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Constipation is a common problem and includes symptoms of straining, discomfort and difficulty in passing stool. Mary Rose Day, Teresa Wills and Alice Coffey discuss the advantages and disadvantages of laxatives to combat the condition
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Dr.MaryRoseDay
TeresaWills
Dr.AliceCoffey
Dr.MaryRoseDay
TeresaWills
Dr.AliceCoffey
Dr.MaryRoseDay
TeresaWills
Dr.AliceCoffey
Mary Rose Day1 College Lecturer,
mr.day@ucc.ie; Teresa Wills2 College
Lecturer, t.wills@ucc.ie; Alice Coey3
College Lecturer, a.coey@ucc.ie — all
at Catherine McAuley School of Nursing
and Midwifery, University College Cork
Constipation is a common problem and includes symptoms of straining, discomfort
and diculty in passing stool. Mary Rose Day, Teresa Wills and Alice Coey discuss the
advantages and disadvantages of laxatives to combat the condition
Constipation and the pros and
cons of laxatives for older adults
2
Constipation is common across all care settings.
Approximately 43% of acute hospital in-patients
develop symptoms (Noiesen et al, 2013) and 20%
of older people in a community population suffer
symptoms (Spinzi et al, 2009). In addition, constipation
affects up to 80% of long-term care residents (Potter and
Wagg, 2005; Rao and Go, 2010). There are wide variations
in prevalence estimates in the UK, varying from 12.2% to
52% and higher prevalence is reported among women and
older adults (Shafe et al, 2011).
Constipation has been referred to as a constellation of
symptoms and a gastrointestinal disorder. Normal bowel
function consists of the absorption of nutrients, electro-
lytes and water from the gut and the large bowel absorbs
primarily water (Roerig et al, 2010). The important fea-
ture of constipation is reduced water in the faeces, which
results in the passage of hard faeces infrequently and
with difculty (Gray, 2011). Constipation can be dened
primarily as symptoms of straining, hard stool, discom-
fort and difculty in passing stool (Hicks, 2001). Fur-
thermore it is frequently cited as infrequent defecation
(less than three times a week), which causes discomfort
(Müller-Lissner et al, 2013). According to the Rome III
Criteria for constipation, a person must have experienced
or have present at least two of the symptoms outlined in
Box 1, for at least 3 of the previous 6months.
Constipation is a clinical condition that can signicant-
ly impact on mental health and wellbeing of older adults.
Age-related dietary changes, reduction in mobility, and
multiple comorbidities can give rise to increased preva-
lence risk of constipation (Joanne Briggs Institute, 2008).
Constipation can lead to signicant abdominal pain,
appetite suppression, faecal incontinence, lowered self-
esteem, social isolation, poorer health and quality of life
(Sun et al, 2011; Koloski et al, 2013; Wang et al, 2013).
All of the above will signicantly impact on personal and
public health burden (McMillan, 2002). Mild constipa-
tion may be managed with lifestyle changes, exercise,
walking and an increase in bre intake. More chronic
constipation will require a range of treatments, which
may include laxatives.
A European study by Müller-Lissner et al (2013) used
the internet to survey 1941 participants, of whom 1335
had chronic constipation. Laxatives were used by 68%
of respondents (n=855/1255), however, 28% of partici-
pants were dissatised with their treatment for chronic
constipation. Use of laxatives and prescribed medication
are higher among residents in long-term care than com-
munity-dwelling older adults (Cusack et al, 2012).
What are laxatives?
Laxatives are the most widely used medications and are
useful for short-term management of constipation but
are primarily used to treat chronic constipation. Laxatives
when ingested, act directly on the gut (or gut contents)
to increase stool frequency or ease stool passage (Ford,
2012). Laxatives enhance retention of uids, decrease
absorption of uids, and alter motility by either inhibiting
1
3
Box 1. Rome III criteria for constipation
Straining at stool at least 25% of the time
Hard stools at least 25% of the time
A feeling of incomplete evacuation at least 25% of the
time
A feeling of anal blockage at least 25% of the time
Manual manoeuvres for rectal emptying at least 25%
of the time
Two stools or less per week
From: Muller-Lisner, 2009.
