Constipation Treatment: Stepwise Approach from Lifestyle to Surgery

Constipation management follows a tiered algorithm:

1. Lifestyle (First-Line)

• Fiber 25–35 g/day (soluble + insoluble) + water 2–3 L
• Regular exercise (stimulates colonic motility)
• Defecation routine: post-prandial, unhurried, proper posture (footstool)

2. OTC Laxatives

• Bulk-forming (psyllium): Safest long-term
• Osmotic (PEG 3350, lactulose, Mg): Draw water into lumen
• Stool softeners (docusate): Limited evidence alone
• Stimulants (senna, bisacodyl): Short-term only

3. Prescription Agents

• Secretagogues: Linaclotide, plecanatide, lubiprostone (IBS-C/CIC)
• Prucalopride (prokinetic)

4. Rectal Therapies

• Enemas (saline, mineral oil), suppositories (bisacodyl, glycerin) — acute relief

5. Biofeedback

For dyssynergic defecation (pelvic floor incoordination) — high success.

6. Surgery (Rare)

• Colectomy with ileorectal anastomosis (refractory slow transit)
• Rectopexy (rectal prolapse)
• Diverting colostomy (last resort)

7. Medication Review

Opioids, anticholinergics, Ca/Fe supplements, antihypertensives, antipsychotics — adjust/deprescribe.

8. Behavioral Therapy

CBT for fear-avoidance, toilet anxiety.

See a clinician for alarm signs (weight loss, bleeding, anemia, family history, new onset >50) or refractory symptoms.