Practice Parameters for the Evaluationand Management of Constipation
Charles A. Ternent, M.D., Amir L. Bastawrous, M.D., Nancy A. Morin, M.D.,C. Neal Ellis, M.D., Neil H. Hyman, M.D., W. Donald Buie, M.D., and The StandardsPractice Task Force of The American Society of Colon and Rectal Surgeons
T he American Society of Colon and Rectal methods of care or exclusive of methods of care
Surgeons is dedicated to ensuring high-quality
reasonably directed to obtaining the same results.
patient care by advancing the science, prevention,
The ultimate judgment regarding the propriety of any
and management of disorders and diseases of the
specific procedure must be made by the physician in
colon, rectum, and anus. The Standards Committee is
light of all of the circumstances presented by the
composed of Society members who are chosen
because they have demonstrated expertise in thespecialty of colon and rectal surgery. This Committee
was created to lead international efforts in definingquality care for conditions related to the colon,
An organized search of MEDLINE, PubMed, and
rectum, and anus. This is accompanied by develop-
the Cochrane Database of Collected Reviews was
ing Clinical Practice Guidelines based on the best
performed through October 2006. Key-word combi-
available evidence. These guidelines are inclusive,
nations included constipation, obstructed defecation,
and not prescriptive. Their purpose is to provide
slow transit, surgery, rectocele, rectal intussuception,
information on which decisions can be made, rather
pelvic dyssynergia, anismus, paradoxical puborecta-
than dictate a specific form of treatment. These
lis, and related articles. Directed searches of the
guidelines are intended for the use of all practi-
embedded references from the primary articles also
tioners, health care workers, and patients who desire
were accomplished in selected circumstances.
information about the management of the conditionsaddressed by the topics covered in these guidelines.
It should be recognized that these guidelines
STATEMENT OF THE PROBLEM
should not be deemed inclusive of all proper
Constipation is a symptom-based disorder of unsat-
isfactory defecation that may be associated withinfrequent stools, difficult stool passage, or both
Reprints are not available.
The diagnostic criteria for functional constipation
Correspondence to: Neil H. Hyman, M.D., Fletcher Allen Health
according to the Rome III consensus include two or
Care, 111 Colchester Avenue, Fletcher 301, Burlington, Vermont05401.
more of the following symptoms: straining, lumpy or
Dis Colon Rectum 2007; 50: 2013–2022
hard stools, sensation of incomplete evacuation, sen-
sation of anorectal obstruction, and manual maneuvers
* The American Society of Colon and Rectal SurgeonsPublished online: 31 July 2007
to facilitate defecation more than 25 percent of the
Dis Colon Rectum, December 2007
time, and less than three unassisted defecations per
hemochezia, weight loss of more than 10 pounds,
week. These symptoms need to be present for at least
family history of colon cancer or inflammatory bowel
three days per month during the previous three months
disease, anemia, change in bowel habits or blood in
with symptom onset at least six months before
the stool, which suggest the need for more aggres-
diagnosis.Loose stools must be rarely present without
sive endoscopic and/or radiologic evaluation.An
the use of laxatives, and there must be insufficient
adequate history may help to identify factors associ-
criteria for irritable bowel syndrome The
ated with constipation, such as immobility, psychiat-
symptoms of chronic constipation frequently overlap
ric illness, contributing medications, endocrine
with constipation-predominant IBThe Rome III
etiologies, such as diabetes and hypothyroidism,
diagnostic criteria for IBS include abdominal pain or
previous pelvic surgery, or symptoms consistent with
discomfort at least three days per month in the
constipation-predominant irritable bowel syndrome
previous three months (symptom onset more than 3
(IBS)–The history may suggest the presence of
months before diagnosis) with two or more features:
obstructed defecation if there is straining with bowel
improvement with defecation, onset associated with a
movements, incomplete evacuation, sensation of
change in frequency of stool and/or change in the
obstructed defecation, and the use of manual maneu-
form of stoSubclassification into constipation-
vers to aid defecation.Nevertheless, symptoms
predominant IBS (IBS-C) based on the Rome III
alone may not reliably distinguish slow-transit con-
criteria also requires the presence of Bristol Stool
stipation from anorectal dysfunction.