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non-propulsive contractions or stimulating propulsive
contractions (Twycross et al, 2012).
Many factors have resulted in the widespread use of
laxatives. These include an ageing population, low-bre
diets, misconceptions about the normal and desirable
frequency of bowel movements, fear of the consequence of
constipation and availability of over-the-counter laxatives
(Watereld, 2007). In addition, misuse of laxatives is
associated with individuals with eating disorders (anorexia
nervosa and bulimia nervosa). Their primary function
is for weight loss, as laxatives speed up the movement of
faeces through the large intestine. The choice of laxative
can be inuenced by marketing, fashion, availability and
cost (Twycross and Wilcock, 2011) rather than suitability.
However, chronic overuse of laxatives can have adverse
effects (Daniels and Schmelzer, 2013) (Box2).
Chronic overuse of laxatives can cause serious side
effects such as:
Dehydration
Hypokalaemia
Hypernatraemia
Cathartic colon (anatomic and physiologic changes in
the colon that arises from the chronic use of stimulant
laxatives)
Electrolyte imbalance
Tachycardia
Faecal incontinence
Headache
Diarrhoea
Reduction in colonic motility
Apathy and diarrhoea (Arslan and Eser, 2011).
Types of laxatives
The function of laxatives is to increase peristalsis to move
faeces in the bowel in four ways, which will affect a resi-
dent’s choice of laxative (Watereld, 2007). There are
four main groups of laxatives, all of which have advan-
tages and disadvantages, and they are generally classi-
ed according to their predominant action. The laxative
groups include:
Bulk-forming laxatives
Stimulant laxatives
Box 2. Potential advantages and disadvantages of laxatives
Laxatives Mechanism Potential advantages/disadvantages
Bulk-forming laxatives
(bran, husk and
methylcellulose
Fybogel)
Absorb water from the
intestinal lumen thereby
softening stool consistency
and increasing stool bulk
Most eective in individuals with normal transit constipation.
Useful for people with small, hard stools when they cannot
increase bre intake
Take several days to work and can cause bloating, atulence
and abdominal pain (Watereld, 2007). May interfere with the
absorption of some medications commonly prescribed for use by
older people, e.g. digoxin, warfarin, aspirin, iron and calcium
Stimulant laxatives
(Senokot and bisacodyl
(Dulcolax))
Stimulate the myenteric
nerve plexus thereby causing
rhythmic muscle contractions
and increasing intestinal
motility
Bisacodyl is given only in tablet form due to eects on small
intestine. Bisacodyl and senna should not be used if intestinal
obstruction is suspected (Watereld, 2007)
Prokinetic and antiabsortive/
secreatagogic properties
Abdominal discomfort, dehydration, and loss of electrolytes due
to peristalsis and diarrhoea (Watereld, 2007)
Faecal softeners
(Docusate sodium,
glycerol suppositories
and arachis oil (Liu,
2011)
Osmotic and water binding.
These laxatives lubricate and
soften the stool, and facilitate
water absorption
Allergies to nuts, i.e. arachis oil is nut based
Osmotic laxatives
(lactulose, Movicol,
Laxido and milk of
magnesia)
Osmotic water-binding,
bacterial mass, produces a
softer stool and improves
peristalsis
They are usually well-tolerated and are recommended over
other laxatives in older adults (Gallagher and O’Mahony, 2009).
Adequate uid intake is required. They are contraindicated in
patients with diabetes and should be avoided in patients with
the metabolic disorder galactosaemia. Side eects are atulence
cramping, abdominal discomfort, nausea and vomiting.,
and diarrhoea in higher doses. Not very eective for severe
constipation as they may take up to 3days to take eect
Magcrogols osmotic
agents
Macrogol works usually within 48hours and can be used for
faecal impaction (licensed for 8 sachets for 3days) and severe
constipation in older people who are more at risk of constipation.
It can be used with diabetic patients. Macrogol is contraindicated
in patients with severe inammatory conditions of the intestinal
tract (e.g. ulcerative colitis, Crohn’s disease and toxic megacolon)
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Faecal softeners
Osmotic laxatives.
