Review
A Gap in Our Understanding: Chronic Constipation and Its Comorbid Conditions

https://doi.org/10.1016/j.cgh.2008.07.005Get rights and content

Constipation is one of the most common digestive disorders in the United States; however, the association of this condition with related comorbidities, both gastrointestinal and extraintestinal, is poorly documented. Here, we have reviewed the association of constipation with specific comorbidities. The data suggest that there are considerable clinical consequences associated with constipation. Ultimately, realization of the disease risks associated with chronic constipation may provide the impetus needed to direct new research, and shift attention on the part of patients and practitioners to methods for preventing significant and potentially costly comorbid medical problems.

Section snippets

Pathophysiologic Mechanisms

Chronic constipation, as defined by the Rome III criteria, specifies a minimum 6-month history of symptoms to establish chronicity. The hallmark symptoms include straining, a sense of incomplete evacuation, bowel movement infrequency, and hard stool consistency.3 Of these constipation-defining symptoms, hard stool, straining, and the associated increase in intra-abdominal pressure may be etiologically important in clinical sequelae, such as hemorrhoids, anal fissures, and possibly rectal

Methods

In Medline, a master search set comprised of the subject headings constipation and chronic constipation between the years 1980 and 2007 was created. Subject headings were selected and/or text queries were created for each of the following clinical concepts: hemorrhoids, anal fissures, fissure in ano, anal ulcer, rectal prolapse, stercoral ulcers, rectal ulcers, intestinal volvulus, fecal impaction, obstipation, obstruction, colonic pseudo-obstruction, gastric outlet obstruction, intestinal

Results

Relatively few publications were found in the literature dealing with the association of constipation and various search terms, supporting our initial impression that this area is largely unexplored. Given the limited data, we have confined our review to more commonly discussed anorectal, colonic, and urologic disorders. In the following discussion, each comorbidity is evaluated individually in the context of the currently proposed pathophysiology, specific to the disorder.

Conclusions

The evidence of a cause-and-effect relationship between constipation and comorbid diseases is inferred from association studies and knowledge of the mechanical effects of constipation. However, in some cases there are confounding factors that may predispose to both constipation and comorbid diseases. For example, disruption of the enteric nervous system can lead to motility disorders, with secondary reduction in bowel movement frequency and colonic dilatation. Furthermore, lifestyle factors

References (112)

  • K.M. Hiltunen et al.

    Clinical and manometric evaluation of anal sphincter function in patients with rectal prolapse

    Am J Surg

    (1986)
  • W.A. Peters et al.

    Rectal prolapse in women with other defects of pelvic floor support

    Am J Obstet Gynecol

    (2001)
  • P. Gekas et al.

    Stercoral perforation of the colon: case report and review of the literature

    Gastroenterology

    (1981)
  • C.A. Alessi et al.

    Constipation and fecal impaction in the long-term care patient

    Clin Geriatr Med

    (1988)
  • Y. Romero et al.

    Constipation and fecal incontinence in the elderly population

    Mayo Clin Proc

    (1996)
  • S. Muller-Lissner

    General geriatrics and gastroenterology: constipation and faecal incontinence

    Best Pract Res Clin Gastroenterol

    (2002)
  • Y. Scarlett

    Medical management of fecal incontinence

    Gastroenterology

    (2004)
  • M.C. Roberts et al.

    Constipation, laxative use, and colon cancer in a North Carolina population

    Am J Gastroenterol

    (2003)
  • T. Watanabe et al.

    Constipation, laxative use and risk of colorectal cancer: the Miyagi Cohort Study

    Eur J Cancer

    (2004)
  • T. Otani et al.

    Bowel movement, state of stool, and subsequent risk for colorectal cancer: the Japan public health center-based prospective study

    Ann Epidemiol

    (2006)
  • N.S. Painter et al.

    Segmentation and the localization of intraluminal pressures in the human colon, with special reference to the pathogenesis of colonic diverticula

    Gastroenterology

    (1965)
  • N. Stollman et al.

    Diverticular disease of the colon

    Lancet

    (2004)
  • G. Aggazzotti et al.

    Prevalence of urinary incontinence among institutionalized patients: a cross-sectional epidemiologic study in a midsized city in northern Italy

    Urology

    (2000)
  • P.D. Higgins et al.