Form Scale Types 1 and 2.The numerous possible
A physical examination, including digital rectal
disorders leading to constipation argue for individu-
examination, plus the selective use of anoscopy and
alized evaluation and management according to the
proctosigmoidoscopy may identify the presence of
nature, extent, and chronicity of this common
fecal impaction, stricture, external or internal rectal
prolapse, rectocele, paradoxical or nonrelaxing pubo-rectalis activity, or a rectal mas
EVALUATION OF CONSTIPATION
2. The routine use of blood tests, x-ray studies, or
endoscopy in patients with constipation withoutalarm symptoms is not indicated. Level of Evidence:
1. A problem-specific history and physical exam-
Class V; Grade of Recommendation: D.
ination should be performed in patients with consti-
Evidence to support the routine use of blood tests,
pation. Level of Evidence: Class IV; Grade of
radiography, or endoscopy in the routine evaluation
of patients with constipation without alarm features
A history and physical examination may identify
is lacking.Nevertheless, endoscopic evaluation of
the presence of Balarm symptoms and signs, such as
the colon is justified for patients who meet criteria for
LEVELS OF EVIDENCE AND GRADE RECOMMENDATION
Source of Evidence
Meta-analysis of multiple well-designed, controlled studies, randomized trials with low-false positive and
low-false negative errors (high power)
At least one well-designed experimental study; randomized trials with high false-positive or high false-negative
errors or both (low power)
Well-designed, quasi-experimental studies, such as nonrandomized, controlled, single-group, preoperative–
postoperative comparison, cohort, time, or matched case-control series
Well-designed, nonexperimental studies, such as comparative and correlational descriptive and case studies
Case reports and clinical examples
Grade of Recommendation
Evidence of Type I or consistent findings from multiple studies of Type II, III, or IV
Evidence of Type II, III, or IV and generally consistent findings
Evidence of Type II, III, or IV but inconsistent findings
Little or no systematic empirical evidence
Adapted from Cook DJ, Guyatt GH, Laupacis A, Sackett DL. Rules of evidence and clinical recommendations on the
use of antithrombotic agents. Chest 1992;102(4 Suppl):305S-311S. Sackett DL. Rules of evidence and clinicalrecommendations on the use of antithrombotic agents. Chest 1989;92(2 Suppl):2S-4S.
PRACTICE PARAMETERS FOR CONSTIPATION
screening colonoscopy or those with alarm fea-
small-bowel function and functional results after total
tures.Furthermore, blood tests may be helpful to
abdominal colectomy for colonic inertiaHowever, a
rule out hypercalcemia and/or hypothyroidism.
long-term, prospective study did suggest that patients
3. Anorectal physiology and colon transit time
with generalized gastrointestinal disorder (GID) have a
investigations may help to identify the underlying
diminished long-term success rate after colectomy (13
etiology and improve the outcome in patients with
percent GID vs. 90 percent no GID)Similarly, a high
refractory constipation. Level of Evidence: Class III;
postoperative morbidity from recurrent small-bowel
Grade of Recommendation: B.
obstructions (70 percent) exists in patients with GID
A review of 31 studies of colectomy for constipation
found that preoperative physiologic tests, including at
least anorectal manometry, defecography, and transit
study, resulted in a median satisfaction rate of 89percent compared with 80 percent for an incompletephysiologic evaluatioStudies in which slow co-
1. The initial management of symptomatic consti-
lonic transit had been documented before colectomy
pation is typically dietary modification, including a
for refractory constipation also reported an improved
high-fiber diet and fluid supplementation. Level of
rate of good outcomes (90 vs. 67 percent)
Evidence: Class II; Grade of Recommendation: B.
