Korean J Gastroenterol.  2024 May;83(5):191-196. 10.4166/kjg.2024.044.

Nonpharmacologic Treatment of Chronic Constipation

• Seo M
• Bae JH

• KMID: 2555971
• DOI: http://doi.org/10.4166/kjg.2024.044

Abstract

Functional constipation is a common clinical diagnosis that affects approximately 14% of the world’s population. Non-pharmacological therapies often represent the initial steps in management and may include lifestyle adjustments or changes such as physical activity and diet. Pharmacological options have been used when the non-pharmacological approach has been ineffective. Biofeedback therapy, surgery, sacral nerve stimulation, botulinum toxin injection, and vibrating capsules can be considered in scenarios where the laxatives are ineffective. Biofeedback therapy is highly effective and safe in treating dyssynergic defecation, which affects more than half of patients with chronic constipation. This paper overviews non-pharmacological therapies for functional constipation.

Keyword

Functional; Constipation; Treatment; Biofeedback

Reference

1. Sperber AD, Bangdiwala SI, Drossman DA, et al. 2021; Worldwide prevalence and burden of functional gastrointestinal disorders, results of rome foundation global study. Gastroenterology. 160:99–114.e3.

2. Drossman DA, Hasler WL. 2016; Rome IV-functional GI disorders: Disorders of gut-brain interaction. Gastroenterology. 150:1257–1261. DOI: 10.1053/j.gastro.2016.03.035. PMID: 27147121.

3. Cho YS, Lee YJ, Shin JE, et al. 2023; 2022 Seoul consensus on clinical practice guidelines for functional constipation. J Neurogastroenterol Motil. 29:271–305. DOI: 10.5056/jnm23066. PMID: 37417257. PMCID: PMC10334201.

4. Portalatin M, Winstead N. 2012; Medical management of constipation. Clin Colon Rectal Surg. 25:12–19. DOI: 10.1055/s-0032-1301754. PMID: 23449608. PMCID: PMC3348737.

5. Gearry R, Fukudo S, Barbara G, et al. 2023; Consumption of 2 green kiwifruits daily improves constipation and abdominal comfort-results of an international multicenter randomized controlled trial. Am J Gastroenterol. 118:1058–1068. DOI: 10.14309/ajg.0000000000002124. PMID: 36537785. PMCID: PMC10226473.

6. Koyama T, Nagata N, Nishiura K, Miura N, Kawai T, Yamamoto H. 2022; Prune juice containing sorbitol, pectin, and polyphenol ameliorates subjective complaints and hard feces while normalizing stool in chronic constipation: A randomized placebo-controlled trial. Am J Gastroenterol. 117:1714–1717. DOI: 10.14309/ajg.0000000000001931. PMID: 35971232. PMCID: PMC9531972.

7. Bayer SB, Heenan P, Frampton C, et al. 2022; Two gold kiwifruit daily for effective treatment of constipation in adults-a randomized clinical trial. Nutrients. 14:4146. DOI: 10.3390/nu14194146. PMID: 36235798. PMCID: PMC9572406.

8. Wilson PB. 2020; Associations between physical activity and constipation in adult Americans: Results from the National Health and Nutrition Examination Survey. Neurogastroenterol Motil. 32:e13789. DOI: 10.1111/nmo.13789. PMID: 31905422.

9. Song BK, Cho KO, Jo Y, Oh JW, Kim YS. 2012; Colon transit time according to physical activity level in adults. J Neurogastroenterol Motil. 18:64–69. DOI: 10.5056/jnm.2012.18.1.64. PMID: 22323989. PMCID: PMC3271256.

10. Rao SS, Benninga MA, Bharucha AE, Chiarioni G, Di Lorenzo C, Whitehead WE. 2015; ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders. Neurogastroenterol Motil. 27:594–609. DOI: 10.1111/nmo.12520. PMID: 25828100. PMCID: PMC4409469.

11. Sharma A, Herekar A, Yan Y, Karunaratne T, Rao SSC. 2022; Dyssynergic defecation and other evacuation disorders. Gastroenterol Clin North Am. 51:55–69. DOI: 10.1016/j.gtc.2021.10.004. PMID: 35135665.

12. Chiarioni G, Salandini L, Whitehead WE. 2005; Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation. Gastroenterology. 129:86–97. DOI: 10.1053/j.gastro.2005.05.015. PMID: 16012938.

13. Rao SSC, Valestin JA, Xiang X, Hamdy S, Bradley CS, Zimmerman MB. 2018; Home-based versus office-based biofeedback therapy for constipation with dyssynergic defecation: a randomised controlled trial. Lancet Gastroenterol Hepatol. 3:768–777. DOI: 10.1016/S2468-1253(18)30266-8. PMID: 30236904.

