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  • Review Article
  • Published:

Diagnosis and management of chronic constipation in adults

Nature Reviews Gastroenterology & Hepatology volume 13, pages 295–305 (2016)Cite this article

Subjects

Key Points

  • Constipation is common, impairs quality of life and consumes considerable health-care resources

  • Recognition of whether constipation is primary or secondary is key for appropriate management

  • A detailed history and physical examination including digital rectal examination is important and can identify an evacuation disorder

  • Physiological tests such as colonic transit assessment, anorectal manometry and the balloon expulsion test can facilitate stratification of patients with different constipation subtypes

  • Newer drugs, such as linaclotide and lubiprostone, laxatives, and biofeedback therapy can considerably improve symptoms in patients with chronic constipation

Abstract

Constipation is a heterogeneous, polysymptomatic, multifactorial disease. Acute or transient constipation can be due to changes in diet, travel or stress, and secondary constipation can result from drug treatment, neurological or metabolic conditions or, rarely, colon cancer. A diagnosis of primary chronic constipation is made after exclusion of secondary causes of constipation and encompasses several overlapping subtypes. Slow-transit constipation is characterized by prolonged colonic transit in the absence of pelvic floor dysfunction. This subtype of constipation can be identified using either the radio-opaque marker test or wireless motility capsule test, and is best treated with laxatives such as polyethylene glycol or newer agents such as linaclotide or lubiprostone. If unsuccessful, subspecialist referral should be considered. Dyssynergic defecation results from impaired coordination of rectoanal and pelvic floor muscles, and causes difficulty with defecation. The condition can be identified using anorectal manometry and balloon expulsion tests and is best managed with biofeedback therapy. Opioid-induced constipation is an emerging entity, and several drugs including naloxegol, methylnaltrexone and lubiprostone are approved for its treatment. In this Review, we provide an overview of the burden and pathophysiology of chronic constipation, as well as a detailed discussion of the available diagnostic tools and treatment options.

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Figure 1: Four main subtypes of dyssynergic defecation can be observed by anorectal manometry.
Figure 2: Proposed management algorithm for chronic constipation.
Figure 3: Proposed evaluation and treatment of suspected colonic dysmotility or pelvic floor disorder in chronic constipation.

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References

  1. Higgins, P. D. & Johanson, J. F. Epidemiology of constipation in North America: a systematic review. Am. J. Gastroenterol. 99, 750–759 (2004).

    Article  PubMed  Google Scholar 

  2. Belsey, J., Greenfield, S., Candy, D. & Geraint, M. Systematic review: impact of constipation on quality of life in adults and children. Aliment. Pharmacol. Ther. 31, 938–949 (2010).

    CAS  PubMed  Google Scholar 

  3. Dennison, C. et al. The health-related quality of life and economic burden of constipation. Pharmacoeconomics 23, 461–476 (2005).

    Article  PubMed  Google Scholar 

  4. Rao, S. S. et al. Psychological profiles and quality of life differ between patients with dyssynergia and those with slow transit constipation. J. Psychosom. Res. 63, 441–449 (2007).

    Article  PubMed  Google Scholar 

  5. Rao, S. S. Constipation: evaluation and treatment of colonic and anorectal motility disorders. Gastroenterol. Clin. North Am. 36, 687–711 (2007).

    Article  PubMed  Google Scholar 

  6. Pare, P., Ferrazzi, S., Thompson, W. G., Irvine, E. J. & Rance, L. An epidemiological survey of constipation in Canada: definitions, rates, demographics, and predictors of health care seeking. Am. J. Gastroenterol. 96, 3130–3137 (2001).

    Article  CAS  PubMed  Google Scholar 

  7. Bharucha, A. E., Pemberton, J. H. & Locke, G. R. 3rd. American Gastroenterological Association technical review on constipation. Gastroenterology 144, 218–238 (2013).

    Article  PubMed  Google Scholar 

  8. Mugie, S. M., Benninga, M. A. & Di Lorenzo, C. Epidemiology of constipation in children and adults: a systematic review. Best Pract. Res. Clin. Gastroenterol. 25, 3–18 (2011).

    Article  PubMed  Google Scholar 

  9. Dukas, L., Willett, W. C. & Giovannucci, E. L. Association between physical activity, fiber intake, and other lifestyle variables and constipation in a study of women. Am. J. Gastroenterol. 98, 1790–1796 (2003).