The aim is to restore the amount of water in the fae-
ces by: reducing bowel transit time (exercise, stimulant
laxatives, and osmotic laxatives), increasing faecal water
(osmotic laxatives, stimulant laxatives) and increasing
the ability of the faeces to retain the water (bre, osmotic
laxatives) (Twycross et al, 2012).
Newer laxatives available include prucalopride, lubi-
prostone and linaclotide and efcacy has been shown
in some trials. Prucalopride activates the 5-HT4 recep-
tors for the neurotransmitter serotonin. This allegedly
increases motility of the intestinal system and results in
more frequent bowel movements. According to current
guidance (National Institute for Health and Care Excel-
lence (NICE), 2013), prucalopride is recommended for
the treatment of chronic constipation only in women
when treatment has failed—‘using at least two laxatives
from different classes, at the highest tolerated recom-
mended doses for at least 6months’. The study samples
used mostly women, so there is inconclusive evidence
whether prucalopride works for men.
Practical considerations
History of bowel function experience
A person-centred holistic assessment should include:
Psychosocial history
Bladder function
Bladder and uid diary
Dietary bre intake
Physical activity
Current medications
History of laxative use
Concerns related to current bowel habit compared to
past habit.
Evidence-based guidelines recommend using a bowel
diary (NICE, 2007) and history of bowel function (size,
consistency, frequency) in conjunction with the Bristol
Stool Form Scale (Heaton and Lewis, 1997, NICE 2007)
(Figure 1). The assessment documents type, dose, and
duration of any previous laxative use (Gray, 2011). Evi-
dence-based guidelines identify the digital rectal exami-
nation (DRE) as an essential component of bowel assess-
ment (NICE, 2007).
DRE is an invasive procedure and involves observing
the perianal area and inserting a lubricated gloved nger
in the person’s rectum. Consent must be obtained before
undertaking DRE. To make a clear diagnosis, nurses need
specialist knowledge and skills and competence to assess
bowel dysfunction and undertake a DRE (Kyle, 2007).
Furthermore health professionals need to explore the
self-care strategies already tried before informing older
people about options and treatments. Anecdotal evidence
suggests that older people will have explored a number of
solutions to constipation before they seek advice from a
health professional. Further investigations are required
if there are suspicions of an underlying gastrointestinal
disorder, e.g. weight loss, blood in stool, rectal bleed-
ing, cramping, abdominal pain, and nausea (Tack et al,
2011).
Dietary considerations
Some foods may reduce or increase the effect of laxa-
tives. Foods such as chocolate, rice, white bread, cream
cheese, pasta and supplements like iron and calcium
can have a constipating effect, and foods such as whole
grain, prunes, sugar substitutes (sorbitol) and fat substi-
tutes (olestra) may cause diarrhoea (Gelinas, 2012). A
food and uid diary can be used to aid assessment (Kyle,
2011).
There may be more than one solution
A person-centred approach is recommended with op-
tions such as a mix of diet, uids exercise and a laxative
solution, while enabling the person to retain control over
their treatment. Treatment regimens need to be tailored
to suit type of constipation (acute or chronic) and degree
of constipation. An understanding of the pathophysiol-
ogy and specic symptoms in the individual can improve
outcomes (Fosnes et al, 2011). Individuals can be advised
on the best position to adopt when toileting, e.g. sitting
with knees slightly higher than the hips and supporting
the feet on steps if necessary (Sikirov, 2003).
Individualised care
Special attention should be paid to medical history, cardiac
and renal function, interaction between prescribed and
over-the-counter medication, food interaction, cost and
side effects (Rao and Go, 2010). Glucose levels need to be
monitored carefully in people with diabetes as many laxa-
tives contain carbohydrate that may raise blood sugar.
Figure 1. Bristol Stool Form Scale
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Patient education
Constipation can indicate that an older adult may be
dehydrated. Older adults require education on the dangers
of dehydration and the necessity of adequate hydration
while on laxatives. This may discourage self-treatment of
constipation using laxatives.
Fluid and electrolyte imbalance
Health professionals need to observe for signs of uid and
electrolyte imbalance (Daniels and Schmelzer, 2013). If
faecal incontinence has occurred, this may be due to im-
paction with overow or overuse of laxatives. Clear writ-
ten information needs to be provided on the mode of ac-
tion of the prescribed laxative with instruction on correct
dosage and timing of administration. Advice needs to be
given to older adults on the potential complications that
can arise from prolonged use of laxatives.