14. Özkütük N, Eşer İ, Bor S. 2021; Effectiveness of biofeedback therapy on quality of life in patients with dyssynergic defecation disorder. Turk J Gastroenterol. 32:22–29. DOI: 10.5152/tjg.2020.19678. PMID: 33893763. PMCID: PMC8975507.

15. Rao SS, Seaton K, Miller M, et al. 2007; Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol. 5:331–338. DOI: 10.1016/j.cgh.2006.12.023. PMID: 17368232.

16. Rao SS, Valestin J, Brown CK, Zimmerman B, Schulze K. 2010; Long-term efficacy of biofeedback therapy for dyssynergic defecation: randomized controlled trial. Am J Gastroenterol. 105:890–896. DOI: 10.1038/ajg.2010.53. PMID: 20179692. PMCID: PMC3910270.

17. Lee HJ, Boo SJ, Jung KW, et al. 2015; Long-term efficacy of biofeedback therapy in patients with dyssynergic defecation: results of a median 44 months follow-up. Neurogastroenterol Motil. 27:787–795. DOI: 10.1111/nmo.12552. PMID: 25807997.

18. Sheng QS, Lin JJ, Chen WB, et al. 2014; Comparison of hand-assisted laparoscopy with open total colectomy for slow transit constipation: a retrospective study. J Dig Dis. 15:419–424. DOI: 10.1111/1751-2980.12156. PMID: 24798314.

19. Wei D, Cai J, Yang Y, et al. 2015; A prospective comparison of short term results and functional recovery after laparoscopic subtotal colectomy and antiperistaltic cecorectal anastomosis with short colonic reservoir vs. long colonic reservoir. BMC Gastroenterol. 15:30. DOI: 10.1186/s12876-015-0257-7. PMID: 25887580. PMCID: PMC4367911.

20. Chen W, Jiang CQ, Qian Q, Ding Z, Liu ZS. 2015; Antiperistaltic side-to-side ileorectal anastomosis is associated with a better short-term fecal continence and quality of life in slow transit constipation patients. Dig Surg. 32:367–374. DOI: 10.1159/000437234. PMID: 26302872.

21. De Marco P, Militello G, Tutino R, et al. 2018; The management of the slow transit constipation in the laparoscopic era. G Chir. 34:297–302.

22. Yang D, He L, Su TR, Chen Y, Wang Q. 2019; Outcomes of laparoscopic subtotal colectomy with cecorectal anastomosis for slow-transit constipation: a single center retrospective study. Acta Chir Belg. 119:83–87. DOI: 10.1080/00015458.2018.1467145. PMID: 29701506.

23. Xie XY, Sun KL, Chen WH, et al. 2019; Surgical outcomes of subtotal colectomy with antiperistaltic caecorectal anastomosis vs total colectomy with ileorectal anastomosis for intractable slow-transit constipation. Gastroenterol Rep (Oxf). 7:449–454. DOI: 10.1093/gastro/goz014. PMID: 31857907. PMCID: PMC6911993.

24. Patton V, Balakrishnan V, Pieri C, et al. 2020; Subtotal colectomy and ileorectal anastomosis for slow transit constipation: clinical follow-up at median of 15 years. Tech Coloproctol. 24:173–179. DOI: 10.1007/s10151-019-02140-5. PMID: 31907721.

25. Yang YP, Shi J, Zhao ZY, Yu LY, Liu TJ. 2020; Subtotal colectomy with antiperistaltic cecosigmoidal anastomosis may be another suitable option for slow transit constipation: Experiences from Chinese people. Medicine (Baltimore). 99:e19065. DOI: 10.1097/MD.0000000000019065. PMID: 32049806. PMCID: PMC7035066.

26. Tian Y, Wang L, Ye JW, et al. 2020; Defecation function and quality of life in patients with slow-transit constipation after colectomy. World J Clin Cases. 8:1897–1907. DOI: 10.12998/wjcc.v8.i10.1897. PMID: 32518779. PMCID: PMC7262699.

27. McCoy JA, Beck DE. 2012; Surgical management of colonic inertia. Clin Colon Rectal Surg. 25:20–23. DOI: 10.1055/s-0032-1301755. PMID: 23449085. PMCID: PMC3348730.

28. Knowles CH, Grossi U, Chapman M, Mason J. NIHR CapaCiTY working group; Pelvic floor Society. 2017; Surgery for constipation: systematic review and practice recommendations: Results I: Colonic resection. Colorectal Dis. 19 Suppl 3:17–36. DOI: 10.1111/codi.13779. PMID: 28960923.

29. Dudekula A, Huftless S, Bielefeldt K. 2015; Colectomy for constipation: time trends and impact based on the US Nationwide Inpatient Sample, 1998-2011. Aliment Pharmacol Ther. 42:1281–1293. DOI: 10.1111/apt.13415. PMID: 26423574.

