Chronic constipation is a common complaint and adversely impacts quality of life. Most patients with chronic constipation largely present to the primary care physician, who is most often the first point of contact for the patient. Though it can be managed at the primary care level, in some instances, chronic constipation requires specialist care.

For patients, symptoms like straining while passing stools and consistency of stools are how they define constipation, and not the number of stools per week. The first step is to identify whether constipation is primary or secondary. Majority of constipation is due to primary causes such as functional constipation, irritable bowel syndrome with constipation (IBS-C). However, constipation can also secondary to metabolic, endocrinal, neurological, psychological causes or some medications, which must be ruled out as the cause. Functional constipation must be differentiated from IBS-C as the management may differ. Similarly, other causes of constipation such as rectocele and enterocele must be kept in mind as they are likely to be missed. Physicians managing chronic constipation should be alert about the alarm symptoms, which are red flags for colorectal cancer. 

This article also discusses the treatment approaches in primary care and states that constipation can either be managed in a step-wise manner or drugs with different mechanisms of action can be combined to treat the constipation, if secondary causes are excluded. The author briefly discusses lifestyle modifications (exercise, increased fluid intake and dietary fiber) that are usually recommended as the first-line treatment, various laxatives such as bulking agents like soluble fiber (psyllium) and osmotic laxatives like polyethylene glycol. Stimulant laxatives, rectal suppositories and probiotics as treatment for constipation are also touched upon. The beneficial effects of polyethylene glycol, an osmotic laxative are supported by evidence, which also document its superiority to lactulose. If the patient does not respond to treatment or if a secondary cause is suspected, the patient should be referred to specialist intervention for appropriate investigations, as many of them are usually not done in primary care. The management of constipation has to be individualized to enhance the quality of life for the patient. It is a condition that merits thoughtful consideration.

Hungin AP. Dig Dis. 2021 Apr 18. doi: 10.1159/000516489.