Advertisement

Chronic Constipation: a Review of Current Literature

  • Hani SbahiEmail author
  • Brooks D. Cash
Large Intestine (B Cash, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Large Intestine

Abstract

Chronic constipation is a common health condition representing a substantial proportion of primary care visits and referrals to specialist providers. Chronic constipation can have a significant negative effect on health-related quality of life and has been associated with psychological distress in severely affected patients. It has the potential to cause patients to curtail work, school, and social activities. While different pathophysiological mechanisms have been implicated in the development of chronic constipation, in some instances, the causes of chronic constipation are not easily determined. Expenditures for the evaluation and management of chronic constipation represent a significant burden on patients and payers, and it is important for clinicians to have a clear understanding of the different pathophysiological mechanisms associated with constipation, understand the different testing modalities and treatments that are available including their appropriateness and limitations, and tailor that knowledge to the management of individual patients.

Keywords

Constipation Chronic constipation Management of chronic constipation Pelvic floor dysfunction Dyssynergic defecation Types of constipation 

Notes

Compliance with Ethics Guidelines

Conflict of Interest

Hani Sbahi declares no conflict of interest.

Brooks D. Cash reports personal fees from Takeda, Actavis, Astra Zeneca, Ironwood, and Sucampo, outside the submitted work.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Suares N, Ford A. Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis. Am J Gastroenterol. 2011;106(9):1582–91.PubMedCrossRefGoogle Scholar
  2. 2.
    McCrea G, Miaskowski C, Stotts N, et al. A review of the literature on gender and age differences in the prevalence and characteristics of constipation in North America. J Pain Symptom Manag. 2009;37(4):737–45.CrossRefGoogle Scholar
  3. 3.
    Mugie S, Benninga M, Di Lorenzo C. Epidemiology of constipation in children and adults: a systematic review. Best Pract Res Clin Gastroenterol. 2011;25(1):3–18.PubMedCrossRefGoogle Scholar
  4. 4.
    Dennison C, Prasad M, Lloyd A, et al. The health-related quality of life and economic burden of constipation. PharmacoEconomics. 2005;23(5):461–76.PubMedCrossRefGoogle Scholar
  5. 5.
    Sanchez MI, Bercik P. Epidemiology and burden of chronic constipation. Can J Gastroenterol. 2011;25(Suppl B):11B–5B.PubMedGoogle Scholar
  6. 6.
    Basilisco G, Coletta M. Chronic constipation: a critical review. Dig Liver Dis. 2013;45(11):886–93.PubMedCrossRefGoogle Scholar
  7. 7.•
    Bharucha A, Pemberton J, Locke G. American Gastroenterological Association technical review on constipation. Gastroenterology. 2013;144(1):218–38. A valuable comprehensive review of chronic constipation.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Herz M, Kahan E, Zalevski S, et al. Constipation: a different entity for patients and doctors. Fam Pract. 1996;13(2):156–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Longstreth G, Thompson W, Chey W, et al. Functional bowel disorders. Gastroenterology. 2006;130(5):1480–91.PubMedCrossRefGoogle Scholar
  10. 10.
    Gallagher P, O'Mahony D. Constipation in old age. Best Pract Res Clin Gastroenterol. 2009;23(6):875–87.PubMedCrossRefGoogle Scholar
  11. 11.
    Andromanakos NP, Pinis SI, Al K. Chronic severe constipation: current pathophysiological aspects, new diagnostic approaches, and therapeutic options. Eur J Gastroenterol Hepatol. 2015;27(3):204–14.PubMedCrossRefGoogle Scholar