    Article  PubMed  Google Scholar 

  10. Coremans, G., Margaritis, V. & Gebruers, K. Is there a genetic component in chronic functional constipation? Gastroenterology 128 (Suppl. 2), A272 (2005).

    Google Scholar 

  11. Mudipalli, R. S., Remes-Troche, J. M., Andersen, L. & Rao, S. S. Functional chest pain: esophageal or overlapping functional disorder. J. Clin. Gastroenterol. 41, 264–269 (2007).

    Article  PubMed  Google Scholar 

  12. Locke, G. R. et al. Overlap of gastrointestinal symptom complexes in a US community. Neurogastroenterol. Motil. 17, 29–34 (2005).

    Article  PubMed  Google Scholar 

  13. Rao, S. S. in Yamada's Textbook of Gastroenterology 6th edn (eds Podolsky, D. K. & Kalman, D.) 757–780 (John Wiley & Sons, 2016).

    Google Scholar 

  14. Burgell, R. E. et al. Assessment of rectal afferent neuronal function and brain activity in patients with constipation and rectal hyposensitivity. Neurogastroenterol. Motil. 25, 260–268 (2013).

    Article  CAS  PubMed  Google Scholar 

  15. Drossman, D. A. The functional gastrointestinal disorders and the Rome III process. Gastroenterology 130, 1377–1390 (2006).

    Article  PubMed  Google Scholar 

  16. Rao, S. S., Sadeghi, P., Beaty, J. & Kavlock, R. Ambulatory 24-hour colonic manometry in slow-transit constipation. Am. J. Gastroenterol. 99, 2405–2416 (2004).

    Article  PubMed  Google Scholar 

  17. Bassotti, G., de Roberto, G., Castellani, D., Sediari, L. & Morelli, A. Normal aspects of colorectal motility and abnormalities in slow transit constipation. World J. Gastroenterol. 11, 2691–2696 (2005).

    Article  PubMed  PubMed Central  Google Scholar 

  18. Dinning, P. G. & Di Lorenzo, C. Colonic dysmotility in constipation. Best Pract. Res. Clin. Gastroenterol. 25, 89–101 (2011).

    Article  PubMed  Google Scholar 

  19. Dinning, P. G. et al. Pancolonic spatiotemporal mapping reveals regional deficiencies in, and disorganization of colonic propagating pressure waves in severe constipation. Neurogastroenterol. Motil. 22, e340–e349 (2010).

    Article  CAS  PubMed  Google Scholar 

  20. Rao, S. S., Sadeghi, P., Batterson, K. & Beaty, J. Altered periodic rectal motor activity: a mechanism for slow transit constipation. Neurogastroenterol. Motil. 13, 591–598 (2001).

    Article  CAS  PubMed  Google Scholar 

  21. Ravi, K. et al. Phenotypic variation of colonic motor functions in chronic constipation. Gastroenterology 138, 89–97 (2010).

    Article  PubMed  Google Scholar 

  22. Bassotti, G., Iantorno, G., Fiorella, S., Bustos-Fernandez, L. & Bilder, C. R. Colonic motility in man: features in normal subjects and in patients with chronic idiopathic constipation. Am. J. Gastroenterol. 94, 1760–1770 (1999).

    Article  CAS  PubMed  Google Scholar 

  23. Herve, S. et al. Results of 24-h manometric recording of colonic motor activity with endoluminal instillation of bisacodyl in patients with severe chronic slow transit constipation. Neurogastroenterol. Motil. 16, 397–402 (2004).

    Article  CAS  PubMed  Google Scholar 

  24. Knowles, C. H. & Farrugia, G. Gastrointestinal neuromuscular pathology in chronic constipation. Best Pract. Res. Clin. Gastroenterol. 25, 43–57 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  25. Rao, S. S., Tuteja, A. K., Vellema, T., Kempf, J. & Stessman, M. Dyssynergic defecation: demographics, symptoms, stool patterns, and quality of life. J. Clin. Gastroenterol. 38, 680–685 (2004).

    Article  PubMed  Google Scholar 

  26. Rao, S. S., Welcher, K. D. & Leistikow, J. S. Obstructive defecation: a failure of rectoanal coordination. Am. J. Gastroenterol. 93, 1042–1050 (1998).

