The American Society of Colon and Rectal Surgeons has released updated clinical practice guidelines on the evaluation and management of patients with chronic constipation. 

Chronic constipation affects approximately 15% of the global population, with higher prevalence in North America and Europe. Risk factors include age over 65 years, female sex, low-fiber diets, and non-White race.

"The complex etiology and variable severity of constipation symptoms mandate an individualized approach to evaluation and treatment," remarked senior guideline author Ian M. Paquette, MD, of the University of Cincinnati​. 

To develop the updated guidelines, published in Diseases of the Colon & Rectum, the American Society of Colon and Rectal Surgeons (ASCRS) Clinical Practice Guidelines Committee​ reviewed 134 English-language studies published between January 1, 2014, and February 1, 2024, to develop 13 recommendations.

Each recommendation in the updated guidelines was labeled as either "strong" or "conditional," following the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system for assessing the certainty of evidence.

Among the six strong recommendations were:

• A directed history and physical examination should be performed.
• The initial management of symptomatic constipation involves dietary modifications, adequate fluid intake, and fiber supplementation.
• Osmotic laxatives are appropriate first-line medical therapy to manage chronic constipation. Stimulant laxatives such as bisacodyl may be considered for rescue therapy or as second-line treatment if needed.
• Colonic motility and transit should be measured before considering surgical intervention.
• Biofeedback therapy is recommended as first-line treatment in patients with symptomatic pelvic floor dyssynergia.
• Stapled transanal rectal resection (STARR) is not recommended for the repair of rectocele or internal rectal intussusception because of the high complication rates associated with the procedure.

In addition to the strong recommendations, the guidelines include seven conditional recommendations:

• Objective measures assessing the nature and severity of constipation can be useful in evaluating patients.
• Patients who do not improve with dietary changes, fiber therapy, and osmotic laxatives should be evaluated for outlet dysfunction. Anorectal physiology testing or dynamic imaging by fluoroscopic defecography, magnetic resonance imaging defecography, or dynamic ultrasound may help identify functional or structural causes.
• Botulinum toxin injections into the puborectalis and external sphincter muscles may be considered in patients with outlet dysfunction related to a nonrelaxing puborectalis muscle.
• Patients with significant outlet dysfunction from a rectocele may be considered for surgical repair after addressing other functional issues such as a nonrelaxing puborectalis muscle.
• Repair of rectal intussusception may be considered in patients with severe obstructed defecation who have not responded to nonoperative treatments.
• Patients with isolated refractory colonic slow-transit constipation may benefit from total abdominal colectomy with ileorectal anastomosis.
• Fecal diversion may be considered in patients with intractable constipation that has not responded to other treatment options.

"Given the range of specialties that manage constipation, a collaborative approach is often warranted to achieve optimal patient outcomes," concluded the guideline authors.

No conflicts of interest were reported, and no funding was received for the preparation of these guidelines.