  12. 12.
    Xu L, WY W, Jiang J, et al. Clinical benefits after soluble dietary fiber supplementation: a randomized clinical trial in adults with slow-transit constipation. Zhonghua Yi Xue Za Zhi. 2014;94(48):3813–6.PubMedGoogle Scholar
  13. 13.
    Voderholzer W, Schatke W, Mühldorfer B, et al. Clinical response to dietary fiber treatment of chronic constipation. Am J Gastroenterol. 1997;92(1):95–8.PubMedGoogle Scholar
  14. 14.
    Hammer J, Phillips S. Fluid loading of the human colon: effects on segmental transit and stool composition. Gastroenterology. 1993;105(4):988–98.PubMedGoogle Scholar
  15. 15.
    Stephen A, Wiggins H, Cummings J. Effect of changing transit time on colonic microbial metabolism in man. Gut. 1987;28(5):601–9.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Penning C, Steens J, van der Schaar P, et al. Motor and sensory function of the rectum in different subtypes of constipation. Scand J Gastroenterol. 2001;36(1):32–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Rao S, Seaton K, Miller M, et al. Psychological profiles and quality of life differ between patients with dyssynergia and those with slow transit constipation. J Psychosom Res. 2007;63(4):441–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Lembo A, Camilleri M. Chronic constipation. N Engl J Med. 2003;349(14):1360–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Mertz H, Naliboff B, Mayer E. Physiology of refractory chronic constipation. Am J Gastroenterol. 1999;94:609–15.PubMedCrossRefGoogle Scholar
  20. 20.
    Preston D, Lennard-Jones J. Severe chronic constipation of young women: 'idiopathic slow transit constipation'. Gut. 1986;27(1):41–8.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    He C, Burgart L, Wang L, et al. Decreased interstitial cell of Cajal volume in patients with slow-transit constipation. Gastroenterology. 2000;118(1):14–21.PubMedCrossRefGoogle Scholar
  22. 22.
    Wedel T, Spiegler J, Soellner S, et al. Enteric nerves and interstitial cells of Cajal are altered in patients with slow-transit constipation and megacolon. Gastroenterology. 2002;123(5):1459–67.PubMedCrossRefGoogle Scholar
  23. 23.
    Tzavella K, Riepl R, Klauser A, et al. Decreased substance P levels in rectal biopsies from patients with slow transit constipation. Eur J Gastroenterol Hepatol. 1996;8(12):1207–11.PubMedCrossRefGoogle Scholar
  24. 24.
    Cortesini C, Cianchi F, Infantino A, et al. Nitric oxide synthase and VIP distribution in enteric nervous system in idiopathic chronic constipation. Dig Dis Sci. 1995;40(11):2450–5.PubMedCrossRefGoogle Scholar
  25. 25.
    Vierhout ME, Schreuder HW, Veen HF. Severe slow-transit constipation following radical hysterectomy. Gynecol Oncol. 1993;51:401–3.PubMedCrossRefGoogle Scholar
  26. 26.
    MacDonald A, Baxter J, Bessent R, et al. Gastric emptying in patients with constipation following childbirth and due to idiopathic slow transit. Br J Surg. 1997;84(8):1141–3.PubMedCrossRefGoogle Scholar
  27. 27.
    Barnes P, Lennard-Jones J, Hawley P, et al. Hirschsprung's disease and idiopathic megacolon in adults and adolescents. Gut. 1986;27(5):534–41.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Tack J, Müller-Lissner S, Stanghellini V, et al. Diagnosis and treatment of chronic constipation—a European perspective. Neurogastroenterol Motil. 2011;23(8):697–710.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Bharucha AE, Wald A, Enck P, et al. Functional anorectal disorders. Gastroenterology. 2006;130(5):1510–8.PubMedCrossRefGoogle Scholar
  30. 30.
    Chiarioni G, Whitehead WE, Pezza V, et al. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology. 2006;130:657–64.PubMedCrossRefGoogle Scholar
