Options go beyond laxatives and include behavioural treatment as well as new drugs

Although slow to emerge, major advances have occurred in understanding the causes and management of constipation. It now receives the attention deserved of a symptom that affects a quarter of the population at some time. Most important is the recognition that different pathophysiological processes can result in the final common symptoms of decreased bowel frequency or impaired rectal evacuation. Different clinical syndromes require different therapeutic approaches.

Bowel frequency is influenced by several factors including intake of dietary fibre, emotional make up, and psychological morbidity. Introspective individuals have a lower bowel frequency and produce less stool than extroverts. Infrequent bowel actions in the absence of symptoms can be regarded as part of the normal spectrum of bowel frequency. Low bowel frequency is more common in women.

Controlled cross sectional studies have shown that psychological morbidity is commonly associated with severe constipation.1 In some patients it is the key causative factor. Other factors include childhood problems such as sexual or physical abuse, loss of a parent through death or separation, or disturbed toileting behaviour. Underlying depression is another cause. For some the gut is their “outlet valve” for the normal stresses of living. The pathways between brain and gut that link emotions to bowel function have been largely characterised and shown to involve cerebral corticotrophin releasing factor and efferent autonomic pathways. Although psychological factors should be sought at …