Evaluation and treatment of constipation

What is the approach to the evaluation and treatment of constipation?

There are several principles in approaching the evaluation and treatment of constipation.The first principle is todifferentiate between acute (recent onset) and chronic constipation.Thus, with acute constipation that is worsening, itis necessary to assess for the cause early so as not to overlook aserious illness that should be treated urgently.The second principle is to start treatmentearly and use the treatments that have the least potential for harm. This willprevent constipation from worsening, and it also will prevent potential damage tothe colon that can be caused by the frequent use of stimulantlaxatives. The third principle is to know when it is time to evaluate the causeof chronic constipation. Evaluation for the cause of chronic constipation needsto be done if there is no response to the simple treatments.The goal of treatment in constipation should not be a bowel movement everyday, but a bowel movement every two to three days without difficulty (withoutstraining). Start with the simple things. Don't suppress urges to defecate.When the urge comes, find a toilet. With the assistance of your physician andpharmacist, determine if there are drugs that you are taking that could becontributing to the constipation. See if the drugs can be discontinued orchanged. Increase the fiber in your diet by consuming more fruits, vegetables,and whole grains. (There are other health benefits from this recommendation aswell.) It may be difficult to get enough fiber in the diet to effectively treat constipation, so don't hesitate to take fiber supplements if necessary (wheatbran, psyllium, etc.). Use increasing amounts of fiber and/or change the type offiber consumed until there is a satisfactory result. Don't expect fiber towork overnight. Allow weeks for adequate trials.What if constipation does not respond to these simple, safe measures? Theseefforts should not be discontinued but other measures should be added. If the constipation is infrequent, that is, every few weeks (as it can be when due tothe menstrual cycle), it probably doesn't matter what other measures are added-emollient,saline, or hyper-osmolar laxatives, enemas, and suppositories. Even stimulantlaxatives every four to six weeks are unlikely to damage the colon. Unfortunately,the tendency when using stimulant laxatives is to unconsciously increase thefrequency of their use. Before you know it, you're taking them every week, ormore often, and permanent damage might result.If constipation is a continuous rather than an intermittent problem, probably thesafest laxatives to take on a regular basis are the hyper-osmolar laxatives. Their use should be supervised by a physician. Aswith fiber, increasing doses of different hyper-osmolar laxatives should be triedover several weeks until a satisfactory type and dose of laxative is found.Hyper-osmolar laxatives, however, can be expensive. Milk of magnesia is the mildestof the saline laxatives, is inexpensive, and provides a good alternative. Mostpatients can adjust the dose of milk of magnesia to soften the stool adequatelywithout developing diarrhea or leakage of stool.Prunes and prune juice have been used for many years to treat mild constipation. There is no evidence that the mild stimulant effects of prunes or prune juice damage the colon. Stronger stimulant laxatives usually are recommended only as a last resort after non-stimulant treatments have failed. Many people take herbs to treat their constipation because they feel more comfortable using a "natural" product.