The balloon expulsion test is a simple screening
Conservative measures should be attempted before
procedure to exclude pelvic floor dyssynergia (PFD),
surgical intervention for Empiric treat-
because symptoms alone may not be enough to
ment for constipation with a high-fiber diet seems to
distinguish between slow-transit constipation and
be an inexpensive and effective therapeutic interven-
outlet obstructioA prospective study of balloon
tion for addressing constipation-related bowel dys-
expulsion in patients with constipation found a spec-
The daily intake of 25 g of fiber per day
ificity and negative predictive value for excluding PFD
has been shown to increase the stool frequency in
of 89 and 97 percent, respectively. A nonpathologic
patients with chronic constipation. Furthermore, in-
balloon expulsion test may avoid the use of other
creasing fluid intake to 1.5 to 2 liters per day has been
pelvic floor investigations, such as anorectal manome-
shown in a randomized, clinical trial of chronic
try, surface EMG studies, and defecography
constipation to increase stool frequency and decrease
Anorectal manometry and surface anal electromyog-
the need for laxative in individuals already consuming
raphy may help to confirm pelvic floor dyssynergia or
a high-fiber Increased physical activity also
anismus.The presence of Hirschprung_s disease also
seems to be helpful.
can be suggested by anorectal manometry when the
2. The use of polyethylene glycol, tegaserod, and
rectoanal inhibitory reflex is absenDefecography is
lubiprostone for the management of chronic consti-
probably the most useful diagnostic technique for
pation is appropriate when dietary management is
identifying internal rectal intussuception. In the setting
inadequate. Level of Evidence: Class II; Grade of
of obstructed defecation, defecography may help to
detect structural causes, such as intussuception, rec-
Polyethylene glycol (PEG) can be used to promote
tocele with retained stool, pelvic dyssynergia, and
bowel function in patients with chronic constipation.
extent of rectal emptying. Defecography has been
A randomized, clinical trial found that daily therapy
shown to have good interobserver agreement for
with 17 g of PEG laxative for 14 days resulted in
enterocele and rectocele and fair-to-moderate inter-
significant improvement of bowel movement fre-
observer agreement for intussuception and anismus
quency in patients with constipation compared with
The measurement of colon transit time using radi-
placebo at two weeksProkinetic agents, such as
opaque markers in patients with suspected slow-transit
the 5-HT4 receptor partial agonist tegaserod maleate,
constipation is inexpensive, simple, and safe. There are
can be used for treatment of constipation-predominant
different methodologies that produce similar
IBS. Seven short-term, placebo-controlled studies ful-
results,–including the use of radioisotope
filled the inclusion criteria for the Cochrane review in
markers.The interpretation of colon transit stud-
patients with constipation-predominant IBS. Tegaserod
ies may be facilitated by knowledge of the status of
improved the number of bowel movements and days
the pelvic floor in the patient with constipation.
without bowel movements compared with placebo.
Some studies have not found a relationship between
Another systematic review found good evidence to
Dis Colon Rectum, December 2007
support the use of PEG and tegaserod for the treatment
taking laxatives and 174 patients taking placebo. The
of constipation.Furthermore, clinical outcome anal-
treatment group was noted to have a mean increase
ysis of a single-blind, randomized, multicenter trial of
of 0.9 stools per week and a mean increase in stool
the treatment of idiopathic constipation during three
weight of 42 g, but these findings were not different
months with PEG or lactulose showed that signifi-
than the placebo effect at a four-week duration.
cantly more patients were successfully treated with
Furthermore, long-term laxative usage can result in
PEG than lactulose (53 vs. 24 percent) with overall
the development of cathartic colon.
decreased total management costs
Lubiprostone (Amitiza) is an oral bicyclic fatty acid
that selectively activates Type 2 chloride channels in the
INDICATIONS FOR SURGERY
apical membrane of the gastrointestinal epithelium,
resulting in increased fluid secretion. Two randomized,double-blind, multicenter, Phase III studies in patientswith chronic idiopathic constipation have shown that
1. Patients with refractory slow-transit constipation
the frequency of spontaneous bowel movements
may benefit from total abdominal colectomy with
(SBMs) was significantly greater in patients receiving
ileorectal anastomosis (TAC-IRA). Level of Evidence:
lubiprostone 24 mg twice per day than in those receiving
Class III; Grade of Recommendation: B.
