Cited by 655Gastrointestinal motility and disordersPelvic floor disorders treatmentsCongenital gastrointestinal and neural anomalies

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Mechanisms, Evaluation, and Management of Chronic Constipation

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Bharucha, Adil E., Lacy, Brian E.·2020·Gastroenterology

DOI 10.1053/j.gastro.2019.12.034PMC PMC7573977

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Abstract

With a worldwide prevalence of 15%, chronic constipation is one of the most frequent gastrointestinal diagnoses made in ambulatory medicine clinics, and is a common source cause for referrals to gastroenterologists and colorectal surgeons in the United States. Symptoms vary among patients; straining, incomplete evacuation, and a sense of anorectal blockage are just as important as decreased stool frequency. Chronic constipation is either a primary disorder (such as normal transit, slow transit, or defecatory disorders) or a secondary one (due to medications or, in rare cases, anatomic alterations). Colonic sensorimotor disturbances and pelvic floor dysfunction (such as defecatory disorders) are the most widely recognized pathogenic mechanisms. Guided by efficacy and cost, management of constipation should begin with dietary fiber supplementation and stimulant and/or osmotic laxatives, as appropriate, followed, if necessary, by intestinal secretagogues and/or prokinetic agents. Peripherally acting μ-opiate antagonists are another option for opioid-induced constipation. Anorectal tests to evaluate for defecatory disorders should be performed in patients who do not respond to over-the-counter agents. Colonic transit, followed if necessary with assessment of colonic motility with manometry and/or a barostat, can identify colonic dysmotility. Defecatory disorders often respond to biofeedback therapy. For specific patients, slow-transit constipation may necessitate a colectomy. No studies have compared inexpensive laxatives with newer drugs with different mechanisms. We review the mechanisms, evaluation, and management of chronic constipation. We discuss the importance of meticulous analyses of patient history and physical examination, advantages and disadvantages of diagnostic testing, guidance for individualized treatment, and management of medically refractory patients.

