• For hard stools, consider using a high dose of an oral macrogol (licensed for use in faecal impaction).
• For soft stools or, for hard stools, after a few days treatment with a macrogol, consider starting or adding an oral stimulant laxative.
• If the response to oral laxatives is insufficient or not fast enough, consider:
• Using a suppository: bisacodyl for soft stools; glycerol alone or glycerol plus bisacodyl for hard stools.
• Using a mini enema: docusate (softener and weak stimulant) or sodium citrate (osmotic).
• If the response is still insufficient:
• Consider using a sodium phosphate or an arachis oil retention enema (placed high if the rectum is empty but the colon is full).
• For hard faeces it can be helpful to give the arachis oil enema overnight before giving a sodium phosphate (large volume) or sodium citrate (small volume) enema the next day.
• Enemas may need to be repeated several times to clear hard impacted faeces.
• The final choice of laxative will depend on individual preference and what has previously been tried.
• Reinforce advice about the role of diet, fluid intake, and exercise in maintaining regular bowel movements and preventing problems from recurring.
• Regular use of a laxative may also be needed to maintain comfortable defecation. See Treating chronic constipation.

• The aim of treatment should be to achieve complete disimpaction, with the minimum of discomfort. This may require several days in which doses and combinations of laxatives are adjusted.
• Enemas may need a district nurse or a carer to administer them.
• For more information on the pros and cons of the various laxatives, see Advantages/disadvantages of laxatives

The recommended approach is largely based on expert opinion as there is limited evidence from clinical trials [Petticrew et al, 2001; American College of Gastroenterology Chronic Constipation Task Force, 2005; Longstreth et al, 2006].