    Article  CAS  PubMed  Google Scholar 

  27. Reiner, C. S. et al. MR defecography in patients with dyssynergic defecation: spectrum of imaging findings and diagnostic value. Br. J. Radiol. 84, 136–144 (2011).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Rao, S. S., Ozturk, R., De Ocampo, S. & Stessman, M. Pathophysiology and role of biofeedback therapy in solitary rectal ulcer syndrome. Am. J. Gastroenterol. 101, 613–618 (2006).

    Article  CAS  PubMed  Google Scholar 

  29. Scott, S. M., van den Berg, M. M. & Benninga, M. A. Rectal sensorimotor dysfunction in constipation. Best Pract. Res. Clin. Gastroenterol. 25, 103–118 (2011).

    Article  CAS  PubMed  Google Scholar 

  30. Rattanakovit, K., Rao, S., Amieva, M., Mack, A. & Dewitt, A. Dyssynergia or no dyssynergia: phenotypic categorization of constipated patients with high resolution anorectal manometry (HRAM). Am. J. Gastroenterol. 110 (Suppl. 1s), S593 (2015).

    Article  Google Scholar 

  31. Rao, S. S. Dyssynergic defecation and biofeedback therapy. Gastroenterol. Clin. North Am. 37, 569–586 (2008).

    Article  PubMed  PubMed Central  Google Scholar 

  32. Chey, W. D., Kurlander, J. & Eswaran, S. Irritable bowel syndrome: a clinical review. JAMA 313, 949–958 (2015).

    Article  CAS  PubMed  Google Scholar 

  33. Spiller, R. & Lam, C. An update on post-infectious irritable bowel syndrome: role of genetics, immune activation, serotonin and altered microbiome. J. Neurogastroenterol. Motil. 18, 258–268 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  34. Sachdev, A. H. & Pimentel, M. Antibiotics for irritable bowel syndrome: rationale and current evidence. Curr. Gastroenterol. Rep. 14, 439–445 (2012).

    Article  PubMed  Google Scholar 

  35. Shepherd, S. J., Lomer, M. C. & Gibson, P. R. Short-chain carbohydrates and functional gastrointestinal disorders. Am. J. Gastroenterol. 108, 707–717 (2013).

    Article  CAS  PubMed  Google Scholar 

  36. Halmos, E. P., Power, V. A., Shepherd, S. J., Gibson, P. R. & Muir, J. G. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology 146, 67–75 (2014).

    Article  CAS  PubMed  Google Scholar 

  37. Coss-Adame, E. & Rao, S. S. Brain and gut interactions in irritable bowel syndrome: new paradigms and new understandings. Curr. Gastroenterol. Rep. 16, 37 (2014).

    Article  Google Scholar 

  38. Mayer, E. A. & Tillisch, K. The brain-gut axis in abdominal pain syndromes. Annu. Rev. Med. 62, 381–396 (2011).

    Article  CAS  PubMed  Google Scholar 

  39. Tantiphlachiva, K., Rao, P., Attaluri, A. & Rao, S. S. Digital rectal examination is a useful tool for identifying patients with dyssynergia. Clin. Gastroenterol. Hepatol 8, 955–960 (2010).

    Article  PubMed  Google Scholar 

  40. Tornblom, H. et al. Colonic transit time and IBS symptoms: what's the link? Am. J. Gastroenterol. 107, 754–760 (2012).

    Article  PubMed  Google Scholar 

  41. Remes-Troche, J. M. & Rao, S. S. Diagnostic testing in patients with chronic constipation. Curr. Gastroenterol. Rep. 8, 416–424 (2006).

    Article  PubMed  Google Scholar 

  42. Videlock, E. J., Lembo, A. & Cremonini, F. Diagnostic testing for dyssynergic defecation in chronic constipation: meta-analysis. Neurogastroenterol. Motil. 25, 509–520 (2013).

    Article  CAS  PubMed  Google Scholar 

  43. Bertschinger, K. M. et al. Dynamic MR imaging of the pelvic floor performed with patient sitting in an open-magnet unit versus with patient supine in a closed-magnet unit. Radiology 223, 501–508 (2002).

    Article  PubMed  Google Scholar 

  44. Dvorkin, L. S. et al. Open-magnet MR defaecography compared with evacuation proctography in the diagnosis and management of patients with rectal intussusception. Colorectal Dis. 6, 45–53 (2004).

    Article  CAS  PubMed  Google Scholar 

  45. Rao, S. S., Kavlock, R. & Rao, S. Influence of body position and stool characteristics on defecation in humans. Am. J. Gastroenterol. 101, 2790–2796 (2006).