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Age-stratified diagnostic value of high-resolution anorectal manometry in women with severe rectocele: interactions between anal relaxation rate and maximum anal resting pressure
Geng, H. Z., Lin, X., Xu, C., Cong, J., Zhang, Z., & Li, Y. (2025) · International Journal of Colorectal Disease · doi:10.1007/s00384-025-04963-1 · Cited by 2
“Defecography remains the gold standard for structural evaluation [6, 7], while three-dimensional (3D) high-resolution anorectal manometry (HR-ARM) offers detailed functional assessments.”
Icariside II ameliorates slow transit constipation by inhibiting macrophage polarization and suppressing the cGAS-STING pathway
Jiang, Z., Yin, F., Ping, Y., Ma, W., Dou, X., Li, R., Zheng, K., Tong, Y., Han, L., Fu, L., et al. (2025) · European Journal of Pharmacology · doi:10.1016/j.ejphar.2025.178166 · Cited by 2
Analyzing the causal relationship between gut microbiota, metabolites, and constipation: A Mendelian randomization study
He, M., Wang, S., Zhang, J., & Yong, Z. (2025) · Medicine · doi:10.1097/md.0000000000044542 · Cited by 2
“[2] A review of the literature indicates that the prevalence of constipation among adults is 15.3% based on the Roman standard, with a higher prevalence in women than in men.”
Influential
Constipation and Incident Cardiovascular Disease
Iwasaki, K., Ejiri, K., Kaneko, H., Suzuki, Y., Miyoshi, T., Taya, S., Masuda, T., Takaya, Y., Akagi, S., Okada, A., et al. (2025) · JACC Asia · doi:10.1016/j.jacasi.2025.07.027 · Cited by 2
Irritable Bowel Syndrome in Inflammatory Bowel Disease: An Evidence-Based Practical Review
Butt, M. F., Reghefaoui, M. H., Benedict, A. S., Reghefaoui, M., Al-Jabir, H. M., Shaikh, A., Vojtekova, K., Moran, G. W., Corsetti, M., & Aziz, Q. (2025) · Journal of Clinical Medicine · doi:10.3390/jcm15010116 · Cited by 3
“Defecatory disorders are defined as difficulty in evacuating stool from the rectum in patients with chronic or recurring symptoms of constipation [126–128].”
Bifidobacterium breve and lacto-N-neotetraose mediate gut microbiota-derived acetate to regulate defecation performance and intestinal barrier function in constipated mice
Shan, Y., Liu, X., Ma, W., Qu, Y., & Bian, C. (2026) · Journal of Dairy Science · doi:10.3168/jds.2025-27163 · Cited by 2
l -Arabinose attenuates loperamide-induced constipation through the regulation of gut microbiota in mice
Zheng, S., Zheng, H., Huang, Y., Liang, B., Gong, Y., Shen, J., Liu, W., Xu, X., Ma, Y., Liu, Z., et al. (2026) · Food & Function · doi:10.1039/d4fo03554b · Cited by 2
Mitochondrial fusion targeted supramolecular peptide hydrogel for gut neuroprotection
Sun, W., Han, L., Bi, Y., Yin, F., Li, R., Tong, Y., Zhang, J., Ding, D., & Sun, D. (2026) · Biomaterials · doi:10.1016/j.biomaterials.2026.124061 · Cited by 2
Dietary strategies for chronic constipation: smartly targeting hormonal and reflex pathways for optimal recovery
Ribichini, E., Scalese, G., Mocci, C., Amicis, N. D., & Severi, C. (2026) · Frontiers in Pharmacology · doi:10.3389/fphar.2026.1738562 · Cited by 2
Rothia mucilaginosa alleviates constipation through gut microbiota remodeling and neuroactive pathway activation
Jiang, P., Yang, X., 张城浩, Guo, Z., Li, Y., & Xu, C. (2026) · BMC Microbiology · doi:10.1186/s12866-026-05126-0 · Cited by 2
“With a world-wide prevalence of 15%, chronic constipation is one of the most frequent gastrointestinal diagnoses made in ambulatory medicine clinics [1, 2].”
Effects of a Supervised Telerehabilitation‐Based Exercise Program on Constipation Symptoms and Quality of Life in Adults With Chronic Constipation: A Randomized Controlled Trial
Can, Ö. F., Şavkın, R., & Kutluana, U. (2026) · Neurogastroenterology & Motility · doi:10.1111/nmo.70354 · Cited by 2
“Defecation depends on coordinated abdominal wall activation, pelvic floor relaxation, anorectal opening, and effective generation of intra-abdominal pressure; disruption of abdominal–pelvic coordination is particularly relevant in defecatory disorders [23, 26].”
Microbiota–immune–enteric nervous system interactions in functional constipation: a narrative review and hypothesis-generating framework
Ge, D., Zhan, Y., Wen, Y., Wu, R., Xu, Q., Ao, Z., Shu, Y., & Tang, X. (2026) · Frontiers in Immunology · doi:10.3389/fimmu.2026.1851825 · Cited by 2
Physiotherapy management of anorectal dysfunction
