Constipation can be defined as “a symptom-based disorder which describes defecation that is unsatisfactory because of infrequent stools, difficulty passing stools, or the sensation of incomplete emptying.”

Management

• Advice to reduce or stop any medication that may be causing or contributing to symptoms such as codeine-containing medicines.

• Advice on contributing lifestyle factors such as dietary fibre, fluid intake and physical activity.

• Offering drug treatment with oral laxatives using a stepped approach. Bulk-forming laxatives are used as first-line treatment then an osmotic or stool-softening laxative. Following this, a stimulant laxative may then be added.

• SAFETY NET: Most laxatives work within 3 days and should only be used for a short-time.

Lifestyle advice

• Diet: Eat a healthy, balanced diets including fruits containing sorbitol e.g., apples, grapes, raisins, apricots, raspberries and strawberries. Gradually increase dietary fibre by adding wheat bran or oats, for example.

• Fluid intake: Drink plenty of water and other fluids and avoid alcohol.

• Toilet routine: Give plenty of time to go to the toilet and don’t delay the urge to go to the toilet.

• Physical activity: Increasing your daily physical activity can help with going to the toilet more regularly.

Red Flags

A patient should be referred if they present in the pharmacy with any of the following symptoms.

Same day referral:

• Patients over 40 years old with a marked change in bowel habits with no obvious cause - suspect rectal carcinoma.

Refer as soon as practicable:

• Longer than 14 days duration with no identifiable cause.

• Tiredness - check for anaemic or thyroid dysfunction.

• Pain on defecation that might cause the patient to suppress the defecation reflex - check for anal fissure

Bulk-forming laxatives

Examples: ispaghula husk (Fybogel)

Mechanism of action: These laxatives absorb liquid in the intestines and swell to form a soft, bulky stool. The bowel is stimulated normally due to the presence of a bulky mass.

Osmotic laxatives

Examples: lactulose, macrogol (Movicol, Laxido, CosmoCol, Molaxole)

Mechanism of action: These laxatives draw water into the bowel from the rest of the body to soften the stool and make it easier to pass.

Stool-softening laxatives

Examples: docusate

Mechanism of action: These laxatives work in a similar way to osmotic laxatives by increasing the water absorbed by the stool. This makes it softer and easier to pass.

Stimulant laxatives

Examples: bisacodyl, senna

Mechanism of action: These laxatives cause peristalsis by stimulating colonic nerves (senna) or colonic and rectal nerves (bisacodyl.)

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