Timing of laxatives
Appropriate timing of laxatives is essential to their effec-
tiveness. Nurses should also consider the effect of laxa-
tives on patients sleep and other activities of daily living
when administering them (Daniels and Schmelzer, 2013).
Conclusion
Constipation is a constellation of symptoms that can
be readily diagnosed using the Rome III criteria. The
assessment of symptoms can be undertaken using
the Bristol Stool Form Scale. A holistic person-centred
assessment includes psychosocial history, bowel and
uid diary, bladder function, dietary bre intake, physical
activity, current medications, history of laxative use and a
DRE. There are a wide range of laxatives readily available.
However, the type of laxative chosen needs to be based
on type of constipation, medical history and individual’s
tolerance and preferences.
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Key words
Constipation is more common in older adults and aects 20% of
community dwelling adults and up to 80% of residents living in long-term
care environments
Constipation is associated with poor health outcomes and increased
health-care costs and will impact on public health burden
Chronic constipation is a clinical condition that requires a holistic
assessment and an individualized approach
Assessment needs to identify constipation and out rule any underlying
pathology before prescribing laxatives
Laxative is a common treatment and the type of laxative prescribed should
be based on the type of constipation that is present
... The oral intake of unabsorbable disaccharides may affect carbohydrate metabolism by reducing transit time and, possibly, glucose absorption [25,26]. The intake of both the 20 g and 30 g lactulose doses, regardless of the formulation, resulted in a slight net decrease in blood glucose concentrations of approx. ...
... 35,45 Day et al argue that individualized care is recommended and that a combination of several treatment options may be needed to treat constipation and, above all, they emphasize investigating which strategies the patients themselves use. 46 Dimidi et al argue that numerous symptoms are identified by patients but are often not diagnosed by healthcare professionals according to diagnostic criteria or tools. 47 This indicates that it is necessary to take the patient's view into consideration when diagnosing the condition. ...
Article
Full-text available
Purpose: Constipation is a common and troublesome condition among older patients and can result in a variety of negative health consequences. It is often undiagnosed or undertreated. Healthcare professionals have a responsibility to understand and address patients' overall healthcare needs; so exploring their experiences is, therefore, highly relevant. The purpose of the study was to explore healthcare professionals' experiences of assessing, treating and preventing constipation among older patients. Methods: A qualitative design with an exploratory approach was used. The participants (registered nurses and physicians) were purposively sampled from three wards in a geriatric department in a medium-sized hospital in Sweden. Data were collected through focus group discussions and individual interviews, and analyzed using content analysis. Results: Three categories were generated: Reasons for suboptimal management of constipation, Strategies for management, and Approaching the patients' needs. In the care of older patients at risk of or with constipation, decisions were made based on personal knowledge, personal experience and clinical reasoning. A person-centered approach was highlighted but was not always possible to incorporate. Conclusion: Different strategies for preventing and treating constipation were believed to be important, as was person-centered care, but were found to be challenging in the complexity of the care situation. It is important that healthcare professionals reflect on their own knowledge and clinical practice. There is a need for more support, information and specific guidance for healthcare professionals caring for older patients during hospitalization. Overall, this study underscores the importance of adequate access to resources and education in constipation management and that clinical guidelines, such as the Swedish Handbook for Healthcare, could be used as a guide for delivering high-quality care in hospitals.
... Day, Wills and Coffey (46) argue that individualized care is recommended and that a combination of several treatment options may be needed to treat constipation and, above all, they emphasize investigating which strategies the patients themselves use. Dimidi, Cox, Grant, Scott and Whelan (47) argue that numerous symptoms are identi ed by patients but are often not diagnosed by healthcare professionals according to diagnostic criteria or tools. ...