  31. 31.
    Rao S, Seaton K, Miller M, et al. Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol. 2007;5(3):331–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Heymen S, Scarlett Y, Jones K, et al. Randomized, controlled trial shows biofeedback to be superior to alternative treatments for patients with pelvic floor dyssynergia-type constipation. Dis Colon Rectum. 2007;50(4):428–41.PubMedCrossRefGoogle Scholar
  33. 33.
    Henderson P, DiPalma J. Diagnosing irritable bowel syndrome: a changing clinical paradigm. South Med J. 2011;104(3):195–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Lewis S, Heaton K. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol. 1997;32(9):920–4.PubMedCrossRefGoogle Scholar
  35. 35.
    Rao S, Meduri K. What is necessary to diagnose constipation? Best Pract Res Clin Gastroenterol. 2011;25(1):127–40.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Tantiphlachiva K, Rao P, Attaluri A, et al. Digital rectal examination is a useful tool for identifying patients with dyssynergia. Clin Gastroenterol Hepatol. 2010;8(11):955–60.PubMedCrossRefGoogle Scholar
  37. 37.
    Rao S, Ozturk R, Laine L. Clinical utility of diagnostic tests for constipation in adults: a systematic review. Am J Gastroenterol. 2005;100(7):1605–15.PubMedCrossRefGoogle Scholar
  38. 38.
    American College of Gastroenterology Chronic Constipation Task Force. An evidence-based approach to the management of chronic constipation in North America. Am J Gastroenterol. 2005;100 suppl 1:S1–4.CrossRefGoogle Scholar
  39. 39.
    Cash BD, Acosta RD, Chandrasekhara V, et al. The role of endoscopy in the management of constipation. Gastrointest Endosc. 2014;80(4):563–5.PubMedCrossRefGoogle Scholar
  40. 40.
    Gupta M, Holub J, Knigge K, et al. Constipation is not associated with an increased rate of findings on colonoscopy: results from a national endoscopy consortium. Endoscopy. 2010;42(03):208–12.PubMedCrossRefGoogle Scholar
  41. 41.
    Remes-Troche J, Rao S. Diagnostic testing in patients with chronic constipation. Curr Gastroenterol Rep. 2006;8(5):416–24.PubMedCrossRefGoogle Scholar
  42. 42.
    Shorvon P, McHugh S, Diamant N, et al. Defecography in normal volunteers: results and implications. Gut. 1989;30(12):1737–49.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Gladman M, Aziz Q, Scott S, et al. Rectal hyposensitivity: pathophysiological mechanisms. Neurogastroenterol Motil. 2009;21(5), 508-e5.CrossRefGoogle Scholar
  44. 44.
    Rao S. Dyssynergic defecation. Gastroenterol Clin N Am. 2001;30(1):97–114.CrossRefGoogle Scholar
  45. 45.•
    Rao S, Singh S. Clinical utility of colonic and anorectal manometry in chronic constipation. J Clin Gastroenterol. 2010;44(9):597–609. A superb review of colonic and anorectal manometry with detailed explanation on the technical aspects of the tests.PubMedCrossRefGoogle Scholar
  46. 46.
    Deen K, Premaratna R, Fonseka M, et al. The recto-anal inhibitory reflex: abnormal response in diabetics suggests an intrinsic neuroenteropathy. J Gastroenterol Hepatol. 1998;13(11):1107–10.PubMedCrossRefGoogle Scholar
  47. 47.
    Vorobyov G, Achkasov S, Biryukov O. Clinical features, diagnostics and treatment of Hirschsprung’s disease in adults. Color Dis. 2010;12(12):1242–8.CrossRefGoogle Scholar
  48. 48.
    Lin H, Prather C, Fisher R, et al. Measurement of gastrointestinal transit. Dig Dis Sci. 2005;50(6):989–1004.PubMedCrossRefGoogle Scholar
  49. 49.
    Rao S, Welcher K, Leistikow J. Obstructive defecation: a failure of rectoanal coordination. Am J Gastroenterol. 1998;93(7):1042–50.PubMedCrossRefGoogle Scholar
  50. 50.
    Johanson J, Kralstein J. Chronic constipation: a survey of the patient perspective. Aliment Pharmacol Ther. 2007;25(5):599–608.PubMedCrossRefGoogle Scholar