    Article  PubMed  Google Scholar 

  46. Lee, Y. Y., Erdogan, A. & Rao, S. S. High resolution and high definition anorectal manometry and pressure topography: diagnostic advance or a new kid on the block? Curr. Gastroenterol. Rep. 15, 360 (2013).

    Article  PubMed  Google Scholar 

  47. Raizada, V., Bhargava, V., Karsten, A. & Mittal, R. K. Functional morphology of anal sphincter complex unveiled by high definition anal manometery and three dimensional ultrasound imaging. Neurogastroenterol. Motil. 23, 1013–e460 (2011).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. Chiarioni, G., Kim, S. M., Vantini, I. & Whitehead, W. E. Validation of the balloon evacuation test: reproducibility and agreement with findings from anorectal manometry and electromyography. Clin. Gastroenterol. Hepatol. 12, 2049–2054 (2014).

    Article  PubMed  Google Scholar 

  49. Rao, S. S., Ozturk, R. & Laine, L. Clinical utility of diagnostic tests for constipation in adults: a systematic review. Am. J. Gastroenterol. 100, 1605–1615 (2005).

    Article  PubMed  Google Scholar 

  50. Camilleri, M. et al. Wireless pH-motility capsule for colonic transit: prospective comparison with radiopaque markers in chronic constipation. Neurogastroenterol. Motil. 22, 874–e233 (2010).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Rao, S. S. et al. Evaluation of gastrointestinal transit in clinical practice: position paper of the American and European Neurogastroenterology and Motility Societies. Neurogastroenterol. Motil. 23, 8–23 (2011).

    Article  CAS  PubMed  Google Scholar 

  52. Camilleri, M. et al. American Neurogastroenterology and Motility Society consensus statement on intraluminal measurement of gastrointestinal and colonic motility in clinical practice. Neurogastroenterol. Motil. 20, 1269–1282 (2008).

    Article  CAS  PubMed  Google Scholar 

  53. Singh, S., Heady, S., Coss-Adame, E. & Rao, S. S. Clinical utility of colonic manometry in slow transit constipation. Neurogastroenterol. Motil. 25, 487–495 (2013).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  54. Markland, A. D. et al. Association of low dietary intake of fiber and liquids with constipation: evidence from the National Health and Nutrition Examination Survey. Am. J. Gastroenterol. 108, 796–803 (2013).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  55. Rao, S. S., Yu, S. & Fedewa, A. Systematic review: dietary fibre and FODMAP-restricted diet in the management of constipation and irritable bowel syndrome. Aliment. Pharmacol. Ther. 41, 1256–1270 (2015).

    Article  CAS  PubMed  Google Scholar 

  56. Suares, N. C. & Ford, A. C. Systematic review: the effects of fibre in the management of chronic idiopathic constipation. Aliment. Pharmacol. Ther. 33, 895–901 (2011).

    Article  CAS  PubMed  Google Scholar 

  57. Bijkerk, C. J., Muris, J. W., Knottnerus, J. A., Hoes, A. W. & de Wit, N. J. Systematic review: the role of different types of fibre in the treatment of irritable bowel syndrome. Aliment. Pharmacol. Ther. 19, 245–251 (2004).

    Article  CAS  PubMed  Google Scholar 

  58. Attaluri, A., Donahoe, R., Valestin, J., Brown, K. & Rao, S. S. Randomised clinical trial: dried plums (prunes) versus psyllium for constipation. Aliment. Pharmacol. Ther. 33, 822–828 (2011).

    Article  CAS  PubMed  Google Scholar 

  59. Kamm, M. A. et al. Oral bisacodyl is effective and well-tolerated in patients with chronic constipation. Clin. Gastroenterol. Hepatol 9, 577–583 (2011).

    Article  CAS  PubMed  Google Scholar 

  60. Chang, L., Lembo, A. & Sultan, S. American Gastroenterological Association Institute Technical Review on the pharmacological management of irritable bowel syndrome. Gastroenterology 147, 1149–1172 (2014).

    Article  PubMed  Google Scholar 

  61. Ford, A. C. & Suares, N. C. Effect of laxatives and pharmacological therapies in chronic idiopathic constipation: systematic review and meta-analysis. Gut 60, 209–218 (2011).

    Article  PubMed  Google Scholar 

  62. Lee-Robichaud, H., Thomas, K., Morgan, J. & Nelson, R. L. Lactulose versus polyethylene glycol for chronic constipation. Cochrane Database Syst. Rev. 7, CD007570 (2010).

