Chronic Constipation -- Defining the Problem and Clinical Impact Brooks D. Cash, MD, FACP Background and Context Clinical Definitions and Terms Chronic constipation is a common complaint encountered in multiple clinical practice settings. In the past, approaches to define constipation have included using: (1) symptoms such as straining, hard stools, infrequency, and scybala, among others; (2) parameters of defecation that are outside the 95th percentile of normal; and/or (3) physiologic evidence of prolonged whole gut or colonic transit. In an attempt to impose some definitional uniformity for clinical research, the Rome II Committee on Functional Gastrointestinal Disorders set forth criteria for the diagnosis of chronic constipation in 1999 which include a description of chronicity (12 weeks in the previous year, which do not need to be consecutive) and symptoms (2 of which must be present at least 25% of the time).[1] These symptoms include: fewer than 3 bowel movements per week, hard or lumpy stools, straining with defecation, a sensation of incomplete evacuation, a sensation of anorectal obstruction, and the use of manual maneuvers to assist defecation. The Rome II criteria may, in select cases, permit the classification of chronic constipation into 1 of 3 subtypes: colonic inertia (delayed motility), outlet obstruction, and functional constipation. It is i mportant to note that in order to be diagnosed with chronic constipation using the Rome II criteria, patients specifically must not fulfill the criteria for irritable bowel syndrome (IBS). The primary differentiating factor between these 2 diagnoses is the presence and prominence of abdominal pain or discomfort that is relieved with defecation in patients with IBS. Challenges in Identifying/Diagnosing Chronic Constipation Recognizing chronic constipation can be a challenge, mainly because there is a significant disconnection between patient definitions of constipation and those of clinicians. In a study of the bowel habits of factory workers in the United Kingdom performed in the 1960s, more than 99% of those surveyed had a bowel movement frequency between 3 per day to 3 per week, and it is this definition of "normal" bowel movement frequency that continues to prevail in the medical community.[2] Bowel movement infrequency, however, is only one component of the chronic constipation syndrome, and there is abundant evidence that it is not the primary symptom that patients cite when they describe themselves as constipated. According to several large epidemiologic studies, patients with chronic constipation are more apt to cite straining, a sense of incomplete or ineffective defecation, and hard or lumpy stools than infrequency as the most bothersome symptoms of constipation.[3-5] Using random telephone interviews of more than 10,000 individuals, the Epidemiology of Constipation (EPOC) Study in the United States determined that only 26% of patients fulfilling symptom-based criteria (similar to the Rome II criteria) for chronic constipation actually had less than 3 bowel movements per week and that other symptoms, such as bloating, abdominal heaviness/fullness, unsuccessful bowel movements, and a feeling of blockage were reported with similar frequency.[6] It is interesting that among individuals who fulfilled these symptom-based criteria, only 37% of women and 59% of men described themselves as constipated, highlighting the diversity between symptom-based criteria and self-report of constipation. Objective measures designed to facilitate the diagnosis of constipation have been slow to develop. The Bristol Stool Form Scale has been validated and is increasingly being used in clinical trials and routine clinical practice.[7] Other objective measures, such as stool texture analysis or colonic motility studies, however, have either not correlated with the symptoms of chronic constipation, have not been sufficiently sensitive or specific, or have remained inaccessible or largely unknown to primary care practitioners. Attempts to objectify the diagnostic criteria for chronic constipation may have significant limitations, resulting in the omission of a significant portion of patients with the condition. This was demonstrated in the results of a Canadian population survey reported by Pare and colleagues[8] in which there was significant congruence between the Rome I and Rome II criteria for a wide range of demographic features of individuals with chronic constipation. When compared against the demographic features of patients with self-reported chronic constipation, however, this congruence was largely absent. In other words, each approach (self-report vs symptom-based criteria) appears to identify a unique patient population that ultimately may be labeled with the same diagnosis. Thus, it is important that clinicians understand not only the symptom-based criteria for chronic constipation but also the other complaints and descriptors that patients may use to define their chronic constipation. Scope of the Problem A recent systematic review of the epidemiology of chronic constipation by Higgins and Johanson[9] indicated a prevalence of chronic constipation in North America ranging from 1.9% to 27.2%. As alluded to previously, self-reported constipation prevalence tends to be greater than estimates using symptom-based criteria. Characteristics consistently associated with chronic constipation from this review