When Should Persistent Constipation Be Medically Assessed?
General patient information for adults with persistent or recurring bowel symptoms
General information only: This article provides general educational information. It is not a diagnosis, treatment recommendation, or substitute for individual medical advice. Constipation has many possible causes and the appropriate assessment depends on a person’s symptoms, medical history, medicines, examination and risk factors. See your GP or treating clinician for advice relevant to you. Call 000 in a medical emergency. |
What Is Chronic Constipation?
Constipation can mean different things to different people. It may involve hard or lumpy stools, excessive straining, a feeling of incomplete emptying, a sensation of blockage, the need to use manual manoeuvres, or infrequent bowel motions. Stool frequency alone does not define constipation.
Under the Rome IV framework, functional constipation is diagnosed from a pattern of symptoms rather than from a single test. Symptoms are generally present during the previous three months, with onset at least six months before diagnosis. A clinician also considers whether another condition or medicine better explains the symptoms.
When Is Medical Assessment Appropriate?
Occasional constipation is common. Medical assessment is reasonable when symptoms are persistent, recurrent, changing, troublesome, or not improving with appropriate initial measures. Earlier assessment is appropriate when there are warning features.
Possible Causes
Constipation is a symptom, not a single disease. More than one factor may contribute. Possible causes include:
Functional constipation or constipation-predominant irritable bowel syndrome (IBS-C).
Medicines, particularly opioid analgesics and some other prescribed or over-the-counter medicines.
Defecatory disorders, including pelvic floor dyssynergia.
Slow movement of stool through the colon in selected patients.
Metabolic or endocrine disorders, such as hypothyroidism or hypercalcaemia, when clinically relevant.
Structural bowel or anorectal conditions, such as a stricture, rectal prolapse or other outlet problem.
Colorectal cancer or other bowel disease in a minority of patients, particularly when other concerning features are present.
Pelvic Floor and Defecatory Disorders
Some people have difficulty coordinating the pelvic floor and anal sphincter during defecation. Symptoms may include prolonged straining, a sensation of blockage, incomplete emptying or the need for manual assistance. When a defecatory disorder is suspected, specialist assessment may include anorectal manometry and a balloon expulsion test. Biofeedback-based pelvic floor therapy is an established treatment for appropriately diagnosed dyssynergic defecation.
Warning Signs
Seek urgent medical assessment | Arrange prompt medical review |
Severe or worsening abdominal pain with marked distension, persistent vomiting, or inability to pass stool or wind | Rectal bleeding or blood mixed with stool |
Bowel Cancer Screening and Symptoms Are Different
The Australian National Bowel Cancer Screening Program is for eligible people who do not have bowel symptoms. People with rectal bleeding, unexplained weight loss, iron-deficiency anaemia or a persistent change in bowel habit should seek medical assessment rather than rely on a screening test. The clinician can determine whether diagnostic testing is required.
How Constipation Is Assessed
Assessment usually begins with a history, medication review and physical examination. A rectal examination may be appropriate when an anorectal or defecatory disorder is suspected. Investigations are selected according to the clinical situation; not every patient requires blood tests, imaging or colonoscopy.
Investigation | When it may be considered |
Selected blood tests | Tests such as a full blood count, iron studies, thyroid function, calcium, glucose or electrolytes may be useful when the history or examination suggests a secondary cause. Broad routine testing is not required for every patient. |
Colonoscopy | May be indicated for alarm features, a positive bowel screening test, relevant colorectal cancer risk, or another clinical indication. Constipation alone does not automatically require colonoscopy. |
CT colonography | May be used as an alternative structural assessment in selected patients when colonoscopy is unsuitable or incomplete. |
Anorectal manometry and balloon expulsion testing | May be used when a defecatory disorder such as dyssynergic defecation is suspected. |
Defecography or MRI defecography | Used selectively when a structural or functional evacuation disorder is suspected. |
Colonic transit testing | May be used in selected patients with persistent symptoms to assess slow transit, usually after initial treatment and consideration of a defecatory disorder. |
Treatment
Treatment depends on the cause, severity of symptoms, other medical conditions, medicines and patient preference. The following information describes general approaches and should not be interpreted as a personalised treatment plan.
Diet, activity and bowel routine
- A gradual increase in dietary fibre may help some people. Fibre should be individualised because it can worsen bloating or discomfort in others.
- Maintain adequate fluid intake for your circumstances. Drinking excessive amounts of water does not necessarily improve constipation when hydration is already adequate.
- Regular physical activity may support general bowel function and overall health where medically appropriate.
- Respond to the urge to defecate and allow unhurried toilet time. A footstool may help some people achieve a more effective toileting position.