    Google Scholar 

  63. Singh, S. & Rao, S. S. Pharmacologic management of chronic constipation. Gastroenterol. Clin. North Am. 39, 509–527 (2010).

    Article  PubMed  Google Scholar 

  64. Camilleri, M. et al. Effect of a selective chloride channel activator, lubiprostone, on gastrointestinal transit, gastric sensory, and motor functions in healthy volunteers. Am. J. Physiol. Gastrointest. Liver Physiol. 290, G942–G947 (2006).

    Article  CAS  PubMed  Google Scholar 

  65. Lembo, A. J. et al. Long-term safety and effectiveness of lubiprostone, a chloride channel (ClC-2) activator, in patients with chronic idiopathic constipation. Dig. Dis. Sci. 56, 2639–2645 (2011).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  66. Busby, R. W. et al. Linaclotide, through activation of guanylate cyclase C, acts locally in the gastrointestinal tract to elicit enhanced intestinal secretion and transit. Eur. J. Pharmacol. 649, 328–335 (2010).

    Article  CAS  PubMed  Google Scholar 

  67. Castro, J. et al. Linaclotide inhibits colonic nociceptors and relieves abdominal pain via guanylate cyclase-C and extracellular cyclic guanosine 3′,5′-monophosphate. Gastroenterology 145, 1334–1346 (2013).

    Article  CAS  PubMed  Google Scholar 

  68. Chey, W. D. et al. Linaclotide for irritable bowel syndrome with constipation: a 26-week, randomized, double-blind, placebo-controlled trial to evaluate efficacy and safety. Am. J. Gastroenterol. 107, 1702–1712 (2012).

    Article  CAS  PubMed  Google Scholar 

  69. Rao, S. et al. A 12-week, randomized, controlled trial with a 4-week randomized withdrawal period to evaluate the efficacy and safety of linaclotide in irritable bowel syndrome with constipation. Am. J. Gastroenterol. 107, 1714–1724 (2012).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  70. Camilleri, M. Guanylate cyclase C agonists: emerging gastrointestinal therapies and actions. Gastroenterology 148, 483–487 (2015).

    Article  PubMed  Google Scholar 

  71. Miner, P. B. et al. Plecanatide, a novel uroguanylin analog: a 12-week, randomized, double-blind, placebo-controlled, dose ranging trial to evaluate efficacy and safety in patients with irritable bowel syndrome with constipation (IBS-C). Am. J. Gastroenterol. 109 (Suppl. 2), S541 (2014).

    Article  Google Scholar 

  72. Jarmuz, A., Zielinska, M., Storr, M. & Fichna, J. Emerging treatments in neurogastroenterology: perspectives of guanylyl cyclase C agonists use in functional gastrointestinal disorders and inflammatory bowel diseases. Neurogastroenterol. Motil. 27, 1057–1068 (2015).

    Article  CAS  PubMed  Google Scholar 

  73. Cash, B. D. & Chey, W. D. Review article: the role of serotonergic agents in the treatment of patients with primary chronic constipation. Aliment. Pharmacol. Ther. 22, 1047–1060 (2005).

    Article  CAS  PubMed  Google Scholar 

  74. Tack, J. & Corsetti, M. Prucalopride: evaluation of the pharmacokinetics, pharmacodynamics, efficacy and safety in the treatment of chronic constipation. Expert Opin. Drug Metab. Toxicol. 8, 1327–1335 (2012).

    Article  CAS  PubMed  Google Scholar 

  75. Shin, A. et al. Systematic review with meta-analysis: highly selective 5-HT4 agonists (prucalopride, velusetrag or naronapride) in chronic constipation. Aliment. Pharmacol. Ther. 39, 239–253 (2014).

    Article  CAS  PubMed  Google Scholar 

  76. Camilleri, M. et al. Emerging treatments in neurogastroenterology: a multidisciplinary working group consensus statement on opioid-induced constipation. Neurogastroenterol. Motil. 26, 1386–1395 (2014).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  77. Garnock-Jones, K. P. & McKeage, K. Methynaltrexone. Drugs 70, 919–928 (2010).

    Article  CAS  PubMed  Google Scholar 

  78. Yuan, C. S. et al. Tolerability, gut effects, and pharmacokinetics of methylnaltrexone following repeated intravenous administration in humans. J. Clin. Pharmacol. 45, 538–546 (2005).

