Management of constipation: A narrative review of evolving strategies and methodological challenges

Abstract

Constipation is a common multifactorial gastrointestinal disorder with a significant impact on quality of life, healthcare utilization, and economic burden. It encompasses a spectrum of symptoms, including infrequent bowel movements (fewer than three per week), lumpy or hard stools (Bristol Stool Form Scale 1 or 2), straining, difficult stool passage, a sense of incomplete evacuation, etc. When no organic cause is identifiable, the condition is labeled as functional constipation. Pharmacological management of constipation has been extensively explored, with several new therapies added to the armamentarium in the last decade. However, its management remains challenging due to heterogeneous etiologies, varied diagnostic approaches, and the broad spectrum of therapeutic options. This narrative review summarizes contemporary strategies for the management of constipation, encompassing lifestyle and dietary modifications, pharmacological therapies, behavioral interventions, and surgical options for refractory cases. Traditional laxatives continue to form the mainstay of treatment, but newer agents such as prosecretory drugs, serotonergic agonists, and bile acid modulators have expanded therapeutic possibilities, offering targeted mechanisms and improved tolerability. Non-pharmacological approaches, including biofeedback for pelvic floor dysfunction and neuromodulation techniques, provide effective alternatives in selected patients. Despite these advances, substantial methodological variability exists in clinical trials, including differences in diagnostic criteria, endpoints, and follow-up durations, limiting the generalizability of findings. A more standardized framework for defining outcomes and assessing long-term efficacy is needed to strengthen evidence-based practice. Ultimately, the management of constipation requires an individualized approach that integrates symptom severity, underlying pathophysiology, patient preference, and availability of resources. Newer research is focused on tailoring treatment to special groups of patients with refractory constipation, surgical modalities for patients with neurogenic bowel, and microbiome modulation using artificial intelligence.

Keywords: Constipation; Gastrointestinal motility disorders; Irritable bowel syndrome; Defecation disorders; Colonic transit; Pelvic floor disorders; Prokinetic agents; Disorders of gut-brain interactions

Core Tip: Chronic constipation is a heterogeneous disorder encompassing distinct pathophysiologic phenotypes, including normal-transit constipation, slow-transit constipation, defecatory disorders, and a broad range of secondary organic causes. Failure to recognize these subtypes contributes to suboptimal treatment responses and inconsistent outcomes in both clinical practice and trials. Accurate diagnosis requires a structured, stepwise approach integrating careful history, targeted physical examination, and selective use of physiologic and imaging investigations. Management should be phenotype-driven, combining lifestyle measures, pharmacologic therapy, and pelvic floor-directed interventions when appropriate. Emphasizing mechanism-based evaluation and individualized treatment strategies is essential to improve long-term outcomes and reduce unnecessary therapeutic escalation.