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Full-text available
Background Constipation is a common and troublesome condition among older patients and can result in a variety of negative health consequences. It is often undiagnosed or undertreated. Healthcare professionals have a responsibility to understand and address patients’ overall healthcare needs so exploring their experiences is, therefore, highly relevant. The purpose of the study was to explore healthcare professionals’ experiences of assessing, treating and preventing constipation among older patients. Methods A qualitative design with an exploratory approach was used. The participants were purposively sampled from three wards in a geriatric department in a medium-sized hospital in Sweden. Data were collected through focus group interviews and individual interviews and analyzed using content analysis. Results Three categories were generated: depending on resources and uncertainties, using different strategies, and approaching the patients’ needs. In the care of older patients at risk of or with constipation, decisions were made based on personal knowledge, personal experience and clinical reasoning. A person-centered approach was highlighted but was not always possible to incorporate. Conclusions Different strategies for preventing and treating constipation were believed to be important, as was person-centered care, but were found to be difficult to perform. Healthcare professionals need adequate resources. Evidence-based clinical guidelines might help the delivery of high-quality care. Constipation needs to be given more focus in hospitals in order to potentially improve the care and patient outcomes for older people.
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Functional constipation (FC) is one of the common diseases among children. The aim of this study was to investigate the health-related quality of life (HRQOL) in preschool children diagnosed with FC and the impact of the condition on affected families. In this cross-sectional, case-control study, 152 children aged 3-6 years with FC, 176 healthy children aged 3-6 years without FC, and their primary caregivers were selected. Chinese versions of the PedsQL(TM) 4.0 Generic Core Scale and the Family Impact Module (FIM) were used to assess childhood HRQOL and the impact of FC on family members, respectively. HRQOL scores were compared between children with FC and healthy children. In addition, a multiple step-wise regression with demographic variables of children and their caregivers, family economic status, duration and symptoms of FC, as independent variables, was used to determine factors that influenced HRQOL in children and had impacted caregivers. Scores of physical, emotional, social and school functions, and summary scales were significantly lower in children with FC than in healthy children (p < 0.05). Physical, emotional, social, cognitive, and communication scores for caregivers, as well as daily activities and relationships for families of children with FC, were significantly lower than those of caregivers and families with healthy children (p < 0.05). Children's ages, duration of FC, symptoms of FC, the child-caregiver relationship, family economic status, and caregiver education level emerged as the main factors influencing HRQOL in children, caregivers, and family members. FC had a significant impact on HRQOL of affected children and their caregivers, as well as their family functions. Social characteristics of children and caregivers, duration and symptoms of FC and family economic status significantly affected HRQOL of children and caregivers, as well as family functions of children with FC.
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This article provides an overview of the main types of laxative. There is a consideration of the factors involved in the choice of laxative, including their mode of action. Different prescribing scenarios are summarized in four flowcharts, and a case study provides the opportunity to consolidate prescribing issues in the management of constipation.
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Constipation is a highly prevalent and difficult‐to‐cure health problem, forcing 10–20% of the worldwide population to seek medical care. Efficacy of treatments varies greatly among individuals, and problems are becoming more frequent despite higher consumption of fibre‐rich foods, the most popular solution for preventing such gastrointestinal disorders. The evidence that consumption of fibre prevents and relieves constipation is unconvincing or uncertain. The food industry has made great efforts to develop fibre‐rich ingredients, especially those from food by‐products and wastes. Except for psyllium and wheat bran, most of these ingredients have intermediate or low laxative potential and their efficacy needs to be confirmed by more clinical studies. This review suggests that there are major discrepancies between the proposed fibre‐enriched ingredients and the consumers' needs. As a lasting solution to prevent constipation, the true impact of dietary fibre and potent food‐grade laxatives might also be limited by overeating.
Article
To examine the prevalence and incidence of patient-reported symptoms of constipation in acutely hospitalised medical patients. Constipation is a common medical problem with severe consequences, and most people suffer from constipation at some point in their lives. In the general population, constipation is one of the most common complaints and is a significant personal and public health burden. Alteration in patients' patterns of elimination while in hospital has long been identified as either a potential or an actual problem that requires attention. Knowledge of the prevalence and incidence of constipation during hospitalisation is only sporadic. The study was descriptive and a prospective cohort design was chosen. The Constipation Assessment Scale was translated into Danish and was used for the assessment of patient-reported bowel function. Five nurses made the assessments at admission to the acute medical ward and three days after admission. Three hundred and seventy-three patients participated in this study. Thirty-nine percent of the patients showed symptoms of constipation at admission. Of the patients who did not have the symptoms at admission, 43% developed the symptoms during the first three days of their stay in hospital. Significantly more of the older patients developed symptoms of moderate constipation. The incidence rate was 143 new cases per 1000 patient days. In this study, symptoms of constipation were common among patients acutely admitted to hospital due to different medical conditions. Symptoms of constipation were also developed during the first three days of the stay in hospital. The study highlights the need to develop both clinical guidelines towards treating constipation, and preventive measures to ensure that patients do not become constipated while staying in hospital.
