Chronic Constipation

An Evidence-Based Review

Lawrence Leung, MBBChir, FRACGP, FRCGP; Taylor Riutta, MD; Jyoti Kotecha, MPA, MRSC; Walter Rosser, MD, MRCGP, FCFP


J Am Board Fam Med. 2011;24(4):436-51. 

In This Article


It is indeed surprising that as a common condition found in at least one quarter of patients, chronic constipation is treated in a wide variety of ways, with relatively little evidence-based data, especially regarding dietary fiber, fluids and exercise. As with any other condition, a thorough history and physical examination is mandatory, with additional blood and special tests to confirm the diagnosis of chronic constipation and its subtypes. A practical triage approach is summarized in Figure 1), and the various evidence-based options for managing chronic constipation are listed in the order of their level of recommendation in Table 1. In summary, family physicians should look for pelvic floor dysfunction as a cause of chronic constipation, which is best treated by biofeedback. The classic triad of increasing dietary fiber, exercise, and fluids will benefit patients with actual deficiencies. The best pharmacological treatment for chronic constipation caused by slow colonic transit time is to start with a bulk-forming agent (psyllium or bran) and with a stool softener/osmotic agent (lactulose, PEG, or docusate), then add in stimulants (bisacodyl or senna) and finally the newer agents for severe or resistant cases (chloride channel activators or 5-HT4 agonist). In recalcitrant cases, surgical treatment may be considered.

Figure 1.

Flow diagram for management of chronic constipation.


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