  51. 51.
    Müller-Lissner S, Tack J, Feng Y, et al. Levels of satisfaction with current chronic constipation treatment options in Europe—an internet survey. Aliment Pharmacol Ther. 2012;37(1):137–45.PubMedCrossRefGoogle Scholar
  52. 52.
    Sahin M, Dogan I, Cengiz M, et al. The impact of anorectal biofeedback therapy on the quality of life of patients with dyssynergic defecation. Turk J Gastroenterol. 2015;26(2):140–4.PubMedCrossRefGoogle Scholar
  53. 53.•
    Lee H, Boo S, Jung K, et al. Long-term efficacy of biofeedback therapy in patients with dyssynergic defecation: results of a median 44 months follow-up. Neurogastroenterol Motil. 2015. A trial assessing the long-term efficacy of biofeedback therapy in a large group of patients with dyssynergic defecation, concluding that biofeedback therapy is durable and efficacy was maintained for more than 2 years in a sizable proportion of constipated patients with dyssynergic defecation.Google Scholar
  54. 54.
    Muller-Lissner S, Kamm M, Scarpignato C, et al. Myths and misconceptions about chronic constipation. Am J Gastroenterol. 2005;100(1):232–42.PubMedCrossRefGoogle Scholar
  55. 55.
    Lacy B, Hussain Z, Mearin F. Treatment for constipation: new and old pharmacological strategies. Neurogastroenterol Motil. 2014;26(6):749–63.PubMedCrossRefGoogle Scholar
  56. 56.
    Dukas L. Association between physical activity, fiber intake, and other lifestyle variables and constipation in a study of women. Am J Gastroenterol. 2003;98(8):1790–6.PubMedCrossRefGoogle Scholar
  57. 57.
    DiPalma JA. Current treatment options for chronic constipation. Rev Gastroenterol Disord. 2004;4 Suppl 2:S34–42.PubMedGoogle Scholar
  58. 58.
    Tack J. Current and future therapies for chronic constipation. Best Pract Res Clin Gastroenterol. 2011;25(1):151–8.PubMedCrossRefGoogle Scholar
  59. 59.
    Tack J, Müller–Lissner S. Treatment of chronic constipation: current pharmacologic approaches and future directions. Clin Gastroenterol Hepatol. 2009;7(5):502–8.PubMedCrossRefGoogle Scholar
  60. 60.
    Cash BD, Lacy BE. Systematic review: FDA-approved prescription medications for adults with constipation. Gastroenterol Hepatol. 2006;2(10):736–49.Google Scholar
  61. 61.
    DiPalma J, Cleveland M, McGowan J, et al. A randomized, multicenter, placebo-controlled trial of polyethylene glycol laxative for chronic treatment of chronic constipation. Am J Gastroenterol. 2007;102(7):1436–41.PubMedCrossRefGoogle Scholar
  62. 62.
    DiPalma J, Cleveland M, McGowan J, et al. A comparison of polyethylene glycol laxative and placebo for relief of constipation from constipating medications. South Med J. 2007;100(11):1085–90.PubMedCrossRefGoogle Scholar
  63. 63.
    Di Palma J, Smith J, Cleveland M. Overnight efficacy of polyethylene glycol laxative. Am J Gastroenterol. 2002;97(7):1776–9.PubMedCrossRefGoogle Scholar
  64. 64.
    Mueller-Lissner S, Kamm M, Wald A, et al. Multicenter, 4-week, double-blind, randomized, placebo-controlled trial of sodium picosulfate in patients with chronic constipation. Am J Gastroenterol. 2010;105(4):897–903.PubMedCrossRefGoogle Scholar
  65. 65.
    Kamm M, Mueller–Lissner S, Wald A, et al. Oral bisacodyl is effective and well-tolerated in patients with chronic constipation. Clin Gastroenterol Hepatol. 2011;9(7):577–83.PubMedCrossRefGoogle Scholar
  66. 66.
    Schiffhauer E, Vij N, Kovbasnjuk O, et al. Dual activation of CFTR and CLCN2 by lubiprostone in murine nasal epithelia. Am J Physiol Lung Cell Mol Physiol. 2013;304(5):L324–31.PubMedPubMedCentralCrossRefGoogle Scholar
  67. 67.
