Questionnaire/history: Passage of stools less frequently than the person's normal pattern? Frequency of stools? - < 3 bowel movements per week? Excessive straining? Duration of constipation? Consistency of stools? - Hard/small (pebble-lie)? - Large stools (eg with blockage of toilet)? Nocturnal symptoms? Associated symptoms? - Rectal discomfort? - Feeling of incomplete evacuation? - Rectal bleeding? - Abdominal pain? - Bloating? - Abdominal distension? - Nausea? - Vomiting? - Fever? Urinary symptoms? - Urinary incontinence or retention? Non-specific symptoms in elderly? - Confusion or delirium, functional decline? - Loss of appetite or nausea? - Overflow diarrhoea? - Urinary retention? Faecal loading or impaction? - Hard, lumpy stools? - Large and infrequent passed stools? - Every 7-10 days? - Small and relatively frequent stools (eg every 2-3 days)? - Having to use manual methods to extract faeces? - Overflow faecal incontinence or loose stools? Red flags? - Appetite loss (unexplained)? - Weight loss (unexplained)? - Anaemia? - Abdominal or rectal mass? - Anal mass or anal ulceration (unexplained)? - Deep vein thrombosis? Past medical history? Family history? - Colorectal cancer? - Inflammatory bowel disease? Current medication? - Laxatives? Drug allergies? Examination (if suspected underlying cause): General nutritional status? Signs of weight loss? Abdominal exam? - Distension? - Mass? - Palpable colon? - Bowel sounds? DRE? Management Advised: - To read PIL 'Constipation' at NHS Health A to Z - To eat a healthy, balanced diet and to have regular meals - To include whole grains, fruits (and their juices) high in sorbitol (eg apples and pears) - To gradually increase fibre intake (benefit may take several weeks) - To have an adequate fluid intake - To visit the website of the Association of UK Dieticians to read Fact Sheets on fibre and fluid - To have regular activity an exercise - To have a regular, unhurried toilet routine giving time to ensure the defecation is complete and to respond immediately to the sensation of needing to defecate Drug treatment: To reduce or stop any drug treatment that may be causing or contributing to symptoms if possible and appropriate 1. Ispaghula (Fybogel) 1 sachet bd (10) 2. Macrogol (Movicol or Laxido Orange) 1-3 sachets in divided doses (10/30 or 20/30) if stool remains hard or difficult to pass and Lactulose oral solution 15 ml bd (300 ml) as second-line 3. Sennoside B (Senna) 7.5 mg 1-2 tablets nocte (20), bisacodyl (Dulcolax) 5 mg 1-2 tablets nocte, docusate 100 mg up to 5 capsules in divided doses (30) if stools soft but difficult to pass or sensation of inadequate emptying If opioid-induced? Osmotic and stimulant laxative or docusate (which also has stool-softening properties) To gradually reduce and stop laxative once stools soft and formed without straining at least three times/week Faecal loading/impaction: 1. Macrogol (Movicol or Laxido Organge) 8 sachets within 6 h (10/30 or 20/30) 2. Stimulant laxative (as above) (in addition) if ongoing hard stools after a few days of treatment 3. Sodium phosphate (Phosphates enema (Formula B) 128ml standard or long tube or Cleen Ready-to-use 133ml enema) 1 enema daily (1) (place high if the rectum is empty but the colon is full) or sodium citrate (Micralax Micro-enema 5ml) 1 enema daily (1) if response still adequate, may need to be repeated several times Reference(s): NICE CKS: Constipation in adults Information for patient/carer(s): NHS Health A to Z: Constipation Patient: Constipation in Adults