Constipation is a still among the prevalent diseases that pose difficulties for an individual to pass stool and characterized by a reduced frequency of bowel movement and having less than three bowel movements per week. Constipation is a familiar condition that can be observed in many individuals, and it may be caused by different conditions. 

Various subtypes of constipation have been observed, and each of them is characterized by specific properties and causes. Functional constipation is the most common subtype usually found in children and adults where they experience rare and difficult bowel movements with no internal or organic cause. This is the main challenge for 29.6% of children globally. It constitutes to about 3% to 5% of pediatric visits only in the United States and requires high annual healthcare expenses. The pathophysiologic process is frequently a mixture of factors. Nearly 84% of the children who are functionally constipated are also incontinent of feces, while approximately 1/3 of the cases are due to constipation being behavioural. Other factors that contribute to this include, dehydration, painful urination, diet, fluid intake, fever, psychological issues etc.  

Chronic idiopathic constipation is the other prominent part of distension, and inconsistent bowel movements shown by a defect in string production and expulsion of stool.  

Constipation is a most serious health issue in 15% of Americans and 12% of people worldwide, and it is more widespread in the States and the Asia-Pacific areas. It is a problem for all age groups, but affects the elderly more often due to dietary habits, less muscle mass, and the use of medicines. Women on the other hand may experience constipation than men in a ratio of 3:1. This disease is often noticed during pregnancy. Other non-white populations in the US have a 30% increased prevalence of constipation over whites. The people in Asia has the lowest rate, while those who adhere to Western diet culture are more prone to the disease. 

Constipation is a state that is mainly caused by the form of feces and the way a person defecates. Especially, solid, hard to evacuate the balls are interfering with the passage of the stool, although even soft, bulky stools cause constipation. The disease can be triggered by the colon, rectum, or also by external factors as colon obstruction, slow colonic motility, and outlet obstruction. Inadequate dietary habits, medications, systemic endocrine or neurologic diseases, and psychological problems are the outside factors of constipation. 

Constipation manifests through several subjective symptoms such as increased colonic luminal pressure, which gives rise to diseases like colonic diverticula, hemorrhoidal disease, and anal fissures. All these disturbances happen because of the buildup of colonic luminal pressure and swelling of veins due to hemorrhoidal cushions. It has been found that, even though about 50% of patients with diverticular or anorectal disease, do not report constipation, careful examination finds almost all patients are showing physiological signs of straining and infrequency of bowel movement, mainly due to constipation, while at times diarrhea accompanying patients with irritable bowel syndrome or chronic diarrheal illnesses. 

Constipation is a difficulty that is sometimes caused by a lack of food low in fiber, the purpose of which is to improve a weakened digestive tract and regularize bowel functioning. Dehydration causes the feces to become harder and more solid that makes it difficult to pass the stools. Apart from this, the immobile way of living is also a major catalyst for the above condition. Drugs may also cause constipation as a side effect. The pathological factors like impaired endocrinal functioning, neurological disorders, disorders of the abdomen like hernia, diverticula or gall bladder diseases and gastrointestinal conditions like lactase deficiency, celiac disease etc., contribute to constipation.

Mostly Hormone disorders due to pregnancy can weaken the muscle tissue’s readability of the bowel, status of aging, however, can make more than half of the world to live such a problem because of involuntary change from muscles due to signaling from the brain and muscles that contract the colons moderately to finish the transit of waste. Also, mental stress and emotional status can be palliators in bowel control. Apart from these, the changes in life’s rhythm, migration, some eating habits, contraceptives are the other physical elements. Hence, the poos are in complex movement because of different factors that ought to be measured. 

Prognostic factors in constipation refer to the factors that can explain the long-term course of the condition. The variables include source, severity of condition, medical conditions, psychological factors etc. Recognizing and treating the disease helps to determine the prognosis of the condition along with comorbidities. 

Age group: 

Infants and young children: 

In babies passing stools can be hard, pellet-like or it could take two to four days of crying during passage of the bowels which may manifest constipation. Constipation may be accompanied by crankiness, loss of appetite as well as stomach pain may be observed due to tightness in bowels area. Children of older age category manifesting constipation might experience decreased appetite while at the same time suffering from lack of craving for food. 

Adults: 

Adults may have some signs or symptoms such as being constipated, not being able to completely empty the bowels or pass stool easily, having to strain while having a bowel movement, abdominal cramps or bloating and needing help from their hands so that they can have comfortable bowel movements. 

Older population: 

As people grow older, they tend to experience constipation more often. Symptoms reported in seniors involve less frequent passing of stools and some discomfort around the midsection probably resulting from unidentified stomach issues or gases. 

General examination: 

Evaluate the appearance of patient, vital signs (blood pressure, heart rate, and temperature), and overall well-being. This helps to examine the health condition and provides a baseline for comparison. 