    Wilson N, Schey R. Lubiprostone in constipation: clinical evidence and place in therapy. Ther Adv Chronic Dis. 2015;6(2):40–50.PubMedPubMedCentralCrossRefGoogle Scholar
  68. 68.
    Johanson J, Morton D, Geenen J, et al. Multicenter, 4-week, double-blind, randomized, placebo-controlled trial of lubiprostone, a locally-acting type-2 chloride channel activator, in patients with chronic constipation. Am J Gastroenterol. 2008;103(1):170–7.PubMedCrossRefGoogle Scholar
  69. 69.
    Fukudo S, Hongo M, Kaneko H, et al. Lubiprostone increases spontaneous bowel movement frequency and quality of life in patients with chronic idiopathic constipation. Clin Gastroenterol Hepatol. 2015;13(2):294–301. e5.PubMedCrossRefGoogle Scholar
  70. 70.•
    Barish C, Drossman D, Johanson J, et al. Efficacy and safety of lubiprostone in patients with chronic constipation. Dig Dis Sci. 2009;55(4):1090–7. This study assessed the efficacy and safety of lubiprostone in patients with chronic constipation. The authors concluded that lubiprostone produced a bowel movement in the majority of individuals within 24 h of initial dosing, with sustained improvement in frequency and other constipation symptoms over 4 weeks.PubMedCrossRefGoogle Scholar
  71. 71.
    Drossman D, Chey W, Johanson J, et al. Clinical trial: lubiprostone in patients with constipation-associated irritable bowel syndrome—results of two randomized, placebo-controlled studies. Aliment Pharmacol Ther. 2009;29(3):329–41.PubMedCrossRefGoogle Scholar
  72. 72.•
    Cryer B, Katz S, Vallejo R, et al. A randomized study of lubiprostone for opioid-induced constipation in patients with chronic noncancer pain. Pain Med. 2014;15(11):1825–34. In this study, the authors assessed the efficacy and safety of lubiprostone 24 mg twice daily for the treatment of OIC in adult patients with non-cancer pain. The results confirmed superior efficacy of lubiprostone compared to placebo in terms of increasing SBM frequency, improvement in abdominal discomfort, straining, constipation severity, stool consistency, and patient satisfaction. In addition, lubiprostone was well-tolerated with no serious lubiprostone-related adverse events.PubMedPubMedCentralCrossRefGoogle Scholar
  73. 73.
    Love B, Johnson A, Smith L. Linaclotide: a novel agent for chronic constipation and irritable bowel syndrome. Am J Health Syst Pharm. 2014;71(13):1081–91.PubMedCrossRefGoogle Scholar
  74. 74.
    Lembo A, Schneier H, Shiff S, et al. Two randomized trials of linaclotide for chronic constipation. N Engl J Med. 2011;365(6):527–36.PubMedCrossRefGoogle Scholar
  75. 75.
    Johnston J, Kurtz C, Drossman D, et al. Pilot study on the effect of linaclotide in patients with chronic constipation. Am J Gastroenterol. 2009;104(1):125–32.PubMedCrossRefGoogle Scholar
  76. 76.
    Lembo A, Kurtz C, MacDougall J, et al. Efficacy of linaclotide for patients with chronic constipation. Gastroenterology. 2010;138(3):886–95. e1.PubMedCrossRefGoogle Scholar
  77. 77.
    Johnston J, Kurtz C, MacDougall J, et al. Linaclotide improves abdominal pain and bowel habits in a phase IIb study of patients with irritable bowel syndrome with constipation. Gastroenterology. 2010;139(6):1877–86. e2.PubMedCrossRefGoogle Scholar
  78. 78.
    Rao S, Lembo A, Shiff S, et al. A 12-week, randomized, controlled trial with a 4-week randomized withdrawal period to evaluate the efficacy and safety of linaclotide in irritable bowel syndrome with constipation. Am J Gastroenterol. 2012;107(11):1714–24.PubMedPubMedCentralCrossRefGoogle Scholar
  79. 79.
    Chey W, Lembo A, Lavins B, et al. Linaclotide for irritable bowel syndrome with constipation: a 26-week, randomized, double-blind, placebo-controlled trial to evaluate efficacy and safety. Am J Gastroenterol. 2012;107(11):1702–12.PubMedCrossRefGoogle Scholar
