Chronic Constipation
Chronic constipation is infrequent or difficult bowel movements lasting 3 months or longer, diagnosed per Rome IV criteria and treated per the 2023 AGA-ACG Clinical Practice Guideline.
Symptoms
Fewer than 3 spontaneous bowel movements per week, straining, lumpy or hard stools, a sensation of incomplete emptying, or needing to use manual maneuvers to pass stool.
Causes and risk
Low fiber or fluid intake, inactivity, certain medications (opioids, some antidepressants), and pelvic floor dysfunction can all contribute; risk increases with age.
How it is evaluated
Diagnosis is clinical, based on Rome IV symptom criteria; the American Society of Colon and Rectal Surgeons guideline recommends colonoscopy for alarm features or when a patient is due for routine colorectal cancer screening, rather than treating with laxatives alone.
Treatment
Soluble fiber (psyllium, 20-30g/day) and osmotic laxatives (polyethylene glycol, magnesium oxide) are first-line per the AGA-ACG guideline, with stimulant laxatives as rescue therapy and prescription secretagogues or prucalopride reserved for cases that don't respond to the basics.
When to seek care
Rectal bleeding, unintended weight loss, a change in stool caliber, iron-deficiency anemia, or a family history of colorectal cancer are alarm features requiring evaluation -- new-onset constipation in someone due for colorectal cancer screening should prompt a colonoscopy rather than empiric treatment.