included female sex (average female:male ratio = 2.2), lower socioeconomic class, and lower education level. Although age has been shown to directly correlate with the prevalence of chronic constipation in other epidemiologic studies, a reliable association between advancing age and chronic constipation was not observed in this systematic review. The differences in prevalence between self-reported constipation and chronic constipation diagnosed via symptom-based criteria observed by Higgins and Johanson suggest that self-report may be significantly influenced by sex, race, and socioeconomic and education level. Using conservative estimates from this review, the number of North Americans with chronic constipation, based on the symptom-based criteria (Rome I and II), is approximately 63 million. When self-reported constipation is considered, the prevalence increases to nearly 113 million people. Data from other countries demonstrate remarkable similarities to the data from North America. Cheng and colleagues[10] reported a population prevalence (based on the Rome II criteria) of chronic constipation of between 13.7% and 14.4% in Hong Kong, with a female:male ratio of 1.3:1.0. Echoing the observations of the EPOC study, only 57.4% of individuals fulfilling the Rome II criteria in this study were aware of having constipation. Garrigues and colleagues[11] found that 29.5% of Spanish survey participants (N = 349) had self-reported chronic constipation and that when the Rome I and Rome II criteria were applied, these estimates diminished to 19.2% and 14.0%, respectively. Female sex was significantly associated with chronic constipation across case definitions in this study as well. A Swedish survey comprising 1610 adults, 31-76 years of age, identified 7.8% who felt that they were constipated "often" or "always" and 20.3% who described being constipated "sometimes," with women more than twice as likely to report constipation than men.[12] The characteristics most indicative of constipation from the nonvalidated questionnaire used in this study were the need to use laxatives, hard stools, straining with bowel movements, infrequent bowel movements, and pain with bowel movements. Clinical Impact Burden of Illness Sonnenberg and Koch[13] analyzed data from the National Disease and Therapeutic Index from 1958-1986 and estimated a relatively stable value of 2.5 million annual physician visits for constipation. More recent data that include emergency room encounters puts the number of physician visits for constipation-related complaints at 5.7 million in 2001.[14] The potential impact of chronic constipation takes on greater significance when one considers that, like IBS, healthcare seekers represent the minority of sufferers. In the reports of Pare and colleagues (Canada)[8] and Cheng and colleagues (Hong Kong),[10] only 34% and 25.3%, respectively, of patients with chronic constipation reported physician visits and similar values have been reported in the United States.[3,6] The potential exposure to unrealized healthcare utilization expenditures by this population is only now becoming evident. The annual estimated expenditure for laxatives in the United States of $800 million is likely low, due to the fact that many patients have tried over-the-counter preparations prior to escalating to prescription medications.[15] Using the California Medicaid database, Singh and colleagues[16] determined that approximately 77,000 patients incurred $18 million in healthcare expenses over a 15-month period surrounding the first physician visit for constipation, with most of these expenses arising from gastrointestinal procedures and laboratory testing. In a report published in 1997, Rantis and colleagues[17] found that the mean cost per diagnosis in 51 patients with chronic constipation was $2752 (range, $1150-$4792). Even using the more conservative estimates of prevalence, healthcare seeking, and costs, the annual direct costs attributable to chronic constipation in North America are in the billions of dollars. Impact on Quality of Life Although the direct costs of chronic constipation are daunting, several analyses suggest that the indirect costs of chronic constipation -- such as impaired quality of life, diminished vitality, and decreased productivity -- may actually represent an even greater socioeconomic burden.[5,18] It is well recognized, through studies such as the US Householder Survey, that patients with functional gastrointestinal disorders experience more than twice the number of school or workday absences than individuals without these disorders.[19] Few studies, however, have evaluated the economic impact of impaired functioning due to chronic constipation. Bracco and Kahler[20] recently reported the results of a survey of 24,090 individuals in an effort to shed some light on these issues. Of the individuals surveyed, 1147 (4.76%) reported seeking medical attention for constipation in the previous 12 months. Among the 557 individuals who fulfilled the Rome II criteria for chronic constipation, 76% had seen a physician for this complaint in the previous 6 months, and among the 43% who were employed, 12% reported work absenteeism due to their constipation symptoms in the previous month, equating to a mean rate of 2.4 days per month. Moreover, 60% of these individuals reported some degree of impairment while at work (presenteeism) due to constipation symptoms, amounting to