Vol 83, No 11 (2012)

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Practical approach to constipation in adults

Jacek Hermann, Tomasz Kościński, Michał Drews
Ginekol Pol 2012;83(11).


The authors present epidemiology, etiology, pathophysiology, management, and treatment of constipation including proper qualification for surgery. Constipations can be divided into more common – primary and less frequent – secondary. The latter may occur due to organic lesions of the large bowel, in the course of metabolic and endocrine disorders, or neurological and psychiatric diseases. Constipation may also be a side effect of multiple medications. In turn, primary constipation is either a slower movement of contents within the large bowel or, twice as likely, pelvic floor dysfunction with the inability to adequately evacuate the contents from the rectum. Symptoms such as infrequent defecation and decreased urge to defecate indicate rather colonic inertia whereas prolong straining even in case of loose stools, and feeling of incomplete evacuation are typical of obstructed defecation. Digital rectal examination reveals common anorectal defects presenting with constipation such as tumors, anal fissures and strictures, and rectocele, or less frequent changes such as rectal intussusception and enterocele. Proctologic examination should include the assessment of the anal sphincter tone and the pelvic floor movement. Barium enema or colonoscopy are necessary to confirm or exclude colorectal organic lesions, mostly in patients with alarm features. More accurate differentiation between slow transit constipation and obstructed defecation is possible with tests such as colonic transit time, defecography and anorectal manometry. Treatment of constipation, irrespective of the cause, is initiated with lifestyle modification which includes exercise, increased water intake and a high-fiber diet. Pharmacologic treatment is started with osmotic agents followed by stimulant laxatives. In turn, biofeedback therapy is a method of choice for the treatment of defecation disorders. There is a small group of patients with intractable slow-transit constipation and descending perineum syndrome who require surgery. Surgical treatment is also indicated in patients with symptomatic rectocele, and advanced rectal intussusception. Enterocele can be corrected during perineopexy performed for the descending perineum.

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