    Article  CAS  PubMed  Google Scholar 

  79. Siemens, W., Gaertner, J. & Becker, G. Advances in pharmacotherapy for opioid-induced constipation — a systematic review. Expert Opin. Pharmacother. 16, 515–532 (2015).

    Article  CAS  PubMed  Google Scholar 

  80. Tan, E. K., Cornish, J., Darzi, A. W. & Tekkis, P. P. Meta-analysis: Alvimopan versus placebo in the treatment of post-operative ileus. Aliment. Pharmacol. Ther. 25, 47–57 (2007).

    CAS  PubMed  Google Scholar 

  81. US Department of Health & Human Services. Safety, Enterag (alvimopan) capsules. US Food and Drug Administration [online], (2013).

  82. Corsetti, M. & Tack, J. Naloxegol, a new drug for the treatment of opioid-induced constipation. Expert Opin. Pharmacother. 16, 399–406 (2015).

    Article  CAS  PubMed  Google Scholar 

  83. Chey, W. D. et al. Naloxegol for opioid-induced constipation in patients with noncancer pain. N. Engl. J. Med. 370, 2387–2396 (2014).

    Article  PubMed  CAS  Google Scholar 

  84. Rao, S. S. et al. ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders. Neurogastroenterol. Motil. 27, 594–609 (2015).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  85. Rao, S. S. Dyssynergic defecation. Gastroenterol. Clin. North Am. 30, 97–114 (2001).

    Article  CAS  PubMed  Google Scholar 

  86. Rao, S. S. Biofeedback therapy for constipation in adults. Best Pract. Res. Clin. Gastroenterol. 25, 159–166 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  87. Chiarioni, G., Whitehead, W. E., Pezza, V., Morelli, A. & Bassotti, G. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology 130, 657–664 (2006).

    Article  PubMed  Google Scholar 

  88. Heymen, S. et al. Prospective, randomized trial comparing four biofeedback techniques for patients with constipation. Dis. Colon Rectum 42, 1388–1393 (1999).

    Article  CAS  PubMed  Google Scholar 

  89. Rao, S. S. et al. Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin. Gastroenterol. Hepatol. 5, 331–338 (2007).

    Article  PubMed  Google Scholar 

  90. Hallan, R. I. et al. Treatment of anismus in intractable constipation with botulinum A toxin. Lancet 2, 714–717 (1988).

    Article  CAS  PubMed  Google Scholar 

  91. Podzemny, V., Pescatori, L. C. & Pescatori, M. Management of obstructed defecation. World J. Gastroenterol. 21, 1053–1060 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  92. Lee, H. J. et al. Long-term efficacy of biofeedback therapy in patients with dyssynergic defecation: results of a median 44 months follow-up. Neurogastroenterol. Motil. 27, 787–795 (2015).

    Article  CAS  PubMed  Google Scholar 

  93. Rao, S. S., Enck, P. & Loening-Baucke, V. Biofeedback therapy for defecation disorders. Dig. Dis. 15 (Suppl. 1), 78–92 (1997).

    Article  PubMed  Google Scholar 

  94. Rao, S. S., Erdogan, A., Coss-Adame, E., Valestin, J. & Mattos, M. L. Rectal hyposensitivity: randomized controlled trial of barostat versus syringe-assisted sensory training. Gastroenterology 144 (Suppl. 1), S363 (2013).

    Article  Google Scholar 

  95. Hassan, I. et al. Ileorectal anastomosis for slow transit constipation: long-term functional and quality of life results. J. Gastrointest. Surg. 10, 1330–1336 (2006).

    Article  PubMed  Google Scholar 

  96. Redmond, J. M. et al. Physiological tests to predict long-term outcome of total abdominal colectomy for intractable constipation. Am. J. Gastroenterol. 90, 748–753 (1995).

    CAS  PubMed  Google Scholar 

  97. Pemberton, J. H., Rath, D. M. & Ilstrup, D. M. Evaluation and surgical treatment of severe chronic constipation. Ann. Surg. 214, 403–411 (1991).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  98. Wexner, S. D., Daniel, N. & Jagelman, D. G. Colectomy for constipation: physiologic investigation is the key to success. Dis. Colon Rectum 34, 851–856 (1991).

