• Short duration constipation:
• Give advice about diet, adequate fluid intake, and exercise.
• Offer oral laxatives if dietary measures are ineffective, or while waiting for them to take effect.
• Chronic constipation:
• Relieve faecal impaction, if present.
• Address lifestyle and psychosocial factors:
• Diet, fluid intake, and exercise.
• Behaviour and psychosocial factors contributing to constipation.
• Toileting routines.
• Laxatives are recommended:
• If diet is ineffective, or while waiting for it to take effect.
• For people taking a constipating drug that cannot be stopped.
• For people with other secondary causes of constipation.
• As 'rescue' medicines for episodes of acute constipation
• Adjust dose, choice, and combination of laxatives to balance their purgative, stool softening, and stool bulking actions according to the symptoms, extent of faecal impaction, speed with which relief is required, and response to treatment.

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?

• 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).

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].

• No investigations are routinely required in an adult with constipation.
• However, the assessment might raise the possibility of one or more secondary causes that require special investigations to confirm or exclude them.

These recommendations are pragmatic advice based on expert opinion [American College of Gastroenterology Chronic Constipation Task Force, 2005; Paré et al, 2007].

• Advise the person about lifestyle measures — increasing dietary fibre, drinking an adequate fluid intake, and exercise.
• Offer additional oral laxatives if dietary measures are ineffective, or while waiting for them to take effect.
• Start treatment with a bulk-forming laxative (adequate fluid intake is important).
• If stools remain hard, add or switch to an osmotic laxative.
• If stools are soft but the person still finds them difficult to pass or complains of inadequate emptying, add a stimulant laxative.
• Advise the person that laxatives can be stopped once the stools become soft and easily passed again.

The literature tends to focus on chronic constipation and does not discuss the management of short duration constipation as a particular clinical problem, although it is common in primary care.

These recommendations therefore reflect what is commonly regarded as good practice in UK primary care.

• Dehydration, reduced levels of physical activity, and low levels of dietary fibre are associated with constipation. However, the clinical impression is that increasing fluids above an adequate daily intake, increasing exercise, and advice to increase dietary fibre does not always relieve constipation.
• For all laxatives, trial evidence on efficacy and safety is limited. This is mainly because these agents have been in use for a long time, clinical trials were far less robust at the time they were originally licensed, and few new clinical trials have been done.

• Begin by relieving faecal loading/impaction, if present.
• Set realistic expectations for the results of treatment of chronic constipation.
• Advise people about lifestyle measures — increasing dietary fibre (including the importance of regular meals), drinking an adequate fluid intake, and exercise.
• Laxatives are recommended:
• If lifestyle measures are insufficient, or whilst waiting for them to take effect.
• For people taking a constipating drug that cannot be stopped.
• For people with other secondary causes of constipation.
• As 'rescue' medicines for episodes of faecal loading.
• Start treatment with a bulk-forming laxative.
• It is important to maintain good hydration when taking bulk-forming laxatives. This may be difficult for some people (e.g. the frail or elderly).
• If stools remain hard, add or switch to an osmotic laxative.
• If stools are soft but the person still finds them difficult to pass or complains of inadequate emptying, add a stimulant laxative.
• Adjust the dose, choice, and combination of laxative according to symptoms, speed with which relief is required, response to treatment, and individual preference.
• The dose of laxative should be gradually titrated upwards (or downwards) to produce one or two soft, formed stools per day.

• 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; Hsieh, 2005; Longstreth et al, 2006; Ginsberg et al, 2007; Paré et al, 2007].

• Dehydration, reduced levels of physical activity, and low levels of dietary fibre are associated with constipation. However, the clinical impression is that increasing fluids above an adequate daily intake, increasing exercise, and advice to increase dietary fibre do not always relieve constipation.
• For all laxatives, trial evidence on efficacy and safety is limited. This is mainly because these agents have been in use for a long time, clinical trials were far less robust at the time they were originally licensed, and few new clinical trials have been done.
• For macrogols (products that are relatively new to the UK market), there is consistent evidence from four placebo-controlled trials that macrogols increase the frequency of bowel movements and relieve symptoms [Frizelle and Barclay, 2007]. There are also trials that compare macrogols with other laxatives [Frizelle and Barclay, 2007]. But, as all the trials used fixed doses, the evidence is of little relevance for approaches that adjust doses to the individual's needs.
• There is reasonable consensus between experts [Locke et al, 2000; Hsieh, 2005; Ginsberg et al, 2007; Paré et al, 2007] that for chronic functional constipation in adults:
• Bulk-forming laxatives are a good first-line choice.
• Osmotic and stimulant laxatives are reasonable second-line choices.