Article
LEARNING OUTCOMESOn completion of the article the reader should be able to: •Understand the factors which influence care planning in the management of constipation•Be able to outline the main causes of constipation•Discuss a strategy for the prevention of constipation in the orthopaedic patient•Be aware of the main interventions that a nurse may undertake to treat constipation for this client group.UKCC CATEGORIESThis article will enable the reader to address PREP categories: •Reducing risk•Care enhancement•Practice development•Education development.Examples of how this may be achieved and possible evidence for your portfolio are given throughout the article. Other ways to demonstrate your professional development may be to: •Develop a teaching programme based on the article for your ward area•Develop a protocol for staff to use in the assessment and management of constipation•Use this article to reflect on other patient problems that staff may only associate with older people but which affect all orthopaedic patients.
Article
Data on treatment satisfaction in European men and women with chronic constipation are limited. To assess satisfaction with current treatment among European men and women with chronic constipation. An internet-based survey was conducted in 2009 in 10 European countries: Austria, Germany, France, Ireland, Italy, Spain, Switzerland, the UK, Belgium and the Netherlands. Participants had self-reported chronic constipation (<3 bowel movements/week and ≥1 symptoms for ≥6 months of: pain during defecation; lumpy/hard faeces; and feeling of incomplete evacuation). Demographic data and disease history were collected. For participants using laxatives, drug name/class, satisfaction with treatment and interest in other treatments were collected. Of the 1941 participants screened, 1355 had chronic constipation and met the inclusion criteria (chronic constipation population). The majority of the chronic constipation population who disclosed their sex (n = 811) were women (82%). Sixty-eight per cent of respondents (n = 855/1255) reported using laxatives, with the proportion of laxative users differing between subsets. Twenty-eight per cent (n = 225/793) were (very) satisfied with their treatment, whereas 44% (n = 345/793) were neutral and 28% (n = 223/793) (very) dissatisfied. There was no relationship between type of laxative and degree of (dis)satisfaction. Interest in other treatments was high with 83% (n = 686/827) of respondents ‘absolutely’ or ‘probably’ interested. Respondents dissatisfied with their treatment were more likely to be interested in other treatments. Laxative-use is common for chronic constipation. In this large survey, 28% of participants were dissatisfied with their treatment, with the majority interested in other treatments.
Article
A 25 year old woman attends her general practitioner with a six month history of constipation. Despite having increased her daily intake of fibre and water, she is still only passing two stools a week. Her general practitioner excludes red flag features (box) and finds no abnormality on examination, apart from a loaded rectum. He suggests she try using laxatives to increase her stool frequency, but she is reluctant as she has heard they are not very effective and can have adverse effects. #### Red flag features in chronic constipation12 Laxatives are foods or drugs that, when ingested, act directly on the gut (or gut contents) to increase stool frequency or ease stool passage. They differ from motility agents such as prucalopride, which exert a promotility effect after systemic absorption. Laxatives are used to treat chronic constipation, usually defined as the presence of difficult or infrequent passage of stool, often accompanied by straining or a sensation of incomplete evacuation, with symptoms present for more than three months. Chronic constipation is common in the general population. A recent meta-analysis of population based observational studies reported a pooled prevalence of 14% worldwide, with a significantly higher prevalence in women and people of lower socioeconomic status.3 However, symptoms often fluctuate, and recent community data suggest that persistent symptoms over 10 to 20 years affect only 3% of the population.4 Population based studies also show that constipation affects quality of life, is associated with several comorbidities (including haemorrhoids and anal fissure),5 and may be associated with a modest reduction in survival.6 Laxatives may act by several mechanisms, including bulking the stool volume, softening the stool consistency, increasing the stool volume …