Igualada‐Martinez, P., Breslin, E., Higgins, D., & Hainsworth, A. J. (2022) · Seminars in Colon and Rectal Surgery · doi:10.1016/j.scrs.2022.100936 · Cited by 2
Straining to void at preoperative urodynamic study as a risk factor for prolapse recurrence after surgery
Mancarella, M., Pautasso, S., Novara, L., Piat, F. C., Testa, F., Arrunategui, V. G., Sgrò, L. G., & Biglia, N. (2023) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2023.02.001 · Cited by 2
Chronic constipation with associated comorbid conditions: a physician survey on clinical perspectives on its diagnosis and management
Kumar, R., Ramakrishnan, S. R., & Kulkarni, A. (2023) · International Journal of Advances in Medicine · doi:10.18203/2349-3933.ijam20232834 · Cited by 2
Sodium picosulfate in the clinical practice of a surgeon
Анатольевич, М. И., Владимирович, Л. С., Kozlov, M. P., & Николаевич, П. Н. (2023) · Ambulatornaya khirurgiya = Ambulatory Surgery (Russia) · doi:10.21518/akh2023-016 · Cited by 2
Therapeutic Effect of N-Hexane Extract of Zingiber Officinale (Ginger Oil) on Loperamide Induced Constipation in Wistar Rats
Yongu, A. M., Ogli, S. A., Tersoo, U. G., & Ashiekaa, M. T. (2024) · American Journal of Medical Science and Innovation · doi:10.54536/ajmsi.v3i1.2452 · Cited by 2
Analysis of factors that indicated surgery in 400 patients submitted to a complete diagnostic workup for obstructed defecation syndrome and rectal prolapse using a supervised machine learning algorithm
Marra, A. A., Simonelli, I., Parello, A., Litta, F., Simone, V. D., Campennì, P., & Ratto, C. (2024) · Techniques in Coloproctology · doi:10.1007/s10151-024-02951-1 · Cited by 2
“Likewise, pelvic floor dys-synergia should be immediately detected before considering any surgical treatment because, in that case, a pelvic floor rehabilitation (mainly using a biofeedback approach) could be more successful in terms of ODS symptoms relief [11, 15, 26].”
Prevalence, Bother, and Risk Factors Associated With Occurrence of Pelvic Floor Dysfunctions in Young Women: A Cross-Sectional Survey
Campos, N. C., de Carvalho, G. M., de Santos, R. A., Oliveira, R. D. D. B., de Oliveira, M. M. F., & Figueiredo, E. M. (2024) · Journal of Women s & Pelvic Health Physical Therapy · doi:10.1097/jwh.0000000000000305 · Cited by 2
“20 Moreover, evidence suggests that behavioral habits can influence evacuation mechanics.”
Preclinical pharmacokinetic studies and prediction of human PK profiles for Deg-AZM, a clinical-stage new transgelin agonist
Gu, X., Li, X., Tian, W., Zheng, C., Cai, Y., Xu, X. M., Zhao, C., Liu, H., Sun, Y., Luo, Z., et al. (2024) · Frontiers in Pharmacology · doi:10.3389/fphar.2024.1423175 · Cited by 2
No bidirectional relationship between constipation and colorectal cancer in European and Asian populations: A Mendelian randomization study
Aierken, A., Aizezi, Y., Atabieke, F., Rehaman, M., Aierken, M., & Li, S.-X. (2024) · Medicine · doi:10.1097/md.0000000000040206 · Cited by 2
“[5] .”
Overall and Regional Colonic Transit Abnormalities in Elderly Patients with Constipation
Yang, D. Y., Lupianez‐Merly, C., Jencks, K. J., Burton, D. D., Ryks, M. D., & Camilleri, M. (2025) · Digestive Diseases and Sciences · doi:10.1007/s10620-024-08833-8 · Cited by 2
The impact of sugar-sweetened beverages consumption on constipation: evidence from NHANES
Zhang, X., Liu, M., Wang, Y., Zheng, Y., & Zhou, Y. (2025) · BMC Public Health · doi:10.1186/s12889-025-22265-7 · Cited by 3
“It is defined by three criteria: defecation frequency, stool consistency, and defecation difficulty [3, 4], with constipation specifically indicated by fewer than three bowel movements per week.”
Drug Survival of Drugs Recommended for Irritable Bowel Syndrome: A Retrospective Observational Study
Sandberg‐Janzon, A., & Karling, P. (2025) · Neurogastroenterology & Motility · doi:10.1111/nmo.70063 · Cited by 2
Constipation in a Large Online Cohort of Persons with Parkinson's Disease
Bharucha, A. E., Ghafouri, M., Varma, R., Vierkant, R. A., Rehman, M. A., Bailey, K. R., Bower, J. H., & Savica, R. (2025) · Movement Disorders Clinical Practice · doi:10.1002/mdc3.70168 · Cited by 2
“25 These ﬁ ndings suggest that, of the diseases associated with constipation, the prevalence is arguably among the highest in PD. 25 The proportion of women was greater in PwPD with than without constipation.”
InfluentialSelf-citation
Integrating anorectal manometry, balloon expulsion, and defecography: insights into diagnosing pelvic floor dysfunction