placebo at each weekly time point throughout both
Clinical improvement with total abdominal colectomy
four-week studies (P < 0.05). One study found that the
with ileorectal anastomosis (TAC-IRA) is reported in 50
mean frequency of SBMs in the lubiprostone group
to 100 percent of patients with slow-transit constipation
was five per week compared with four per week in the
The results of segmental colon resection for
placebo group after seven days (P < 0.0001). Signifi-
colonic inertia have been disappointing with some small
cantly greater improvements occurred with lubipro-
series reporting up to a 100 percent failure rate
stone than placebo in the degree of straining, stool
Similarly, the antegrade colonic enema (ACE) proce-
consistency, and constipation severity in both studies
dure has been described for treatment of intractable
at all time intervals up to four weeks (P < 0.05)
constipation. Nevertheless, studies have shown a 33
3. The use of psyllium supplements and lactulose
percent conversion rate to TAC-IRA with associated
for the treatment of chronic constipation is appropri-
stoma complications, wound infection, pain, and
ate. Level of Evidence: Class II; Grade of Recommen-
psychologic problems in aduTAC-IRA has been
reported to have an 8 to 33 percent morbidity from
A systematic review of the literature found that
recurrent bowel obstruction and can be associated with
psyllium and lactulose improved symptoms of consti-
diarrhea, incontinence, and recurrence of constipa-
pation.A prospective, nonrandomized trial studied
Patients should be counseled that the abdominal
224 patients with simple constipation who were treated
pain and bloating may persist postoperatively even after
with ispaghula husk and 170 patients who were treated
normalization of bowel frequency.A retrospective
with other laxatives, mostly lactulose, for up to four
study of 55 patients after TAC-IRA for colonic inertia with
weeks. The husk-treated group produced a higher
normal anal manometry identified prolonged postoper-
percentage of normal, well-formed stools and fewer
ative ileus in 24 percent of cases. Good to excellent
hard stools than other laxatives. The husk was found to
results were reported in 89 percent of patients and poor
be an effective treatment for simple constipation with
results in 11 percent. Postoperative stool frequency was 5,
better stool consistency and lower adverse events
4, and 3 per day at 1, 2, and 12 months, respectiv
compared with lactulose or other laxatives
TAC-IRA is recommended for carefully selected
4. The use of common agents, such as milk of
patients with severe documented colonic inertia and no
magnesia, senna, bisacodyl, and stool softeners, for
evidence of severe or correctable pelvic floor dysfunction
chronic constipation is reasonable. Level of Evi-
after nonoperative treatments have failed.
dence: Class III; Grade of Recommendation: C.
Although constipation is generally relieved after TAC-
Various laxatives may be used for chronic consti-
IRA, studies have shown that, postoperatively, 41 percent
pation but there are inconsistent results in the
of patients are affected with abdominal pain, 65 percent
literature. A meta-analysisfound 11 large, well-
with bloating, 29 percent require assistance with bowel
controlled, published studies regarding the efficacy
movements, 47 percent have some incontinence to gas
of laxatives in constipation. There were 375 patients
or liquid stooand 46 percent may be affected with
PRACTICE PARAMETERS FOR CONSTIPATION
Postoperative quality of life assessment after
with laxatives. These results of biofeedback were
TAC-IRA showed significantly decreased scores com-
sustained at 12 and 24 months along with reductions
pared with those of the general Neverthe-
in straining, sensations of incomplete evacuations,
less, 93 percent of carefully selected patients with TAC
blockage, use of enemas and suppositories, and
would undergo colectomy again for STC given the
abdominal pain. Biofeedback patients reporting the
chanceAn ileostomy is an alternative consideration
major improvement in symptomatology were able to
in many of these patients.
relax the pelvic floor and evacuate a 50-ml balloon at
2. Refractory slow-transit constipation associated
6-month and 12-month follow-up. Therefore, biofeed-
with concomitant pelvic outlet obstruction may benefit
back seems to be the treatment of choice for PFD
from correction of the pelvic floor dysfunction and totalabdominal colectomy with ileorectal anastomosis. Levelof Evidence: Class III; Grade of Recommendation: B.