30. Jiang CQ, Qian Q, Liu ZS, Bangoura G, Zheng KY, Wu YH. 2008; Subtotal colectomy with antiperistaltic cecoproctostomy for selected patients with slow transit constipation-from Chinese report. Int J Colorectal Dis. 23:1251–1256. DOI: 10.1007/s00384-008-0552-7. PMID: 18696088.

31. D'Hoore A, Penninckx F. 2003; Obstructed defecation. Colorectal Dis. 5:280–287. DOI: 10.1046/j.1463-1318.2003.00497.x. PMID: 12814403.

32. Bove A, Pucciani F, Bellini M, et al. 2012; Consensus statement AIGO/SICCR: diagnosis and treatment of chronic constipation and obstructed defecation (part I: diagnosis). World J Gastroenterol. 18:1555–1564. DOI: 10.3748/wjg.v18.i14.1555. PMID: 22529683. PMCID: PMC3325520.

33. Racaniello E, Terzoni S, Accardi R, Ricci C, Boccasanta P, Destrebecq A. 2015; Quality of life of patients undergoing surgery for obstructed defecation syndrome: A before-after study. Int J Surg. 21:18–21. DOI: 10.1016/j.ijsu.2015.06.057. PMID: 26184994.

34. Grossi U, Horrocks EJ, Mason J, Knowles CH, Williams AB. NIHR CapaCiTY working group; Pelvic floor Society. 2017; Surgery for constipation: systematic review and practice recommendations: Results IV: Recto-vaginal reinforcement procedures. Colorectal Dis. 19 Suppl 3:73–91. DOI: 10.1111/codi.13781. PMID: 28960924.

35. Grossi U, Knowles CH, Mason J, et al. 2017; Surgery for constipation: systematic review and practice recommendations: Results II: Hitching procedures for the rectum (rectal suspension). Colorectal Dis. 19 Suppl 3:37–48. DOI: 10.1111/codi.13773. PMID: 28960927.

36. Maeda Y, O'Connell PR, Lehur PA, Matzel KE, Laurberg S. European SNS Bowel Study Group. 2015; Sacral nerve stimulation for faecal incontinence and constipation: a European consensus statement. Colorectal Dis. 17:O74–87. DOI: 10.1111/codi.12905.

37. Thomas GP, Dudding TC, Rahbour G, Nicholls RJ, Vaizey CJ. 2013; Sacral nerve stimulation for constipation. Br J Surg. 100:174–181. DOI: 10.1002/bjs.8944. PMID: 23124687.

38. Kamm MA, Dudding TC, Melenhorst J, et al. 2010; Sacral nerve stimulation for intractable constipation. Gut. 59:333–340. DOI: 10.1136/gut.2009.187989. PMID: 20207638.

39. Knowles CH, Thin N, Gill K, et al. 2012; Prospective randomized double-blind study of temporary sacral nerve stimulation in patients with rectal evacuatory dysfunction and rectal hyposensitivity. Ann Surg. 255:643–649. DOI: 10.1097/SLA.0b013e318247d49f. PMID: 22418005.

40. Zerbib F, Siproudhis L, Lehur PA, et al. 2017; Randomized clinical trial of sacral nerve stimulation for refractory constipation. Br J Surg. 104:205–213. DOI: 10.1002/bjs.10326. PMID: 27779312.

41. Dinning PG, Hunt L, Patton V, et al. 2015; Treatment efficacy of sacral nerve stimulation in slow transit constipation: a two-phase, double-blind randomized controlled crossover study. Am J Gastroenterol. 110:733–740. DOI: 10.1038/ajg.2015.101. PMID: 25895520.

42. Chaichanavichkij P, Vollebregt PF, Scott SM, Knowles CH. 2020; Botulinum toxin type A for the treatment of dyssynergic defaecation in adults: a systematic review. Colorectal Dis. 22:1832–1841. DOI: 10.1111/codi.15120. PMID: 32403161.

43. Chu CY, Su YC, Hsieh PC, Lin YC. 2023; Effectiveness and safety of botulinum neurotoxin for treating dyssynergic defecation: A systematic review and meta-analysis. Toxicon. 235:107311. DOI: 10.1016/j.toxicon.2023.107311. PMID: 37816487.

44. Ron Y, Halpern Z, Safadi R, Dickman R, Dekel R, Sperber AD. 2015; Safety and efficacy of the vibrating capsule, an innovative non-pharmacological treatment modality for chronic constipation. Neurogastroenterol Motil. 27:99–104. DOI: 10.1111/nmo.12485. PMID: 25484196.

45. Rao SSC, Quigley EMM, Chey WD, Sharma A, Lembo AJ. 2023; Randomized placebo-controlled phase 3 trial of vibrating capsule for chronic constipation. Gastroenterology. 164:1202–1210.e6. DOI: 10.1053/j.gastro.2023.02.013. PMID: 36822371.