Zoabi, N., Zelikovich, D., Kanani, F., Ram, E., Issa, A., & Carter, D. (2025) · American Journal of Physiology-Gastrointestinal and Liver Physiology · doi:10.1152/ajpgi.00100.2025 · Cited by 2
Evaluating transanal irrigation for alleviating symptoms of low anterior resection syndrome post rectal cancer surgery: A meta-analysis
Wang, T.-K., Chen, C.-H., Kang, Y., Chen, K., & Chen, K. (2025) · Surgery · doi:10.1016/j.surg.2025.109532 · Cited by 2
Effects and mechanisms of nuciferine on constipation through regulation of the SCF/c-Kit/NF-κB/TLR4 signaling pathway in STC model mice
Zikela, L., Li, X., Zhou, H., Xu, H., Zhu, H., Yu, Z., Wang, D., Gao, J., Ma, Z., Gao, Y., et al. (2025) · The Journal of Nutritional Biochemistry · doi:10.1016/j.jnutbio.2025.110045 · Cited by 2
Regulation of a delicate problem in patients with rectal diseases
Skvortsov, V. V., Еременко, А. А., & Eremenko, N. V. (2022) · Ambulatornaya khirurgiya = Ambulatory Surgery (Russia) · doi:10.21518/1995-1477-2022-19-1-81-88 · Cited by 2
Effectiveness and safety of light vegetarian diet and Qingjiang Tiaochang Recipe for functional constipation
Liu, X., Liu, Y., Chen, J., Wang, H., Wang, Q., Niu, Z., Yun, Z., Ma, B.-Z., & Yao, S. (2020) · Medicine · doi:10.1097/md.0000000000021363 · Cited by 2
“The incidence of constipation in the world is about 15%,([1,2]) In China, the prevalence rate varied from 6% to 13% from 2010 to 2016,([3]) and the prevalence rate of constipation among the elderly in Beijing was 13%.”
Background
Constipación crónica. Conceptos actuales desde la fisiopatología hasta el tratamiento
García‐Zermeño, K. R. (2021) · Acta gastroenteorológica latinoamericana/Acta gastroenterológica latinoamericana · doi:10.52787/zrrj9030 · Cited by 4
Chronische Obstipation – Definition, Diagnostik und Therapie
Peros, G., & Gingert, C. (2022) · coloproctology · doi:10.1007/s00053-022-00613-0 · Cited by 2
Disinergia defecatoria
Poma, M. C. D. Z., & Miranda, C. V. A. (2022) · Interciencia médica · doi:10.56838/icmed.v12i4.116 · Cited by 2
Organ Systems
Smith, F. (2022) · Springer eBooks · doi:10.1007/978-3-031-13388-6_8 · Cited by 2
Are There Sex Differences in Defecation Patterns in Patients with Defecation Disorders? - A Single-center Observational Study
Abe, T., Kunimoto, M., Hachiro, Y., Ota, S., Ohara, K., Inagaki, M., & Murakami, M. (2023) · Journal of the Anus Rectum and Colon · doi:10.23922/jarc.2022-078 · Cited by 2
“However, if patients do not respond to these treatments, specific tests should be considered to evaluate the pathophysiology of their constipation[2].”
BackgroundInfluential
Green and gold kiwifruit powders consumed for 28 days by healthy individuals with occasional constipation are safe and well-tolerated: A randomized controlled trial
Lewis, E. D., Crowley, D. C., Trivedi, R., Wolever, T. M. S., Buggia, M., Graham, E., McKeen, S., Gu, J. L., Rosendale, D., & Evans, M. (2023) · Bioactive Carbohydrates and Dietary Fibre · doi:10.1016/j.bcdf.2023.100382 · Cited by 2
A Novel Vibrating Capsule Treatment for Constipation: A Review of the Literature
Uwawah, T. D., Nduma, B. N., Nkeonye, S., Kaur, D., & Ekhator, C. (2024) · Cureus · doi:10.7759/cureus.52943 · Cited by 2
“On the other hand, secondary constipation may be due to neurological disorders, primary colonic disorders (such as proctitis and cancer), medications (such as opiates or calcium channel blockers), and metabolic disorders (such as hypercalcemia) [6].”
Background
Analysis of the impact on efficacy of lubiprostone dose reduction to manage adverse events in the treatment of chronic constipation in Japan
Ohbayashi, H., Sato, Y., Kiuchi, M., Nagazumi, A., Kanzo, T., & Kimura, T. (2022) · Expert Review of Gastroenterology & Hepatology · doi:10.1080/17474124.2022.2114455 · Cited by 2
Anorectal diseases
Bharucha, A. E., & Cima, R. R. (2022) · Yamada's Textbook of Gastroenterology · doi:10.1002/9781119600206.ch68 · Cited by 2
Self-citation
Constipation in older people: a clinical review for advanced nurse practitioners
Burton, L., & Mortimore, G. (2022) · Gastrointestinal Nursing · doi:10.12968/gasn.2022.20.2.28 · Cited by 1
Awareness and attitude toward antidepressants in the population of Riyadh, Saudi Arabia
Alsenaidi, Y. I., AlDawas, O., AlFihaid, A., AlZimami, M., AlQahtani, R., & Abdulrahman, K. A. B. (2022) · World Family Medicine Journal/Middle East Journal of Family Medicine · doi:10.5742/mewfm.2022.95251360 · Cited by 1

