The term constipation is derived from the Latin word "obstipatio", which means accumulation or congestion. Occasional constipation usually resolves itself. In the case of chronic constipation, the exact trigger often remains unknown. Around 15% of the population suffer from constipation. Before taking laxatives, those affected should first try a dietary fiber supplement and dietary measures.
The normal frequency of bowel movements varies from person to person and is often between three times a day and three times a week. However, if bowel movements occur less frequently than three times a week and are accompanied by other symptoms, such as heavy straining, constipation can be assumed. In this case, the stool is usually hard in consistency and defecation becomes increasingly difficult.
In young adulthood, women are affected by constipation around two to three times more frequently than men. In older to advanced age, men are then affected by constipation about as often as women.
A short-lasting constipation is often known as travel constipation (e.g. when the daily routine is determined by others). In some cases, this form of constipation is also caused by other socio-cultural circumstances or bedriddenness.
The triggers of chronic constipation usually remain unknown. In severe forms of slow transit constipation, problems with the body's intestinal nervous system are assumed. Pregnancy can also lead to constipation. In neurological diseases, constipation symptoms often occur in combination with other complaints, whereby constipation can rarely be treated effectively.
Medication as a cause of constipation:
Constipation-promoting medication | Treatment measure |
Antihypertensives (e.g. calcium antagonists, clonidine) | Other class (e.g. ACE inhibitors) |
Antipsychotics, cyclic antidepressants, anticonvulsants, anti-Parkinson's drugs | Laxatives |
opioids | Laxatives or peripherally acting opioid antagonists (PAMORA) |
In the case of drug-induced constipation, the indication and the necessary dose of the prescribed medication should first be checked. If necessary, it may help to switch to a less constipating agent.
Assured risk factors for the development of constipation are
reduced physical activity
emotional stress
Medication (e.g. antidepressants, opioids)
Neurological diseases (e.g. Parkinson's disease)
Rectal changes
Changed eating habits
Insufficient intake of dietary fiber
Reduced fluid intake
For most sufferers, the main symptoms of constipation are a feeling of fullness, hard bowel movements or heavy straining when defecating. In addition, there are sometimes other discomforts such as headaches, tiredness, fatigue, a feeling of pressure, flatulence, few bowel sounds, a palpable mass in the abdomen, nausea, nausea or loss of appetite. Patients with chronic constipation often suffer from a reduced quality of life.
The so-called "Rome criteria" define the criteria for diagnosing chronic constipation:
At least two of the following symptoms over a period ≥ 3 months with an onset ≥ 6 months:
Severe straining with > 25% of bowel movements
Bulbous or hard stools for > 25% of bowel movements
Feeling of incomplete evacuation with > 25% of bowel movements
Feeling of anorectal blockage in > 25 % of defecations
Manual evacuation maneuvers required for > 25% of defecations (e.g. digital evacuation, manual support of the pelvic floor)
Less than 3 defecations/week
No unformed stools or no sufficient criteria for irritable bowel syndrome
In the diagnosis of constipation, a detailed medical history is usually sufficient to make a diagnosis. Physical examinations are primarily used to rule out organic and anatomical problems. If there are no alarm symptoms (e.g. bloody stools) and the basic diagnostics remain unremarkable, a trial therapy should be started first.
The following examinations are useful in the diagnosis of constipation, but are usually only considered after several unsuccessful treatment attempts:
Extended diagnostics (to rule out neurological or endocrinological forms of constipation, so-called secondary constipation)
Defecography (detects morphological and anatomical problems such as a rectocele)
Anorectal manometry (pathological if there is no relaxation of the sphincter muscle when pushing)
Transit time measurement with radiopaque markers (normal < approx. 70 h) forms the basis for the diagnosis of slow colonic transit (so-called slow transit obstruction, transit time well over 100 hours)
Occasional constipation (e.g. when traveling) is usually self-limiting and can be treated with laxatives if necessary. In addition to constipation, intestinal obstruction often leads to other severe symptoms such as vomiting or colicky pain.
Further examinations in the course of a constipation investigation are, for example
Digital palpation of the rectum and palpation of the abdomen.
Blood test with examination of electrolyte values (especially potassium), thyroid parameters (e.g. TSH) and a test for occult (non-visible) blood in the stool.
Ultrasound examination of the abdomen and a colonoscopy.
In general, there are no disadvantages for physical health due to a reduced stool frequency. However, people with constipation should follow every urge to defecate and not suppress the urge to defecate. Physical activity, such as sport, often triggers the urge to defecate in people who do not suffer from constipation. However, the effectiveness of physical exercise for constipated people is controversial.
Surgical interventions are only used in rare cases of constipation symptoms. If the constipation is triggered by opioids, an attempt at therapy with peripherally acting opioid antagonists (PAMORA) is recommended.
The indication for therapy usually depends on the level of suffering of the person affected. If the constipation is secondary to a disease such as diverticulitis, Crohn's disease or haemorrhoids, the disease must be treated first and foremost.
