Constipation

Basics

  • Unsatisfactory defecation characterized by infrequent stools, difficult stool passage, or both
  • Characteristics include <3 bowel movements a week, hard stools, excessive straining, prolonged time spent on the toilet, a sense of incomplete evacuation, and abdominal discomfort/bloating.

Description



Geriatric Considerations
Colorectal neoplasms may be associated with constipation. Consider new-onset constipation after age 50 years a “red flag.” Use warm water enemas (instead of sodium phosphate enemas) for impaction in geriatric patients. Sodium phosphate enemas have been associated with fatalities and severe electrolyte disturbances.

Pediatric Considerations
Consider Hirschsprung disease (absence of colonic ganglion cells) in cases of pediatric constipation. Hirschsprung disease accounts for 25% of all newborn intestinal obstructions and can present as milder cases diagnosed in older children with chronic constipation, abdominal distension, and decreased growth. Hirschsprung has a 5:1 male-to-female ratio and is associated with inherited conditions (e.g., Down syndrome).

Pregnancy Considerations
Avoid misoprostol.

Epidemiology

  • More pronounced in children and elderly
  • Predominant sex: female > male (2:1)
  • Nonwhites > whites

Incidence

  • 5 million office visits annually
  • 100,000 hospitalizations

Prevalence

  • 16% of adults >18 years of age, rising to 33% of adults >60 years of age
  • 3% of pediatric visits relate to constipation.

Etiology and Pathophysiology

Defecation reflex is a reflex that can be inhibited by voluntarily contracting the external sphincter or facilitated by straining to contract the abdominal muscles while voluntarily relaxing the anal sphincter. Rectal distention initiates the defecation reflex. The urge to defecate occurs with an increase in rectal pressure. Distention of the stomach also initiates rectal contractions and a desire to defecate (gastrocolic reflex).

Risk Factors

  • Extremes of age
  • Polypharmacy
  • Sedentary lifestyle or condition
  • Low-fiber diet and inadequate fluid intake
  • Increased stress

General Prevention

High-fiber diet, adequate fluids, exercise, and training to “obey the urge” to defecate

Commonly Associated Conditions

  • General debilitation (disease or aging)
  • Dehydration
  • Hypothyroidism
  • Hypokalemia
  • Hypercalcemia
  • Nursing home resident

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