Laxatives and prescription medicines
Laxatives are commonly used when simple measures are insufficient. Osmotic laxatives such as polyethylene glycol (macrogol) have evidence supporting their use in chronic idiopathic constipation. Stimulant laxatives may also be useful in selected circumstances. Choice, dose and duration should take account of symptoms, other conditions, current medicines and response to treatment.
Many laxatives can be used safely for longer periods when clinically appropriate. Persistent or worsening symptoms, uncertainty about the diagnosis, or increasing treatment requirements are reasons to review the management plan with a GP, pharmacist or specialist rather than simply escalating treatment without assessment.
Treatment for specific causes
Defecatory disorders: pelvic floor biofeedback is generally preferred when dyssynergic defecation has been appropriately diagnosed.
Opioid-induced constipation: management may include review of the opioid regimen and specific constipation treatment with the prescribing clinician.
IBS-C: treatment may include dietary strategies and selected medicines, guided by symptoms and clinical assessment.
Metabolic or endocrine causes: management is directed at the underlying condition when it is clinically relevant.
When Specialist Assessment May Be Helpful
Referral to a colorectal surgeon may be appropriate when symptoms remain troublesome despite reasonable initial treatment, specialised physiology testing is required, colonoscopy is clinically indicated, or structural disease is suspected. The most appropriate specialist depends on the clinical problem.
Surgery
Surgery is not a routine treatment for chronic constipation. In a small and carefully selected group of patients with severe, objectively confirmed slow-transit constipation, surgery may be considered after comprehensive specialist assessment, exclusion or treatment of defecatory disorders and other causes, and an adequate trial of non-surgical management. Surgery has important short- and long-term risks and requires individual informed consent.
Frequently Asked Questions
I have been constipated for years. Does that mean it is normal for me?
Not necessarily. Longstanding symptoms may still benefit from assessment, especially if the pattern changes, symptoms become more troublesome, treatment stops working, or warning features develop.
Can I keep taking laxatives?
Many laxatives can be used safely for chronic constipation when they are appropriate for the individual. Regular use does not automatically mean an underlying disease is being masked. Review is sensible if symptoms persist, worsen, require increasing treatment, or the diagnosis is uncertain.
Does constipation mean I have bowel cancer?
Usually not. Constipation alone is a non-specific symptom. Concern is greater when there is a persistent new change in bowel habit together with features such as rectal bleeding, iron-deficiency anaemia, unexplained weight loss, a mass, or relevant personal or family history.
Could difficulty passing stool be a pelvic floor problem?
Yes. Excessive straining, a sensation of blockage, incomplete evacuation or the need for manual assistance can suggest a defecatory disorder. A GP or specialist can determine whether anorectal physiology testing is appropriate.
Do I need a colonoscopy because I am constipated?
Not necessarily. Colonoscopy is not routinely required for constipation alone. It may be recommended when there are alarm features, relevant colorectal cancer risk, a positive screening test, or another clinical indication.
Who should I see first?
For most people, a GP is an appropriate first point of assessment. Depending on the findings, referral may be made to gastroenterology, colorectal surgery, pelvic floor physiotherapy or another relevant service.
Seeking Further Assessment
If constipation is persistent, changing, associated with warning features, or not improving with appropriate initial management, discuss it with your GP or treating clinician. If specialist assessment is indicated, your GP can help direct the referral according to the suspected cause.
Practice Information
Dr Devesh Kaushal, MBBS, MS, FRACS
Specialist General Surgeon Campbelltown | Practice interests include upper gastrointestinal and bariatric surgery
Campbelltown Consulting Rooms | 4 Hyde Parade, Campbelltown NSW 2560
Phone: (02) 7906 8312 | Email: [email protected]
A GP referral is generally required for Medicare specialist rebates. Fees, rebates and private health insurance benefits vary according to the service and individual circumstances. Patients should confirm likely costs with the practice and their insurer before treatment where applicable.
Important: This page is educational and does not claim that any particular investigation or treatment is suitable for every person with constipation. Decisions about testing and treatment require individual clinical assessment, discussion of reasonable alternatives, material risks and expected benefits. |
References and Guidance
Rome Foundation. Rome IV diagnostic criteria for functional gastrointestinal disorders.
American Gastroenterological Association and American College of Gastroenterology clinical practice guidance on pharmacological management of chronic idiopathic constipation.
Australian Government Department of Health, Disability and Ageing. National Bowel Cancer Screening Program.
Medical Board of Australia / Ahpra. Advertising guidelines and guidance for regulated health services.
Australian Medical Association. Position Statement on Advertising and Public Endorsement.
Royal Australasian College of Surgeons. Guidance regarding surgical specialty titling and advertising.
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