• In general, the diet should be balanced and contain whole grains, fruits, and vegetables. This is recommended as part of the treatment for constipation. It is also recommended for general health and promoted by the 'five-a-day' policy.
• Fibre intake should be increased gradually (to minimize flatulence and bloating) and maintained for life.
• Adults should aim to consume 18–30 g fibre per day.
• The amounts of fibre in bran and other commonly consumed foods are given in Table 3.
• Although the effects of a high fibre diet may be seen in a few days, it may take as long as 4 weeks.
• Adequate fluid intake is important (particularly with a high fibre diet or fibre supplements), but can be difficult for some people (e.g. frail or elderly).
• Fruits high in fibre and sorbitol, and fruit juices high in sorbitol, can help prevent and treat constipation.

• Sorbitol:
• Fruits (and their juices) that have a high sorbitol content include:
• Apples.
• Apricots.
• Gooseberries.
• Grapes (and raisins).
• Peaches.
• Pears.
• Plums (and prunes).
• Raspberries.
• Strawberries.
• The concentration of sorbitol is about 5–10 times higher in dried fruit.
• Recipes for natural laxatives (with evidence of effectiveness from randomized controlled trials) are given in Table 1 and Table 2.

These recommendations are largely based on expert opinion as there is little relevant direct evidence from clinical trials of dietary fibre [Gillett et al, 2001; North American Society for Pediatric Gastroenterology Hepatology and Nutrition, 2006].

• The Department of Health recommends an intake of at least five portions of fruit or vegetables per person per day to help reduce the risk of some cancers, heart disease, and many other chronic conditions including constipation [DH, 2003].
• The laxative action of fruits such as apricots and prunes is probably due to the fibre and sorbitol they contain.
• Prunes and prune juice [Stacewicz-Sapuntzakis et al, 2001]:
• Fibre content: dried prunes contain about 6.1 g fibre per 100 g prunes; prune juice contains no fibre.
• Sorbitol content: dried prunes contain about 14.7 g sorbitol per 100 g; prune juice contains about 6.1 g sorbitol per 100 g.
• Apricots, fresh [Lo Voi et al, 1995]:
• Sorbitol content: fresh apricots contain about 0.3 g sorbitol per 100 g.

• Defecation should be unhurried, with enough time to ensure that defecation is complete.
• Attempt defecation first thing in the morning, or about 30 minutes after a meal. This may require some planning and time management.
• Respond immediately to the sensation of needing to defecate.
• Inadequate (auditory or visual) privacy can contribute to constipation.
• When mobility is limited, for example in people who are frail or who have dementia, it is important for carers to see that they not only have sufficient help to get to the toilet at the time they need to go, but also have a regular, unhurried toilet routine, with privacy.
• Supported seating can help if the person is unsteady on the toilet.

These recommendations are largely based on expert opinion [Hsieh, 2005; Wilson, 2005; Emly and Rochester, 2006; Ginsberg et al, 2007].

• Occasional 'mass movements' propel the contents of the bowel through the colon. Propulsion of colonic contents is significantly increased in the mornings and after meals — the gastro-colic reflex. Activity of the colon is at a minimum in the late afternoon and at night. In people who are resting, colonic intraluminal pressure activity rises markedly during and after food, but this increase is rarely associated with the propulsive activity found in physically active people.
• The optimal times to have a bowel movement are typically soon after waking and after meals, when colonic activity is greatest.
• Evidence that bowel movements are more likely after awakening in the morning and after meals, and that bowel movements are less likely at night and while at rest, was found in studies of colon activity in healthy volunteers [Bassotti and Gaburri, 1988] and in people with irritable colon syndrome [Holdstock et al, 1970].

• 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].

• Laxatives can be slowly withdrawn when regular bowel movements occur without difficulty (e.g. 2–4 weeks after defecation has become comfortable and a regular bowel pattern with soft, formed stools has been established).
• The rate at which doses are reduced should be guided by the frequency and consistency of the stools. Weaning should be gradual in order to minimize the risk of requiring 'rescue therapy' for recurrent faecal loading. Laxative medication should not be suddenly stopped.
• If a combination of laxatives has been used, reduce and stop one laxative at a time. Begin by reducing stimulant laxatives first, if possible. However, it may be necessary to also adjust the dose of the osmotic laxative to compensate.
• Advise the person that it can take several months to be successfully weaned off all laxatives.
• Relapses are common and should be treated early with increased doses of laxatives.
• Laxatives need to be continued long term for:
• People taking a constipating drug that cannot be stopped.
• People with a medical cause of constipation.

• These recommendations are based on expert opinion [Gillett et al, 2001].