    Article  CAS  PubMed  Google Scholar 

  99. Knowles, C. H., Scott, M. & Lunniss, P. J. Outcome of colectomy for slow transit constipation. Ann. Surg. 230, 627–638 (1999).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  100. Preston, D. M., Hawley, P. R., Lennard-Jones, J. E. & Todd, I. P. Results of colectomy for severe idiopathic constipation in women (Arbuthnot Lane's disease). Br. J. Surg. 71, 547–552 (1984).

    Article  CAS  PubMed  Google Scholar 

  101. Ho, Y. H. & Goh, H. S. The investigation of chronic constipation for surgical management. Singapore Med. J. 37, 291–294 (1996).

    CAS  PubMed  Google Scholar 

  102. Lundin, E., Karlbom, U., Pahlman, L. & Graf, W. Outcome of segmental colonic resection for slow-transit constipation. Br. J. Surg. 89, 1270–1274 (2002).

    Article  CAS  PubMed  Google Scholar 

  103. Abdulla, H., Yu, S., Rattanakovit, K., Badger, C. & Rao, S. S. Small intestinal bacterial overgrowth (SIBO) & fungal overgrowth (SIFO): a frequent & unrecognized complication of colectomy. Am. J. Gastroenterol. 110 (Suppl. 1s), S995 (2015).

    Article  Google Scholar 

  104. Lees, N. P., Hodson, P., Hill, J., Pearson, R. C. & Maclennan, I. Long-term results of the antegrade continent enema procedure for constipation in adults. Colorectal Dis. 6, 362–368 (2004).

    Article  CAS  PubMed  Google Scholar 

  105. Rivera, M. T., Kugathasan, S., Berger, W. & Werlin, S. L. Percutaneous colonoscopic cecostomy for management of chronic constipation in children. Gastrointest. Endosc. 53, 225–228 (2001).

    Article  CAS  PubMed  Google Scholar 

  106. Tackett, L. D., Minevich, E., Benedict, J. F., Wacksman, J. & Sheldon, C. A. Appendiceal versus ileal segment for antegrade continence enema. J. Urol. 167, 683–686 (2002).

    Article  PubMed  Google Scholar 

  107. Kamm, M. A. et al. Sacral nerve stimulation for intractable constipation. Gut 59, 333–340 (2010).

    Article  PubMed  Google Scholar 

  108. Thaha, M. A., Abukar, A. A., Thin, N. N., Ramsanahie, A. & Knowles, C. H. Sacral nerve stimulation for faecal incontinence and constipation in adults. Cochrane Database Syst. Rev. 8, CD004464 (2015).

    Google Scholar 

  109. Dinning, P. G. et al. Treatment efficacy of sacral nerve stimulation in slow transit constipation: a two-phase, double-blind randomized controlled crossover study. Am. J. Gastroenterol. 110, 733–740 (2015).

    Article  PubMed  Google Scholar 

  110. Ramkumar, D. & Rao, S. S. Efficacy and safety of traditional medical therapies for chronic constipation: systematic review. Am. J. Gastroenterol. 100, 936–971 (2005).

    Article  PubMed  Google Scholar 

  111. Brandt, L. J. et al. Systematic review on the management of chronic constipation in North America. Am. J. Gastroenterol. 100 (Suppl. 1), S5–S21 (2005).

    PubMed  Google Scholar 

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Acknowledgements

The authors would like to thank H. Smith (Medical College of Georgia, Augusta, Georgia, USA) for technical and secretarial assistance.

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Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, Augusta University, Medical College of Georgia, 1120 15th Street, AD 2226, Augusta, 30912, GA, USA

    Satish S. C. Rao, Kulthep Rattanakovit & Tanisa Patcharatrakul

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  1. Satish S. C. Rao
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  2. Kulthep Rattanakovit
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  3. Tanisa Patcharatrakul
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Contributions

K.R. drafted the article. K.R., S.S.C.R. and T. P. researched data for the article, provided a substantial contribution to discussion of the content and reviewed/edited the manuscript before submission.

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Correspondence to Satish S. C. Rao.

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Competing interests

S.S.C.R. serves on the advisory boards of Forest Labs, Salix, Synergy and Takeda, and has reviewed research grants from Forest Labs and Medtronic. K.R. and T.P. declare no competing interests.

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Rao, S., Rattanakovit, K. & Patcharatrakul, T. Diagnosis and management of chronic constipation in adults. Nat Rev Gastroenterol Hepatol 13, 295–305 (2016). https://doi.org/10.1038/nrgastro.2016.53

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