• Constipation is defecation that is unsatisfactory because of infrequent stools, difficult stool passage, or seemingly incomplete defecation. Stools are often dry and hard, and may be abnormally large or abnormally small.

• Clarify what the person understands by their constipation.
• Assess the presence and degree of faecal loading/impaction and faecal incontinence.
• Assess the severity and impact of the constipation and any faecal incontinence.
• Assess the role of predisposing factors.
• Identify any organic causes of constipation.
• Assess effectiveness of management to date.
• 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?

In depth

• No investigations are routinely required in an adult with constipation.
• However, if a secondary cause is suspected, special investigations might be required.

In depth

• Refer for suspected cancer if 'red flags' are present.
• Consider surgical referral when there is pain and bleeding on defecation (e.g. from an anal fissure) that is severe or does not respond to treatment for constipation.
• Refer for assessment by a specialist with an interest in constipation when:
• An underlying cause is suspected.
• Treatment is unsuccessful.
• Management may require further tests.
• Assessment is required prior to referral for other interventions (such as psychology, psychiatry).
• Consider referral to a Continence Service (when available) if faecal incontinence is a problem.
• Consider dietetics referral for more detailed support of diet.

In depth