Abdominal examination: 

An abdominal examination involves identifying signs of distension, tenderness, and masses. Abdomen should be carefully palpated to check any areas of abnormality or obvious tenderness. The presence of a firm, palpable mass may suggest fecal impaction. 

Rectal examination:  

This is perfomed to evaluate the rectum and botton part of colon which involves: 

Digital rectal examination (DRE):  

It involves insertion of a gloved, lubricated finger into rectum to assess for fecal imoaction, rectal tone, and abnormalities such as rectal proplapse or masses. 

Proctoscopy or Anoscopy: 

In some cases, an instrument called an anoscope or proctoscopes may be used to visually examine the rectum and lower part of the colon.  

Pelvic floor assessment: 

This may involve a targeted assessment for the strength and tone of the pelvic floor muscles, as well as coordination, using specific techniques such digital palpation etc. 

Neurological disorders 

Reduced physical activity 

Chronic constipation 

Chronic bleeding 

Rectal prolapse 

Hemorrhoids 

Fecal impaction 

Acute Constipation is when a person has the sudden onset of experiencing constipation. It might be the result of dietary changes, dehydration, medication use or traveling.  

Constipation can be managed in many ways, but diet and exercise should be the primary approach rather than the use of laxatives, enemas, and suppositories. Effective methods include dietary supplements with fibers, stimulant laxatives, intestinal secretagogues, and prokinetic agents. PAMORAs may be the first choice for opioid- induced constipation. Surgical procedures are only indicated when the underlying cause is to be treated or in the case of acute complications.  

Gastroenterology

• Psyllium: the dose of the drug varies on quantity of sugar present in the preparations. These formulations must be administered with water. 
• Methylcellulose: this is a nonfermentable product which produces minimum gas and can be tolerable than psyllium. 

Gastroenterology

Docusate: It is employed in patients who are supposed to avoid straining while defecation. It causes the incorporation of fat and water into stools which softens the stools.  

Gastroenterology

Senna concentrate/ docusate:  

The main action of Docusate sodium is in making stool soft through water and fat addition while sennosides enhance stool expulsion either via direct stimulation at intestinal mucosa or nerve plexus leading to increased peristalsis resulting in increased motility of the intestine usually taking 8-12 hours after ingestion. 

Gastroenterology

• Magnesium hydroxide: It brings in the retention of fluid that enhances the peristaltic activity and distends the colon.  
• Magnesium citrate: It empties the bowel by increasing the peristaltic activity. It might cause an increase in the imbalance of electrolytes particularly in younger population or patients suffering from renal insufficiency.  

Gastroenterology

Mineral oil: This is gentle than other laxatives. Prolonged use may cause lipid pneumonia, foreign body reactions and lymphoid hyperplasia. 

Gastroenterology

• Lubiprostone: It is a chloride channel activator that acts locally and enhances a chloride-rich intestinal fluid secretion without the alteration of potassium and sodium concentrations in serum. 
• Linaclotide: it causes the activation of GC-C receptors in the neurons of the intestine and leads to an increased cGMP, fluid secretion, anion secretion and intestinal transit. 
• Plecanatide: The active metabolite and the drug binds to the GC-C and acts locally on the luminal surface of epithelial cells in the intestine. Activation of GC-C leads to increased activity of cGMP which in turn stimulates the secretion of bicarbonate and chloride into lumen. 

Gastroenterology

• Lactulose: This drug causes an osmotic effect in colon which results in the distension of bowel and stimulates peristalsis. 
• Sorbitol: This is a hyperosmotic laxative which has cathartic action in the gastrointestinal tract. 
• Polyethylene glycol: It is used in large volumes for preparing bowel and washout prior to endoscopic or surgical procedures. 
• Lactitol: This drug causes water influx into small intestines which causes laxative effect in colon. 

Gastroenterology

• Senna: sennosides cause defecation by acting on the nerve plexus or intestinal mucosa which leads to the stimulation of peristaltic activity. 
• Castor oil: This is reduced to ricinoleic acid and reduces net fluid absorption and stimulates peristalsis. 

Gastroenterology

Prucalopride: It is a selective 5-HY type-4 receptor which stimulates the colonic peristalsis and therefore increases bowel motility. 

Gastroenterology

• Methylnaltrexone: This drug displaces opiods selectively from mu-opiod receptors outside the CNS.  
• Naloxegol: This is a peripherally acting µ-opiod receptor antagonist. It selectively inhibits the negative opiod effects in the motility and GI function. 

Gastroenterology

For patients with subacute or chronic idiopathic constipation and recurrent constipation, a typical long-term treatment regimen can be considered. Regular follow-ups with a health worker can help to monitor the progress and make necessary adjustments and ensure ongoing management of constipation.