  80. 80.
    Wald A. Constipation. Curr Opin Gastroenterol. 2015;31(1):45–9.PubMedCrossRefGoogle Scholar
  81. 81.
    Shailubhai K, Comiskey S, Foss J, et al. Plecanatide, an oral guanylate cyclase c agonist acting locally in the gastrointestinal tract, is safe and well-tolerated in single doses. Dig Dis Sci. 2013;58(9):2580–6.PubMedCrossRefGoogle Scholar
  82. 82.
    Shailubhai K, Barrow L, Talluto C, et al. Plecanatide, a guanylate cyclase c agonist, improves bowel habits and symptoms associated with chronic constipation in a phase IIa clinical study. ACJ. 2011;11(S2):1174.Google Scholar
  83. 83.
    Simrén M, Bajor A, Gillberg P, et al. Randomised clinical trial: the ileal bile acid transporter inhibitor A3309 vs. placebo in patients with chronic idiopathic constipation—a double-blind study. Aliment Pharmacol Ther. 2011;34(1):41–50.PubMedCrossRefGoogle Scholar
  84. 84.
    Wong B, Camilleri M, McKinzie S, et al. Effects of A3309, an ileal bile acid transporter inhibitor, on colonic transit and symptoms in females with functional constipation. Am J Gastroenterol. 2011;106(12):2154–64.PubMedCrossRefGoogle Scholar
  85. 85.
    Chey W, Camilleri M, Chang L, et al. A randomized placebo-controlled phase IIb trial of a3309, a bile acid transporter inhibitor, for chronic idiopathic constipation. Am J Gastroenterol. 2011;106(10):1803–12.PubMedPubMedCentralCrossRefGoogle Scholar
  86. 86.
    Rao A, Wong B, Camilleri M, et al. Chenodeoxycholate in females with irritable bowel syndrome-constipation: a pharmacodynamic and pharmacogenetic analysis. Gastroenterology. 2010;139(5):1549–58. e1.PubMedPubMedCentralCrossRefGoogle Scholar
  87. 87.
    Portenoy R, Thomas J, Moehl Boatwright M, et al. Subcutaneous methylnaltrexone for the treatment of opioid-induced constipation in patients with advanced illness: a double-blind, randomized, parallel group, dose-ranging study. J Pain Symptom Manag. 2008;35(5):458–68.CrossRefGoogle Scholar
  88. 88.
    Thomas J, Karver S, Cooney GA, et al. Methylnaltrexone for opioid-induced constipation in advanced illness. N Engl J Med. 2008;358(22):2332–43.PubMedCrossRefGoogle Scholar
  89. 89.
    Mackey A, Green L, Greene P, et al. Methylnaltrexone and gastrointestinal perforation. J Pain Symptom Manag. 2010;40(1):e1–3.CrossRefGoogle Scholar
  90. 90.
    Ford A, Brenner D, Schoenfeld P. Efficacy of pharmacological therapies for the treatment of opioid-induced constipation: systematic review and meta-analysis. Am J Gastroenterol. 2013;108(10):1566–74.PubMedCrossRefGoogle Scholar
  91. 91.
    Vaughan-Shaw P, Fecher I, Harris S, et al. A meta-analysis of the effectiveness of the opioid receptor antagonist alvimopan in reducing hospital length of stay and time to GI recovery in patients enrolled in a standardized accelerated recovery program after abdominal surgery. Dis Colon Rectum. 2012;55(5):611–20.PubMedCrossRefGoogle Scholar
  92. 92.
    Corsetti M, Tack J. Naloxegol, a new drug for the treatment of opioid-induced constipation. Expert Opin Pharmacother. 2015;16(3):399–406.PubMedGoogle Scholar
  93. 93.•
    Schey R, Cromwell J, Rao S. Medical and surgical management of pelvic floor disorders affecting defecation. Am J Gastroenterol. 2012;107(11):1624–33. An excellent review of the diagnosis and management of different pelvic floor disorders causing constipation.PubMedPubMedCentralCrossRefGoogle Scholar
  94. 94.
    Chiarioni G, Salandini L, Whitehead W. Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation. Gastroenterology. 2005;129(1):86–97.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Division of GastroenterologyUniversity of South AlabamaMobileUSA

Personalised recommendations