Mechanisms, Evaluation, and Management of Chronic Constipation

Gastroenterology. 2020 Apr;158(5):1232-1249.e3. doi: 10.1053/j.gastro.2019.12.034. Epub 2020 Jan 13.


With a worldwide prevalence of 15%, chronic constipation is one of the most frequent gastrointestinal diagnoses made in ambulatory medicine clinics, and is a common source cause for referrals to gastroenterologists and colorectal surgeons in the United States. Symptoms vary among patients; straining, incomplete evacuation, and a sense of anorectal blockage are just as important as decreased stool frequency. Chronic constipation is either a primary disorder (such as normal transit, slow transit, or defecatory disorders) or a secondary one (due to medications or, in rare cases, anatomic alterations). Colonic sensorimotor disturbances and pelvic floor dysfunction (such as defecatory disorders) are the most widely recognized pathogenic mechanisms. Guided by efficacy and cost, management of constipation should begin with dietary fiber supplementation and stimulant and/or osmotic laxatives, as appropriate, followed, if necessary, by intestinal secretagogues and/or prokinetic agents. Peripherally acting μ-opiate antagonists are another option for opioid-induced constipation. Anorectal tests to evaluate for defecatory disorders should be performed in patients who do not respond to over-the-counter agents. Colonic transit, followed if necessary with assessment of colonic motility with manometry and/or a barostat, can identify colonic dysmotility. Defecatory disorders often respond to biofeedback therapy. For specific patients, slow-transit constipation may necessitate a colectomy. No studies have compared inexpensive laxatives with newer drugs with different mechanisms. We review the mechanisms, evaluation, and management of chronic constipation. We discuss the importance of meticulous analyses of patient history and physical examination, advantages and disadvantages of diagnostic testing, guidance for individualized treatment, and management of medically refractory patients.

Publication types

  • Research Support, N.I.H., Extramural
  • Review

MeSH terms

  • Chronic Disease / epidemiology
  • Chronic Disease / therapy
  • Colon / diagnostic imaging
  • Colon / innervation
  • Colon / metabolism
  • Colon / physiopathology
  • Constipation / diagnosis
  • Constipation / epidemiology
  • Constipation / etiology
  • Constipation / therapy*
  • Defecation / physiology*
  • Defecography
  • Dietary Fiber / administration & dosage
  • Dietary Supplements
  • Digital Rectal Examination
  • Electromyography
  • Gastrointestinal Motility / drug effects
  • Gastrointestinal Motility / physiology*
  • Humans
  • Intestinal Mucosa / drug effects
  • Intestinal Mucosa / metabolism
  • Intestinal Mucosa / physiopathology
  • Laxatives / administration & dosage
  • Magnetic Resonance Imaging
  • Manometry
  • Pelvic Floor / innervation
  • Pelvic Floor / physiopathology
  • Prevalence
  • Receptors, Opioid, mu / antagonists & inhibitors
  • Receptors, Opioid, mu / metabolism
  • Rectum / diagnostic imaging
  • Rectum / innervation
  • Rectum / metabolism
  • Rectum / physiopathology
  • Secretagogues / administration & dosage


  • Dietary Fiber
  • Laxatives
  • Receptors, Opioid, mu
  • Secretagogues