Studies of colectomy for refractory constipation have
OF OBSTRUCTED DEFECATION
demonstrated successful outcomes for TAC-IRA in 89 to
100 percent after preoperative workup, including colontransit study, defecography, and anorectal physiology
Indications for rectocele repair vary but generally
investigation.A thorough preoperative workup may
include relief of the outlet obstruction symptoms
help to exclude patients with constipation-predominant
with manual support of the vaginal wall or rectum
IBS or normal-transit constipation who will be unlikely to
and lack of rectocele emptying on defecography.
benefit from surgical intervention. Furthermore, patients
Although controversial, some propose that rectoceles
with combined STC and outlet obstruction pathology
should be > 4 cm in size to warrant repa
may be offered individualized management.–
1. Surgical repair of a rectocele may appropriately
STC and associated pelvic floor dyssynergia can be
be performed via a transvaginal approach. Level of
treated with biofeedback and TAC-IRA, although this
Evidence: Class III; Grade of Recommendation: C.
group has been shown to have a higher rate of recurrent
The traditional technique for transvaginal rectocele
defecatory problems and lower satisfaction rates after
repair is a nonanatomic, longitudinal plication of the
colectSTC with rectal intussuception and/or non-
rectovaginal fascia with the repair continuing onto the
emptying rectocele/enterocele can be treated with TAC-
perineal body in which any injuries to the puborectalis
IRA after repair of the anatomic cause of the outlet
and perineal muscles also are addressed.This
technique is reported to be successful in preventingvaginal bulging in 80 percent and corrects the need for
MANAGEMENT OF PELVIC FLOOR
digital assistance of defecation in 67 percent of
patientsLess favorable clinical results have beenreported with a failure to relieve evacuatory difficultyor lower rectal symptoms in 33 percent of patients.
1. Biofeedback therapy is appropriately recom-
Postoperative dyspareunia will occur in 25 percent of
mended for treatment of symptomatic pelvic floor
patients and at least 10 percent may recur and require
dyssynergia. Level of Evidence: Class II; Grade of
reoperation; 36 percent will report a problem with fecal
incontinence–A prospective study of rectocele
The success rates of biofeedback for the treatment
repair using xenograft has been reported.Although
of PFD are reported to be 35 to 90 percentA
significant decreases in rectal emptying difficulties
recent, randomized, clinical trial of individuals with
were noted, cure of the rectal emptying difficulties
chronic severe PFD who had failed management
was reported by less than half of the patients at the
with 20 g per day of fiber plus enemas or suppos-
itories up to twice per week were randomized into
Recently, the concept of an anatomic Bdefect
five weekly biofeedback sessions (n = 54) or PEG
specific transvaginal rectocele repair has been de-
14.6 to 29.2 g per day plus five weekly sessions in
scribed. In this technique, the defect in the rectovagi-
constipation prevention. Stool frequency increased in
nal fascial defect is closed transversely. During the
both groups. However, at six months major improve-
short-term, results with this technique seem encour-
ment was reported in the biofeedback group in 80
aging with the symptom of constipation improved in
percent compared with 22 percent of patients treated
more than 80 percent of patients and a low incidence
Dis Colon Rectum, December 2007
of recurrent clinical rectocele or postoperative need
recommended in combination with a conventional
for digital assistance of defecation.A pilot study
sphincteroplasty and/or levatorplasty for the man-
of 30 randomized patients comparing transvaginal to
agement of patients with a symptomatic rectocele
transrectal rectocele repair found that symptoms of
and incontinence secondary to a sphincter defect.
outlet obstruction were significantly alleviated by both
Short-term results of this combined procedure show
approaches (93 percent in the vaginal group and 73
an improvement in evacuation and continence in 75
percent in the transrectal group), but the transvaginal
percent of patients.The transperineal insertion of a
technique had less recurrent rectoceles than the
prosthetic mesh has been described with a significant
transrectal approach (7 vs. 40 percent)None of the
reduction in the need for digital assistance of
patients developed postoperative de novo dyspareunia
defecation and in the size and amount of barium
in this study; however, the sample size was smal
retained in rectoceles.Controlled clinical trials of
2. Surgical repair of a rectocele may appropriately
this technique need to be performed before the role
be performed via a transrectal approach. Level of
of this procedure in the management of rectoceles
Evidence: Class II; Grade of Recommendation: B.
can be determined.