    Epidemiology of constipation in North America: a systematic review

    Am J Gastroenterol

    (2004)
  • D. Mitra et al.

    Healthcare utilization and costs associated with constipation and co-occurring irritable bowel syndrome and constipation compared to matched controls in a large managed care population

    Gastroenterology

    (2007)
  • B.C. Martin et al.

    The annual cost of constipation in the U.S. ambulatory and inpatient care settings

    Gastroenterology

    (2005)
  • K.A. Nyrop et al.

    Costs of health care for irritable bowel syndrome, chronic constipation, functional diarrhoea and functional abdominal pain

    Aliment Pharmacol Ther

    (2007)
  • G. Singh et al.

    Constipation in adults: complications and comorbidities

    Gastroenterology

    (2005)
  • G. Singh et al.

    Complications and comorbidities of constipation in adults

    Gastroenterology

    (2007)
  • D. Mitra et al.

    Healthcare costs and clinical sequelae associated with constipation in a managed care population

    Am J Gastroenterol

    (2007)
  • M.M. Henry et al.

    The pelvic floor musculature in the descending perineum syndrome

    Br J Surg

    (1982)
  • P. Alonso-Coello et al.

    Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis

    Am J Gastroenterol

    (2006)
  • P. Alonso-Coello et al.

    Laxatives for the treatment of hemorrhoids

    Cochrane Database Syst Rev

    (2005)
  • C. Mattana et al.

    Rubber band ligation of hemorrhoids and rectal mucosal prolapse in constipated patients

    Dis Colon Rectum

    (1989)
  • S.L. Jensen

    Diet and other risk factors for fissure-in-anoProspective case control study

    Dis Colon Rectum

    (1988)
  • P. Chassagne et al.

    Does treatment of constipation improve faecal incontinence in institutionalized elderly patients?

    Age Ageing

    (2000)
  • G.W. Tobin et al.

    Faecal incontinence in residential homes for the elderly: prevalence, aetiology and management

    Age Ageing

    (1986)
  • W. Romanczuk et al.

    Chronic constipation: a cause of recurrent urinary tract infections

    Turk J Pediatr

    (1993)
  • P.Z. Neumann et al.

    Constipation and urinary tract infection

    Pediatrics

    (1973)
  • D. Anagnostopoulos et al.

    Constipation: a cause of enuresis

    Pediatr Surg Int

    (1989)
  • S. O'Regan et al.

    Constipation, bladder instability, urinary tract infection syndrome

    Clin Nephrol

    (1985)
  • S. O'Regan et al.

    Constipation a commonly unrecognized cause of enuresis

    Am J Dis Child

    (1986)
  • V. Loening-Baucke

    Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood

    Pediatrics

    (1997)
  • G. Charach et al.

    Alleviating constipation in the elderly improves lower urinary tract symptoms

    Gerontology

    (2001)
  • F. Delco et al.

    Associations between hemorrhoids and other diagnoses

    Dis Colon Rectum

    (1998)
  • R.A. Brook et al.

    Functional gastrointestinal disorder comorbidities: comparisons of prevalence and costs in the 6 months before and after diagnoses of constipation (C) and irritable bowel syndrome and constipation (IBS+C)

    Am J Gastroenterol

    (2007)
  • J.F. Johanson et al.

    Constipation is not a risk factor for hemorrhoids: a case-control study of potential etiological agents

    Am J Gastroenterol

    (1994)
  • C.P. Gibbons et al.

    Role of constipation and anal hypertonia in the pathogenesis of haemorrhoids

    Br J Surg

    (1988)
  • W.H. Thomson

    The nature of haemorrhoids

    Br J Surg

    (1975)
  • D.Z. Lubowski

    Anal fissures

    Aust Fam Physician

    (2000)
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    The authors disclose the following: C.L.B. and K.L.L. are employees of Takeda Pharmaceuticals North America, Inc, Medical & Scientific Affairs. N.J.T. is a consultant to Johnson & Johnson Pharmaceutical R&D, Pfizer, Procter & Gamble, Theravance, Inc, Lexicon Genetics, Inc, Astellas Pharma US, Inc, Pharma Frontiers, Ltd, Callisto Pharmaceuticals, Astra Zeneca, Addex Pharma, Ferring Pharma, and Salix; and received research support from Novartis, Takeda, GlaxoSmithKline, Dynogen, and Tioga.

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