General measures for chronic constipation:
Measure | Level of evidence |
Education about stool frequency | Recommended |
Time for toilet visits | Recommended |
Eating breakfast | Recommended |
Adequate fluid intake | Recommended |
Further increase your fluid intake | Not recommended |
Increase physical activity | Possibly effective |
Trial treatment with dietary fiber | Recommended |
Breakfast greatly increases the motor activity of the colon. The colon also works more intensively after getting up, so breakfast followed by a visit to the toilet is recommended. Increasing the normal amount of fluids to 1.5 to 2 liters has no additional therapeutic effect on constipation. However, if there is a fluid deficit, this should be compensated for.
Before treatment with laxatives, the administration of dietary fiber should be tested. If the symptoms then subside, there is no need for further diagnostics. Foods that increase stool volume include wholegrain products, wheat bran and psyllium husks. Fruit, vegetables and especially salads, on the other hand, contain less effective fiber. However, special types of fruit (e.g. prunes) often contain a large amount of sorbitol, which in itself has a laxative effect. Milk sugar (lactose) in the form of milk or powder also has a laxative effect if the intestinal capacity for lactose absorption is exceeded.
If various nutritional measures succeed in increasing the volume of stool, there is no more straining or paradoxical contraction of the sphincter muscle. The "operating disorder" can also be trained away by explaining the sphincter function to those affected and practising pressing with relaxation of the sphincter muscle during digital palpation. Even more effective is so-called "biofeedback training", which is carried out at home using special equipment.
The dose and frequency of most laxatives depend on the needs of the patient. The aim is always a soft and formed stool that can be defecated without straining. Limiting the duration of intake is often unjustified. If an active ingredient is poorly tolerated or does not have a sufficient effect, it should be changed to another class of active ingredient. Newly developed substances are not superior to older active substances. If necessary, a combination of preparations from different classes can also be successful.
The term saline laxatives refers to magnesium hydroxide, Glauber's salt, Epsom salt and Carlsbad salt. These salts are poorly absorbed by the body and therefore have an osmotic effect. Due to their unpleasant taste, they are not suitable for long-term administration, with the exception of magnesium hydroxide. Caution is advised in patients with cardiac or renal insufficiency, as the salts are absorbed by the body to a certain extent during therapy.
Macrogol is a synthetic, non-bacterially cleavable dietary fiber with a high molecular weight (3350-4000). It binds water when used and thus leads to a laxative effect. As macrogol cannot be broken down, it does not lead to gas formation in the intestine. Adding electrolytes to macrogol does not offer any advantages, but greatly impairs the taste and therefore the acceptance of those affected. The recommended daily dose is around 10 - 30 g.
Small intestinal enzymes can only break down disaccharides and sugar alcohols into monosaccharides to a limited extent or not at all, which is why they have a laxative effect. In contrast, the absorption capacity of sorbitol in the intestine is limited. However, substances such as lactose or lactulose are further processed by colon bacteria, whereupon they lose their ability to bind water and therefore have a less pronounced laxative effect. Particularly with a slow intestinal transit, this results in a strong transformation of the substances. Many sufferers also find the formation of gas or the sweet taste(lactulose) disturbing. The daily dose is 10 to 30 g.
The prokinetic prucalopride acts via the 5-HT4 receptor (serotonin receptor) and is used in patients who respond poorly to other measures. The dose taken once a day is usually 1-4 g.
Other oral laxatives include bisacodyl, sodium picosulphate or anthraquinones.
All laxatives commercially available in Europe can be considered safe and can also be used long-term if the correct dosage is taken. Electrolyte loss can sometimes occur with long-term use and increased dosage, although electrolyte loss is not to be expected with a normal dosage. With a reasonable dose, hypokalemia does not usually occur, although this side effect is often warned of in the literature. Some patients report a slight habituation effect in relation to the laxative effect of oral laxatives and therefore occasionally change the preparation or another class of active ingredient.
Whether rectal or oral laxatives are used often depends on the individual preference of those affected. Rectal treatment options for constipation include enemas, saline clysters and various suppositories (e.g. containing glycerine or bisacodyl). The rectal treatment options have a short onset of action and are easy to control. They can be used particularly well for defecation disorders.
Removal of the colon (colectomy) with retention of the rectum should only be considered in cases of severe slow-transit obstruction refractory to therapy and/or idiopathic megacolon. All disorders with reduced motility of the stomach and small intestine must also be excluded first.
In most cases, the prognosis for constipation is good, as often only travel, stress, lack of exercise and/or a poor diet cause the symptoms. Constipation is often temporary and resolves on its own. Countermeasures such as an increased intake of fiber can get the bowels moving again.
In the case of chronic constipation, oral laxatives often help, although the exact cause of the constipation often remains unknown.
The following measures can help to prevent constipation:
High-fiber diet (whole grain products, prunes, raw vegetables, fresh fruit with peel)
Physical exercise (e.g. walking or sport)
Adequate fluid intake
Sufficient time to go to the toilet. A regular time can help here, which can be practiced.
Sufficient time for physical and mental relaxation
No suppression of the urge to defecate
Dr. med. univ. Moritz Wieser
Thomas Hofko
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