Although transrectal repairs of rectoceles were
4. The role of transrectal stapled repair of recto-
described in the mid 1960s, the suboptimal results
celes and rectal intussuception is uncertain. Level of
in terms of bowel and sexual function of the trans-
Evidence: Class III; Grade of Recommendation: D.
vaginal repairs led to the rediscovery and popularity
The repair of rectoceles and internal intussucep-
of these techniques in the 1980s.Another benefit
tion using endoanal staplers has been reported and
of transanal repair is the ability to address the
continues to be investigated. Initial results with the
coexistent anorectal pathology that will be present
stapled rectocele repair are encouraging in terms of
in up to 80 percent of patients.
evacuatory improvement, but currently there are no
The transrectal, anatomic, defect-specific rectocele
studies comparing it to other methods, nor are long-
repair involves the transverse closure of the rectocele
term outcomes kno–There are reports of
by an interrupted plication of the muscularis anteri-
postoperative bleeding, pain, incontinence, consti-
orly as in a Delorme procedure for rectal prolapse.
pation, and rectovaginal fistula using this tech-
This method results in a relative foreshortening of the
anal canal with diminished internal sphincter func-
5. Surgical repair for rectal intussusception associ-
tion and resting anal pressures leading some to
ated with severe, intractable symptoms of obstructed
conclude that this procedure is contraindicated in
defecation may be considered as a last resort. Level
patients with combined fecal incontinence and
of Evidence: Class III; Grade of Recommendation: C.
A study evaluating the Ivalon rectopexy for
An alternative is a nonanatomic technique in
treatment of rectal intussuception and outlet obstruc-
which the defect is repaired longitudinally by
tion failed to cure defecatory difficulties. Rectopexy
approximating the musculofascial edges of the
was recommended for intussuception associated
defect. This repair tends to be under tension but
with ulcer and bleeding but not for those with
does lengthen the anal canal, which may address the
obstructed defecation symptoms.The Delorme
potential for worsening of fecal incontinence with
repair has been reported in 21 patients with intussu-
the anatomic repair.
ception and outlet obstruction with improvement of
The results with either of these techniques are
symptoms in 71 percent and no recurrent intussu-
comparable with evacuatory difficulty improved in 47
ception.The Wells rectopexy has been reported to
to 84 percent, correction of the need for digital
result in defecographic resolution of the intussucep-
assistance of defecation in 54 to 100 percent, and
tion in 92 percent, but complete symptomatic relief
decreased constipation in 48 to 71 percent. Most of
was rareA study of rectopexy for treatment of
the variations in results seem to be related to
internal intussuception resulted in 70 percent resolu-
differences in patient selection and criteria for
tion of symptoms and healing of all rectal ulcers
evaluating the outcomes.
The Ripstein procedure was shown to achieve
3. The role of transperineal techniques or the use of
complete resolution of symptoms in 20 percent,
prosthetic mesh for rectocele repair is uncertain. Level
partial resolution of outlet obstruction symptoms in
of Evidence: Class III; Grade of Recommendation: D.
32 percent, and no improvement or worsening
Transperineal surgery for rectoceles has been
PRACTICE PARAMETERS FOR CONSTIPATION
Based on these case series, surgical management
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Clarification of hypertension – Diagnosis of primary hyperaldosteronism Marc Beineke The significance of the aldosterone/renin ratio (ARR) in the diagnosis of normo- alaemic and hypokalaemic primary hyper- aldosteronism, the most common causes of secondary hypertension Epidemiology of primary
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