Summary of Various Management Options for Chronic Constipation According to the Strength of Recommendations Taxonomy (SORT)81
| Treatment | Level of Recommendation | Comments | Reference |
|---|---|---|---|
| Nonpharmacological | |||
| Increasing dietary fiber | C | No RCTs, data from multiple observational studies, results conflicting. More likely to be beneficial in people with fibers deficiency. | 34,82–87 |
| Increasing exercise | B | Two small RCTs with opposite results and 2 other cohorts showing benefits. More likely to be beneficial in people with lack of exercise. | 9,83,88,89 |
| Increasing fluids | C | One observational study and 1 controlled trial, the latter showing benefits of increased fluids only in presence of sufficient fiber intake. | 90,91 |
| Biofeedback | B | Useful in pelvic function disorder type of chronic constipation. Benefits reported with both uncontrolled trials and RCTs. However, protocols of biofeedback vary and are heterogeneous in nature; hence recommendation is not standardized. | 46,92–94 |
| Bacteriotherapy (probiotics) | C | One prospective study of bifidobacterium and one uncontrolled trial of Lactobacillus; viability of preparation when consumed is questionable. | 95–97 |
| Surgery (colectomy/hemicolectomy) | B | One systematic review reported benefits based on case reports and no RCT; quality of studies was heterogeneous. | 139 |
| Surgery (partial division of puborectalis) | B | Two RCTs randomizing patients to surgical and nonsurgical treatments (biofeedback or Botulinum toxin injection). | 140,141 |
| Pharmacological | |||
| Psyllium | A | At least 3 well-designed RCTs showing benefits over placebo. | 98–101 |
| Bran | B | Two controlled trials showed benefits in reducing use of laxatives. | 102,103 |
| Methylcellulose | B | Only 1 controlled trial of medium quality. | 104 |
| Polycarbophil | B | Only 1 case series of medium quality. | 105 |
| Polyethylene glycol | A | At least 3 RCTs showing benefits over placebo. | 106–108 |
| Lactulose | A | Two systematic reviews of RCTs with benefits over placebos. | 109,110 |
| Sorbitol | B | One double-blind RCT showing comparable efficacy of sorbitol with lactulose, not placebo. | 111 |
| Magnesium hydroxide (milk of magnesia) | C | No evidence of benefits from any studies, with 1 adverse report of overuse. | 112 |
| Senna | A | At least 3 controlled trials showing benefits over placebo. | 115–117 |
| Docusate sodium | B | One double-blind RCT comparing with psyllium. | 98 |
| Bisacodyl | A | One double-blind RCT with 1 open-labelled controlled trial. | 113,114 |
| Lubiprostone | A | At least 3 double-blind RCTs showing benefits over placebo. | 118–120 |
| Tegaserod | – | At least 3 RCTs from different centers showed benefits over placebo. Withdrawn from market by FDA because of concern; 2 recent cohorts claim no association with cardiovascular risks. | 121–129 |
| Prucalopride | A | At least 3 RCTs showing benefits over placebo, including severe chronic constipation. At present only marketed in Europe. | 130–135 |
| Traditional Chinese medicine | B | Two RCTs showing benefits of a particular formula, yet overall quality of studies are heterogeneous. | 136–138 |
RCT indicates randomized, controlled trial; FDA, Food and Drug Administration.