an estimated 21% decrease in productivity. Among all patients with chronic constipation, regardless of employment status, impairment in daily activities was reported by 72%, representing a 27% reduction in activity level. Irvine and colleagues[18] found similar results in their study of health-related quality of life (HRQOL) involving 1149 Canadians using the SF-36, a validated, generic QOL instrument commonly used in such analyses. Among the 444 (27.2%) patients with self-reported chronic constipation and the 172 (14.9%) fulfilling the Rome II criteria, scores across nearly all mental and physical summary components and subscales of the SF-36 were significantly lower than Canadian normative values as well as those of surveyed patients without any functional gastrointestinal disorder. Among the respondents with self-reported constipation, 28.9% had visited a physician in the previous 12 months for constipation and 14.1% had undergone some diagnostic procedure. Age and female sex were predictors of healthcare-seeking behavior, as was a lower score in the physical component summary score on the SF-36. It is interesting to note that the SF-36 mental summary score of 48.8 observed by Irvine and colleagues was similar to that of patients with chronic gastroesophageal reflux disease (49.2) and end-stage renal disease (47.8),[21,22] whereas the physical component score of 47.3 was higher than that observed with these other conditions, thus shedding some light on the nature of the impairment that accrues with chronic constipation. Similarly, in their population-based survey of chronic constipation and coping strategies, Cheng and colleagues[10] showed that anxiety and depression were more prevalent in constipated subjects compared with nonconstipated subjects. Awareness of symptoms directly correlated to their perceived impact on daily life and was a predictor of healthcare-seeking behavior. Anxiety was directly correlated to the use of various coping strategies, including traditional and nontraditional medicines, lifestyle revisions, and spiritual/emotional interventions, and most constipated patients (90.8%) in this Asian population felt that these strategies were at least somewhat effective for improving their symptoms. Concluding Commentary It is clear that chronic constipation is prevalent in the United States and other developed countries. The first step in optimizing care for our patients with this condition is to recognize its presence. To this end it is important for clinicians to understand both the objective diagnostic criteria as well as common patient-centered subjective cues. Understanding the impact of chronic constipation on the quality of life of affected patients may help identify factors that motivate both adaptive and maladaptive coping behaviors that may, in and of themselves, be opportune therapeutic targets. Multiple studies have demonstrated that most patients with chronic constipation in the United States and North America have tried a variety of traditional or nontraditional therapies and are generally dissatisfied with the results,[23-25] so it is abundantly clear that simply increasing bowel movement frequency is not a sufficient strategy. Although great strides have been made in terms of understanding the epidemiology and burden of chronic constipation, many unanswered questions remain. There are scant data regarding the incidence and natural history of chronic constipation in the United States, and worldwide data for these issues are also lacking. Although several studies have recently examined the impact of this condition on quality of life, translating quality of life into real-world parameters such as productivity costs and healthcare resource utilization needs further analysis. Future studies should necessarily be long-term, population-based analyses that incorporate both self-reported chronic constipation as well as chronic constipation based on clinical criteria, such as the Rome II criteria. With the advent of newer, more effective therapies and direct-to-consumer marketing campaigns, it is very possible that clinicians may see a significant increase in patients seeking care for their symptoms of chronic constipation. Understanding patient concerns and healthcare-seeking behavior will likely be an important aspect of care for these patients and will be crucial in controlling the sizable increase in healthcare expenditures that could result. Furthermore, outcomes research directed at measuring the effects of treatment on these real-world parameters will be important in future analyses of the cost-effectiveness of current and emerging therapies for chronic constipation. Supported by an independent educational grant from Novartis. Brooks D. Cash, MD, FACP , Assistant Professor of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Director of Clinical Research, Division of Gastroenterology and Comprehensive Colon Cancer Center Initiative, National Naval Medical Center, Bethesda, Maryland Disclosure: Brooks D. Cash, MD, FACP, has disclosed that he has served as an advisor or consultant for Novartis. Medscape Gastroenterology. 2005; 7 (1): Medscape Gastroenterology, 4/05 Remember we are NOT Doctors and have NO medical training. This site is like an Encylopedia - there are many pages, many links on many topics. Support our work with any size DONATION - see left side of any page - for how to donate. You can help raise awareness of CAM.