Clarify what the person understands by their constipation, and confirm the diagnosis of constipation:
- What does the person believe to be normal bowel movements?
- What is their normal pattern of defecation?
- When did constipation first become a problem?
- What is the frequency and character of stools?
- Are they hard?
- Are they large (e.g. do they block the toilet sometimes)? Or, are they small, like pebbles?
- Is there discomfort, straining, or bleeding?
Assess the presence and degree of faecal loading/impaction and faecal incontinence:
- Can faecal masses be felt when palpating the lower left abdomen or on rectal examination?
- Is there faecal incontinence, or loose stools?
- Have manual measures been necessary to relieve faecal loading/impaction?
- A finger having to be inserted into the vagina suggests a rectocele.
- A finger in the rectum to push away a flap suggests a rectal ulcer.
- Pressure behind the anus assists defecation if the levator muscles are weak.
- Digital rectal evacuation of faeces confirms severe faecal loading/impaction.
Assess the severity and impact of the constipation and any faecal incontinence:
- Is there nausea, vomiting, loss of appetite, or loss of body weight?
- Is there abdominal pain or abdominal distension?
- Is there pain or bleeding with passing stools?
- Is underwear regularly and involuntarily soiled? If yes, what are the social consequences of this?
- Are there urinary symptoms and/or urinary incontinence?
Assess the role of predisposing factors:
- Is the diet low in fibre. Is the person dehydrated?
- What are the person's toileting habits?
- Do they have unhurried, undisturbed time on the toilet?
- Do they withhold or ignore the urge to go to the toilet?
- Is access to the toilet at home or at work difficult? Is there a lack of privacy (auditory or visual)?
- Have there been changes in routine or lifestyle?
- What is the person's general level of activity and mobility?
- Does the person have an eating disorder, anxiety, or depression?
Identify any organic causes of constipation.
- Does the person have a history or features of:
- An endocrine or metabolic disease, a myopathic condition, or a neurological disease?
- Irritable bowel syndrome?
- Recurrent abdominal pain or discomfort associated with improvement on defecation, changed frequency or appearance of bowel movements.
- For more information see the CKS topic on Irritable bowel syndrome.
- Anal fissure, haemorrhoids, rectal prolapse or rectocele?
- Colonic strictures (following diverticulitis, ischaemia, or surgery)?
- Inflammatory bowel disease?
- Obstructive colonic mass lesions (e.g. colorectal cancer)?
- Careful examination can usually distinguish a faecal mass from a tumour or cyst: firm pressure exerted by a finger will leave a palpable indentation in hard faeces.
- Pelvic floor dyssynergia?
- Having to strain, feeling of incomplete evacuation.
Assess effectiveness of management to date:
- What measures (self-care and prescribed, non-drug and drug) have been tried?
- What has been the response?
Be alert for any 'red flags' that might indicate a serious underlying condition. Is there:
- Persistent unexplained change in bowel habits?
- Palpable mass in the lower right abdomen or the pelvis?
- Persistent rectal bleeding without anal symptoms?
- Narrowing of stool calibre?
- Family history of colon cancer, or inflammatory bowel disease?
- Unexplained weight loss, iron deficiency anaemia, fever, or nocturnal symptoms?
- Severe, persistent constipation that is unresponsive to treatment?
Clarification / Additional information
- Table 1 shows the referral guidelines for suspected cancer published by the National Institute for Health and Clinical Excellence (NICE).
- People who present with symptoms and signs suggestive of colorectal or anal cancer should be urgently referred to a team specializing in the management of lower gastrointestinal cancer (depending on local arrangements).
Table 1. Guidelines for urgent referral of suspected lower gastrointestinal cancer.
Person | Symptoms and signs |
|---|
40 years of age and above | Rectal bleeding with a change in bowel habit towards looser stools and/or increased stool frequency persisting for 6 weeks or more. |
60 years of age and above | Rectal bleeding persisting for 6 weeks or more without a change in bowel habit and without anal symptoms. A change in bowel habit to looser stools and/or more frequent stools persisting for 6 weeks or more without rectal bleeding. |
Of any age | A right abdominal mass consistent with involvement of the large bowel. A palpable rectal mass (intraluminal and not pelvic: a pelvic mass outside the bowel would warrant an urgent referral to a urologist or gynaecologist). |
Woman (not menstruating) | Unexplained iron deficiency anaemia and haemoglobin 10 g/100 mL or less.* |
Man of any age | Unexplained iron deficiency anaemia and haemoglobin 11 g/100 mL or less.* |
* Anaemia considered on the basis of history and examination in primary care not to be related to other sources of blood loss (e.g. ingestion of nonsteroidal anti-inflammatory drugs) or blood dyscrasia. |
|
Basis for recommendation
These recommendations are pragmatic advice based on expert opinion [American College of Gastroenterology Chronic Constipation Task Force, 2005; Longstreth et al, 2006; Paré et al, 2007].