Constipation

Disease Description (Causes and Symptoms)

• Definition summary: Constipation is a condition in which bowel movements do not occur smoothly due to reduced peristaltic movement of the colon or problems with the passage for defecation (e.g., fewer than 2 bowel movements per week, hard stools, accompanying bleeding, etc.).
• Pathophysiology summary:
  • Slow transit: The motility of all or part of the colon decreases, causing stool to remain in the intestine for a long time → increased water absorption makes the stool hard.
  • Outlet obstruction / abnormal defecation control: Stool cannot be expelled through the anus because of inappropriate contraction (or inability to relax) of the pelvic floor muscles (outlet-obstruction constipation).
  • Reduced rectal sensation due to chronic accumulation of stool (rectal enlargement → reduced detection of stool).
• Main causes:
  • Dietary factors (insufficient fiber, insufficient fluid intake), lack of exercise, irregular bowel habits
  • Medications (opioids, anticholinergics, iron preparations, etc.)
  • Endocrine and metabolic diseases (hypothyroidism, diabetes), neuromuscular diseases, postsurgical changes
  • Structural diseases (intestinal stricture, colorectal cancer, congenital megacolon, etc.)
  • Children: Withholding behavior related to the toilet-training period and psychological factors
• Main symptoms:
  • Infrequent or difficult bowel movements (excessive straining, hard stools)
  • Feeling of incomplete evacuation (a sensation that stool remains after defecation), abdominal bloating, abdominal pain
  • Anal pain during defecation, anal bleeding (hemorrhoids or anal fissures may also be present)
  • When chronic, decreased appetite, indigestion, depressed mood, etc.

Treatment Methods

• Nonpharmacological treatment (basic principles)
  • Diet: Increase dietary fiber (fruit, vegetables, whole grains); drink at least approximately 1.5 L of water per day as recommended (consider individual differences)
  • Regular meals (especially breakfast) and bowel habits: Make a habit of going to the toilet within 30 minutes after meals; use a footstool (similar to a squatting position)
  • Exercise: Regular aerobic exercise and abdominal-strengthening exercises, abdominal massage
  • Lifestyle guidance: Defecate immediately when the urge occurs; do not sit on the toilet for more than 10 minutes
• Pharmacological treatment
  • Bulk-forming laxatives: Plant-based fiber (psyillium, etc.) — can be used long term; adequate fluid intake is necessary
  • Osmotic laxatives: PEG (polyethylene glycol), lactulose, magnesium salts, etc. — draw water into the stool to soften it
  • Stimulant laxatives: Sennosides, bisacodyl, etc. — short-term use is recommended (long-term abuse may risk reduced bowel function)
  • Mucolytics/stool softeners: Docusate, etc. (mainly to prevent hardening of the stool)
  • Prokinetic agents and newer medications: Prucalopride (availability varies by country), prucalopride (a selective 5-HT4 agonist), linaclotide/lubiprostone (secretagogues) — considered in patients with severe or medication-resistant symptoms
  • Local treatment: Glycerin suppositories, enemas (short-term use in severe cases)
• Nonpharmacological treatments and procedures
  • Biofeedback (anal-pelvic floor relaxation training): Effective in patients with outlet obstruction (defecatory dysfunction)
  • Enema treatment: Inducing bowel movements in the rectum for a short period (continuous use is not recommended)
• Surgical treatment
  • Considered when there is no response to pharmacological or nonpharmacological treatment and there is generalized colonic paralysis or a definite structural lesion (congenital megacolon, megacolon, severe slow-transit constipation, etc.)
  • Example: Partial or total colectomy (limited application for special indications)
• Precautions and complications
  • Do not abuse stimulant laxatives long term through self-diagnosis (possible dependence, electrolyte abnormalities, and reduced bowel function)
  • Warning symptoms (rectal bleeding, weight loss, anemia, sudden changes in bowel habits, new onset after age 50, etc.) require immediate evaluation to rule out structural diseases such as colorectal cancer
  • Complications: Hemorrhoids, anal fissures, rectal prolapse, worsening diverticular disease, urinary tract infection (in children), malnutrition and growth delay (in severely affected children)

Checklist Before an Outpatient Visit (Including Items to Bring and Example Questions)

• Items to bring (recommended)
  • A list of all medications and supplements currently being taken (including doses and when they were started)
  • Copies of recent test results (blood tests, thyroid tests, colonoscopy, abdominal imaging, etc.)
  • A symptom diary (bowel movement frequency, Bristol Stool Scale records, symptoms, pain, and presence or absence of bleeding during defecation, food and fluid intake)
  • Records of previous treatments (laxatives, enemas, biofeedback, etc.) and responses
  • For children, growth charts and information related to toilet training
• Information to tell the doctor in advance
  • When symptoms began (acute vs. chronic), factors that worsen or improve them, weight changes, and whether sleep is affected
  • Medications currently being taken (especially opioids, antidepressants, anticholinergics, iron, etc.)
  • History of previous surgery (pelvic or abdominal surgery) and neurological diseases
• Example questions (things to ask during the visit)
  • "Do I need any additional tests for my symptoms (such as a colonoscopy or thyroid testing)?"
  • "What are the side effects and recommended duration of use of the medication I am taking now (or planning to use)?"

Examples of General Questions to Ask the Doctor

• "What are the expected effects and side effects of this medication (or treatment)?"
• "What is the prognosis in my case? How quickly will I improve?"
• "What lifestyle changes must I make? Please explain specific dietary and exercise guidelines."
• "Do I need any additional tests or specialized treatment (such as biofeedback or colonoscopy)?"

Examples of Condition-Specific Questions

• For patients with defecatory dysfunction (suspected outlet obstruction):
  • "It feels as though my anal muscles do not relax when I have a bowel movement. Do I need biofeedback therapy? How effective is it?"
• For patients with chronic, medication-resistant symptoms or older patients:
  • "I have tried several medications, but my symptoms have not improved. Can I be evaluated to determine whether I need a colonic transit-time test or surgical treatment?"

(Before the visit, organizing the items to bring and bringing a symptom diary and medication list can help with a more accurate evaluation and the development of a personalized treatment plan.)