Constipation in adults can usually be managed in primary care. However, referral is indicated when:

• Cancer is suspected.
• Referral for colonoscopy should be considered in people over 50 years of age if 'red flags' are present.
• An underlying cause is suspected.
• If an underlying problem is suspected, consider having the results from blood tests for inflammatory markers, hypothyroidism, hypercalcaemia, and coeliac disease available before the person attends their appointment.
• Pain and bleeding on defecation (e.g. from an anal fissure) is severe or does not respond to treatment for constipation.
• Consider consider surgical referral.
• Treatment is unsuccessful.
• Treatment failure may be early, when attempts at relieving faecal loading fail, or late, if there is difficulty maintaining remission.
• Management may require further tests (such as blood tests, radiological imaging for bowel studies, or consideration of rectal suction biopsy, or transit studies).
• Assessment is required prior to referral for other interventions (such as psychology, psychiatry).
• Faecal incontinence is present.
• Referral to Continence Service (if available) may be appropriate for advice and monitoring.
• More detailed support with diet is required.
• Consider dietetics referral.

These recommendations are largely pragmatic, although they also include referral guidelines for suspected cancer published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2005].

• Dietary measures, including an adequate fluid intake, should be advised first-line to prevent or treat constipation in pregnancy.
• Regular light or moderate exercise can also be helpful.
• Laxatives should be considered only if dietary measures fail:
• A bulk-forming laxative is a reasonable first choice.
• If stools remain hard, add or switch to lactulose or a macrogol.
• If stools are soft but the woman still finds them difficult to pass or complains of inadequate emptying, consider a short course of bisacodyl or senna.
• Occasional use of glycerol or bisacodyl suppositories are also an option.

• For further information on the use of laxatives during pregnancy, contact the UK Teratology Information Service (UKTIS), formerly the National Teratology Information Service (NTIS), on 0844 892 0909.

The following recommendations are based on expert advice on drug safety during pregnancy [Schaefer et al, 2007]:

• Bulk-forming laxatives are not absorbed from the gastrointestinal tract and are therefore suitable for use during pregnancy.
• Lactulose is poorly absorbed from the gastrointestinal tract and is also suitable for use during pregnancy.
• Macrogols with a molecular weight of more than 3000 are not absorbed from the gastrointestinal tract.
• Bisacodyl is poorly absorbed from the gastrointestinal tract (only about 5%). It has not been reported to cause teratogenic or fetotoxic effects and is therefore suitable for use during pregnancy.
• Senna is partially absorbed from the gastrointestinal tract but does not appear to be teratogenic. Concerns have been raised that senna should be avoided in the third trimester because a stimulating effect on uterine contractions has been reported with other anthraquinone derivatives. However, this has not been reported with senna.
• Glycerol suppositories are also suitable for use during pregnancy [ABPI Medicines Compendium, 2002].
• Laxatives that are not recommended:
• Docusate is less preferred because there is a single case report of neonatal hypomagnesaemia after maternal overuse of oral docusate sodium. However, docusate could be considered in low doses if the recommended laxatives (above) are unsuccessful [Schaefer et al, 2007].
• Sodium picosulfate: there is less experience with its use in pregnancy, so it is therefore not recommended [ABPI Medicines Compendium, 2006].
• Sodium citrate and sodium phosphate enemas should be avoided if possible during pregnancy, because they may cause fluid and electrolyte imbalances [NTIS, 2002].

• Dietary measures, including an adequate fluid intake (8–10 cups of fluid a day) should be advised first-line to prevent or treat constipation during breastfeeding.
• Regular light or moderate exercise may also be helpful.
• Laxatives should be considered only if dietary measures fail:
• A bulk-forming laxative is a reasonable first choice.
• If stools remain hard, add or switch to lactulose or a macrogol.
• If stools are soft but the woman still finds them difficult to pass or complains of inadequate emptying, consider a short course of bisacodyl or senna.
• Occasional use of glycerol or bisacodyl suppositories are also an option.

• For further information on the use of laxatives during breastfeeding, contact the UK Drugs in Lactation Advisory Service on 0121 311 1974, or see their website atwww.ukmicentral.nhs.uk/drugpreg/guide.htm.

The following recommendations are based on expert advice on drug safety during breastfeeding [Schaefer et al, 2007; UK Drugs in Lactation Advisory Service, 2007]:

• The following laxatives are not absorbed from the gastrointestinal tract, and are therefore suitable for use while breastfeeding:
• Bulk-forming laxatives
• Lactulose
• Macrogols with a molecular weight of more than 3000
• Bisacodyl is poorly absorbed from the gastrointestinal tract (only about 5%) and is therefore considered to be suitable for use during breastfeeding.
• Senna is partially absorbed from the gastrointestinal tract. However, the risk of causing colic and diarrhoea in breastfed infants is small, provided that high doses are avoided.
• Glycerol suppositories are also suitable for use while breastfeeding [ABPI Medicines Compendium, 2002].
• Laxatives that are not recommended for first-line use:
• Docusate is excreted in breast milk [Micromedex, 2007]. However, the risk of causing colic and diarrhoea in breastfed infants is small, provided that high doses are avoided.
• Sodium picosulfate is not known to be excreted in breast milk, but there is less experience with its use. It could be considered in moderate doses if the laxatives recommended above are unsuccessful.
• Sodium citrate or sodium phosphate enemas could also be used if the laxatives recommended above are unsuccessful.

