, editors. Rome II: the Functional Gastrointestinal Disorders. Diagnosis, Pathophysiology and Treatment: a Multinational Consensus. 2nd Edition. McLean: Degnon Associates, 2000</ref> Constipation can cause discomfort for women, as they are still recovering from the delivery process especially if they have had a [[perineal tear]] or underwent an [[episiotomy]].<ref name=":0">{{Cite journal|last1=Turawa|first1=Eunice B.|last2=Musekiwa|first2=Alfred|last3=Rohwer|first3=Anke C.|date=5 August 2020|title=Interventions for preventing postpartum constipation|journal=The Cochrane Database of Systematic Reviews|volume=2020|issue=8|article-number=CD011625|doi=10.1002/14651858.CD011625.pub3|issn=1469-493X|pmid=32761813|pmc=8094226|hdl=10019.1/104303|hdl-access=free}}</ref> Risk factors that increase the risk of constipation in this population include:<ref name=":0" />
* Damage to the levator ani muscles ([[Pelvic floor|pelvic floor muscles]]) during childbirth
* Forceps-assisted delivery
* Lengthy second stage of labor
* Delivering a large child
* Hemorrhoids
[[Hemorrhoid]]s are common in pregnancy and also may get exacerbated when constipated. Anything that can cause pain with stooling (hemorrhoids, perineal tear, episiotomy) can lead to constipation because patients may withhold from having a bowel movement so as to avoid pain.<ref name=":0" />

The pelvic floor muscles play an important role in helping pass a bowel movement. Injury to those muscles by some of the above risk factors (examples- delivering a large child, lengthy second stage of labor, forceps delivery) can result in constipation.<ref name=":0" /> Enemas may be administered during labor and these can also alter bowel movements in the days after giving birth.<ref name=CochraneDatabase/> However, there is insufficient evidence to make conclusions about the effectiveness and safety of laxatives in this group of people.<ref name=":0" />

==See also==
* [[Obstructed defecation]]
* [[Rectal tenesmus]]

==References==
{{Reflist}}

== External links ==
* {{MerckHome|09|129|b}}
* {{MedlinePlusOverview|constipation}}
* [https://gutenberg.org/ebooks/75870 Constipation and its correction by exercise by C. O. Benson]
{{Medical resources
| ICD10 = {{ICD10|K|59|0|k|55}}
| ICD9 = {{ICD9|564.0}}
| MedlinePlus = 003125
| eMedicineSubj = med
| eMedicineTopic = 2833
| DiseasesDB = 3080
| MeshID = D003248
}}
{{Gastroenterology}}
{{Authority control}}

[[Category:Constipation| ]]
[[Category:Conditions diagnosed by stool test]]
[[Category:Digestive disease symptoms]]
[[Category:Diseases of intestines]]
[[Category:Nursing diagnoses]]
[[Category:Waterborne diseases]]
[[Category:Wikipedia medicine articles ready to translate]]
[[Category:Wikipedia emergency medicine articles ready to translate]]
[[Category:Gastrointestinal motility disorders]]