Authors: Bharucha, A. E., & Lacy, B. E.
Affiliations: Mayo Clinic (US)
Corresponding author: Bharucha, Adil E.
ORCID: Bharucha, Adil E.
Lacy, Brian E.
Venue: Gastroenterology
Publisher: Elsevier BV
Published: 2020-04
Volume: 158
Issue: 5
Pages: 1232-1249.e3
ISSN: 0016-5085 (ISSN-L)
DOI: 10.1053/j.gastro.2019.12.034
PMC: PMC7573977
OpenAlex: W3000300599
Cited by: 655
References: 170
Citations by year: 2026: 108 · 2025: 157 · 2024: 115 · 2023: 99 · 2022: 112 · 2021: 46 · 2020: 17
FWCI: 11.88
Type: journal article
Language: en
Open access: green
www.ncbi.nlm.nih.gov
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/legal/tdmrep-license (tdm)
Locations: Gastroenterology (publishedVersion)
PubMed (publishedVersion)
PubMed Central (acceptedVersion)
Funders: National Institute of Diabetes and Digestive and Kidney Diseases
Topics: Health Sciences › Medicine › Gastroenterology › Gastrointestinal motility and disorders
Health Sciences › Medicine › Urology › Pelvic floor disorders treatments
Health Sciences › Medicine › Surgery › Congenital gastrointestinal and neural anomalies
Keywords: chronic constipation, defecation disorders, slow transit constipation, colonic transit, colonic motility, pelvic floor dysfunction, dietary fiber supplementation, laxatives, prokinetic agents, opioid-induced constipation, biofeedback, anorectal manometry, barostat, colectomy, constipation treatment
MeSH terms: Secretagogues, Chronic Disease, Colon, Constipation, Defecation, Dietary Fiber, Electromyography, Gastrointestinal Motility, Humans, Intestinal Mucosa, Magnetic Resonance Imaging, Manometry, Rectum, Prevalence, Receptors, Opioid, mu, Pelvic Floor, Dietary Supplements, Defecography, Digital Rectal Examination, Laxatives

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Mechanisms, Evaluation, and Management of Chronic Constipation

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