• In general, the diet should be balanced and contain whole grains, fruits, and vegetables. This is recommended as part of the treatment for constipation. It is also recommended for general health and promoted by the 'five-a-day' policy.
• Fibre intake should be increased gradually (to minimize flatulence and bloating) and maintained for life.
• Adults should aim to consume 18–30 g fibre per day.
• The amounts of fibre in bran and other commonly consumed foods are given in Table 3.
• Although the effects of a high fibre diet may be seen in a few days, it may take as long as 4 weeks.
• Adequate fluid intake is important (particularly with a high fibre diet or fibre supplements), but can be difficult for some people (e.g. frail or elderly).
• Fruits high in fibre and sorbitol, and fruit juices high in sorbitol, can help prevent and treat constipation.

• Sorbitol:
• Fruits (and their juices) that have a high sorbitol content include:
• Apples.
• Apricots.
• Gooseberries.
• Grapes (and raisins).
• Peaches.
• Pears.
• Plums (and prunes).
• Raspberries.
• Strawberries.
• The concentration of sorbitol is about 5–10 times higher in dried fruit.
• Recipes for natural laxatives (with evidence of effectiveness from randomized controlled trials) are given in Table 1 and Table 2.

These recommendations are largely based on expert opinion as there is little relevant direct evidence from clinical trials of dietary fibre [Gillett et al, 2001; North American Society for Pediatric Gastroenterology Hepatology and Nutrition, 2006].

• The Department of Health recommends an intake of at least five portions of fruit or vegetables per person per day to help reduce the risk of some cancers, heart disease, and many other chronic conditions including constipation [DH, 2003].
• The laxative action of fruits such as apricots and prunes is probably due to the fibre and sorbitol they contain.
• Prunes and prune juice [Stacewicz-Sapuntzakis et al, 2001]:
• Fibre content: dried prunes contain about 6.1 g fibre per 100 g prunes; prune juice contains no fibre.
• Sorbitol content: dried prunes contain about 14.7 g sorbitol per 100 g; prune juice contains about 6.1 g sorbitol per 100 g.
• Apricots, fresh [Lo Voi et al, 1995]:
• Sorbitol content: fresh apricots contain about 0.3 g sorbitol per 100 g.

• Defecation should be unhurried, with enough time to ensure that defecation is complete.
• Attempt defecation first thing in the morning, or about 30 minutes after a meal. This may require some planning and time management.
• Respond immediately to the sensation of needing to defecate.
• Inadequate (auditory or visual) privacy can also contribute to constipation.

These recommendation are largely based on expert opinion [Hsieh, 2005; Wilson, 2005; Emly and Rochester, 2006; Ginsberg et al, 2007].

• Occasional 'mass movements' propel the contents of the bowel through the colon. Propulsion of colonic contents is significantly increased in the mornings and after meals — the gastro-colic reflex. Activity of the colon is at a minimum in the late afternoon and at night. In people who are resting, colonic intraluminal pressure activity rises markedly during and after food, but this increase is rarely associated with the propulsive activity found in physically active people.
• The optimal times to have a bowel movement are typically soon after waking and after meals, when colonic activity is greatest.
• Evidence that bowel movements are more likely after awakening in the morning and after meals, and that bowel movements are less likely at night and while at rest, was found in studies of colon activity in healthy volunteers [Bassotti and Gaburri, 1988] and in people with irritable colon syndrome [Holdstock et al, 1970].

Constipation in adults can usually be managed in primary care. However, referral is indicated when:

• Cancer is suspected.
• Referral for colonoscopy should be considered in people over 50 years of age if 'red flags' are present.
• An underlying cause is suspected.
• If an underlying problem is suspected, consider having the results from blood tests for inflammatory markers, hypothyroidism, hypercalcaemia, and coeliac disease available before the person attends their appointment.
• Pain and bleeding on defecation (e.g. from an anal fissure) is severe or does not respond to treatment for constipation.
• Consider consider surgical referral.
• Treatment is unsuccessful.
• Treatment failure may be early, when attempts at relieving faecal loading fail, or late, if there is difficulty maintaining remission.
• Management may require further tests (such as blood tests, radiological imaging for bowel studies, or consideration of rectal suction biopsy, or transit studies).
• Assessment is required prior to referral for other interventions (such as psychology, psychiatry).
• Faecal incontinence is present.
• Referral to Continence Service (if available) may be appropriate for advice and monitoring.
• More detailed support with diet is required.
• Consider dietetics referral.

These recommendations are largely pragmatic, although they also include referral guidelines for suspected cancer published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2005].