Constipation is a common condition that involves infrequent and/or hard stools, difficulty passing stools or sensation of incomplete emptying or anorectal blockage. Constipation might be due to poor intake of dietary fibre, unhealthy lifestyle, different medical conditions or occur as a side effect of drug therapy.

Article by Bruno Mafrici

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Constipation is a heterogeneous, symptom-based disorder in which people have infrequent and/or hard stools, difficulty passing stools or sensation of incomplete emptying or anorectal blockage (National Institute for Health and Care Excellence (NICE), 2023). The Rome IV diagnostic criteria for constipation include spontaneous bowel movements occurring less than three times a week (Aziz et al, 2020; NICE, 2023). In clinical practice, constipation is often defined as a passage of stools less frequently than the person’s normal pattern (NICE, 2023) and often categorised by using the Bristol stool chart (Figure 1).

Women are more likely to experience constipation than men, especially during pregnancy, and it is also more common in older people (Bowel Interest Group, 2020).

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There are many causes for constipation. The most common risk factors are related to social (ie diet and lifestyle), psychological and physical factors (Table 1).


Table 1. Possible aetiology of constipation
Social Psychological Physical

 - Low fibre diet

 - Low calorie intake

 - Low fluid intake

 - Difficult access to toilet, or changes in normal routine or lifestyle

 - Lack of exercise or reduced mobility

 - Limited privacy when using the toilet.

 - Low educational levels or socio-economic deprivation

 - A family history of constipation

 - Anxiety

 - Depression

 - Somatization disorders

 - Eating disorders

 - History of sexual abuse

 - Female gender

 - During pregnancy and for 6 weeks after giving birth

 - Older age

 - Pyrexia, dehydration, immobility

 - Sitting position on a toilet seat compared with the squatting position for defecation

From: NICE, 2023

Sometimes there is no obvious reason or known cause for constipation. This

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According to NICE (2023), a diagnosis of constipation can be made if an adult present with defecation which is unsatisfactory because of infrequent stools (less than 3 times a week), difficulties passing stools (ie there may be daily bowel movements but associated symptoms such as excessive straining), or a sensation of incomplete emptying or anorectal blockage.

If a diagnosis of constipation is suspected, the following should be considered:

  • any symptoms or signs that may suggest a serious underlying cause, such as colorectal cancer
  • the person's perception of a normal bowel habit may influence the diagnosis of constipation
  • the duration of constipation, and the frequency and consistency of stools
  • associated symptoms such as rectal discomfort, excessive straining, feeling of incomplete evacuation, rectal bleeding, abdominal pain or distension
  • associated fever, nausea, vomiting, loss of appetite and/or weight
  • associated urinary symptoms, urinary incontinence or retention, dyspareunia
  • any family history of colorectal cancer or

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The management of constipation depends on the primary cause. For example, if the cause of constipation is secondary to drug treatment, a full review of the patient current medications will be needed. Before advising on constipation, it is essential that a full clinical history, physical assessment, sign and symptoms, drugs (including over the counter preparations) and diet histories are undertaken. Stress anxiety and depression should also be considered.

Furthermore, the management of constipation will vary depending on its presentation and clinical scenario:

  • short duration constipation
  • chronic constipation
  • faecal loading and/or impaction
  • constipation in pregnancy and breast feeding

In acute medicine, constipation should no be overlooked. In the critical care setting, the incidence of constipation can occur at 83% and has been associated with an increased length of stay and increased duration of mechanical ventilation (Prat et al 2018). Laxative prophylaxis can be used successfully to prevent constipation in the critically

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When considering treatment for constipation, people can often request over-the-counter preparations or drugs to be prescribed without full consideration of diet and lifestyle measures. The treatments for constipation should always include diet and lifestyle measure, and laxative when appropriate.

Diet and lifestyle measures

Dietary changes should be introduced gradually, and the effect should be seen at least after 4-6 weeks of their implementation.


Eating a healthy balanced diet and having regular meals should not be underestimated. The diet should include whole grains and at least five portions of fruit and vegetables. Fruit that are naturally high in sorbitol are also recommended, these include:

  • apple
  • apricot
  • grapes
  • peaches
  • pears
  • plums
  • raspberry
  • strawberry

As well as dried versions, such as:

  • raisins
  • dry apricot
  • prunes

Dietary fibre is considered to be a material resistant to digestion and absorption in the small intestine with a physiological effect associated

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NMC proficiencies

Nursing and Midwifery Council: standards of proficiency for registered nurses

Part 2: Procedures for the planning, provision and management of person-centred nursing care

6. Use evidence-based, best practice approaches for meeting needs for care and support with bladder and bowel health, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions

6.4 assess bladder and bowel patterns to identify and respond to constipation, diarrhoea and urinary and faecal retention

10.1 observe, and assess the need for intervention for people, families and carers, identify, assess and respond appropriately to uncontrolled symptoms and signs of distress including pain, nausea, thirst, constipation, restlessness, agitation, anxiety and depression

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Aziz I, Whitehead WE, Palsson OS et al. An approach to the diagnosis and management of Rome IV functional disorders of chronic constipation. Expert Rev Gastroenterol Hepatol. 2020;14(1):39-46. https://doi.org/10.1080/17474124.2020.1708718 

Blake MR, Raker JM, Whelan K. Validity and reliability of the Bristol Stool Form Scale in healthy adults and patients with diarrhoea-predominant irritable bowel syndrome. Aliment Pharmacol Ther. 2016;44(7):693-703. https://doi.org/10.1111/apt.13746

Bowel Interest Group. Cost of constipation Report. 2020. https://bowelinterestgroup.co.uk/wp-content/uploads/2020/07/Cost-of-Constipation-2020.pdf (accessed 3 November 2023)

British Dietetic Association. Fibre: food fact sheet. 2021. https://www.bda.uk.com/resource/fibre.html (accessed 3 November 2023)

British National Formulary. Constipation. 2023 https://bnf.nice.org.uk/treatment-summaries/constipation/ (accessed 3 November 2023)

De Giorgio R, Ruggeri E, Stanghellini V et al. Chronic constipation in the elderly: a primer for the gastroenterologist. BMC Gastroenterol. 2015;15:130. https://doi.org/10.1186/s12876-015-0366-3

Masri Y, Abubaker J, Ahmed R. Prophylactic use of laxative for constipation in critically ill patients. Annals of thoracic medicine. 2010;5(4), 228–231. https://doi.org/10.4103/1817-1737.69113

National Institute for Health and Care Excellent. Constipation. 2021. https://cks.nice.org.uk/topics/constipation/

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