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Constipation is a common problem at all ages. Reported prevalence rates vary widely, at least partly because criteria for diagnosis vary. A systematic review found the prevalence of constipation worldwide to range from 0.7% to 79% (median 16%). Constipation is twice as common in women as in men and is more common in the elderly. It is particularly common during pregnancy (about 40% of women complain of constipation during pregnancy).
Several physiologic subtypes of chronic constipation have been described, including:
A wide variety of factors can lead to constipation. Many of these are rare and do not need to be excluded unless there is reasonable suspicion that they may be present. The list below is not exclusive:
Do not overlook potential ovarian cancer: - Appendix 4
Ovarian cancer can mimic constipation because it may cause abdominal bloating and a change in bowel habit.
The NICE Suspected Cancer recognition and Referral Guidance 2015 and locally agreed 2WW referral criteria recommend that:
If CA125 < 35 IU/ml: reassure but review if symptoms become more frequent or persistent.
If CA125 >= 35 IU/ml: arrange for a screening abdominal and pelvic USS.
If the USS suggests ovarian cancer, refer urgently under the 2 week wait rule. If it is negative, reassure the patient but review her if her symptoms become more frequent or persistent.
Constipation in adults can usually be managed in primary care. However, referral is indicated as follows:
Consider surgical or gastroenterology referral if:
Consider referral to dietetics if more detailed support with diet is required and the patient has not been helped by the advice in this pathway.
When and how to stop treatment
Consider trialling deprescribing where appropriate to avoid inappropriate long-term laxative use.
Safe to long term if not a stimulant, if patient wishes to stop wean over months as may relapse.
Laxatives can be slowly withdrawn when regular bowel movements occur without difficulty (for example, 2–4 weeks after defecation has become comfortable and a regular bowel pattern with soft,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 minimise 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: