Skip to main content

Chronic Constipation

Chronic constipation affects approximately 15% of adults worldwide.[1][2] Symptoms extend beyond infrequent defecation to include straining, sensation of incomplete evacuation, anorectal blockage, and the need for manual maneuvers.

Epidemiology​

  • Prevalence: about 14% of community adults have chronic idiopathic constipation; prevalence is higher in women (female-versus-male odds ratio 2.22), older adults, and lower-socioeconomic populations.[2]
  • Age: Prevalence increases with age and lower socioeconomic status.[2]
  • Healthcare utilization: One of the most frequent GI diagnoses in ambulatory practice and a common reason for referral to gastroenterologists and colorectal surgeons.[1]
  • Overlap: Chronic constipation and IBS-C overlap substantially; the odds of chronic idiopathic constipation were about eightfold higher in people who also reported IBS (OR 7.98).[2] A large share of patients who fail over-the-counter therapy have a defecatory disorder on physiologic testing.[1][6]

Classification​

Chronic constipation is first partitioned into primary (functional) and secondary forms. Primary constipation is further subdivided by pathophysiology.

CategorySubtypeDefining features
Primary (functional)Normal-transit constipation (NTC)Normal colonic transit; symptom-based; most common subtype
Slow-transit constipation (STC)Delayed colonic transit on scintigraphy or radiopaque markers; high-amplitude propagating contractions may be reduced on manometry.[1]
Defecatory (evacuation) disordersImpaired rectal evacuation from dyssynergia, inadequate propulsion, or structural outlet obstruction. See the dedicated article for physiologic diagnosis (ARM and BET, with defecography when indicated), biofeedback as first-line for symptomatic pelvic floor dyssynergia, botulinum toxin, and structural surgery.[5]
SecondaryMedicationsOpioids (see opioid-induced constipation below), anticholinergics, calcium-channel blockers, iron, calcium, 5-HT3 antagonists, antipsychotics
Metabolic / endocrineHypothyroidism, hypercalcemia, hypokalemia, diabetes, pregnancy
NeurologicParkinson disease, multiple sclerosis, spinal cord injury, autonomic neuropathy
Structural / anatomicColorectal cancer, strictures, anal stenosis, large rectocele, full-thickness intussusception

Defecatory disorders frequently coexist with slow-transit constipation. Treat a confirmed defecatory disorder first and reassess colonic transit after pelvic floor treatment; slow transit often improves once evacuation is restored.[1][6]

Diagnosis​

Symptom criteria and the Rome V update​

The Rome IV functional-constipation criteria require symptoms for the last 3 months with onset at least 6 months prior, and the presence of ≥2 of the following:[3]

  1. Straining during >25% of defecations[3]
  2. Lumpy or hard stools (Bristol 1–2) in >25% of defecations[3]
  3. Sensation of incomplete evacuation in >25% of defecations[3]
  4. Sensation of anorectal obstruction or blockage in >25% of defecations[3]
  5. Manual maneuvers to facilitate >25% of defecations (digital evacuation, splinting of the pelvic floor or posterior vaginal wall)[3]
  6. Fewer than three spontaneous bowel movements per week

Plus:

  • Loose stools are rarely present without the use of laxatives
  • Insufficient criteria for IBS

Rome V (2026) now uses the term chronic constipation and updates the broader bowel and anorectal classification. Symptom questionnaires support characterization but cannot diagnose dyssynergia or rectal sensory disorders without physiologic assessment; see the defecatory-dysfunction update.[11][12]

Initial Evaluation​

A focused history should characterize stool frequency, stool form (Bristol Stool Form Scale), straining, sense of incomplete evacuation, manual maneuvers, duration, and triggers; and should review alarm features: hematochezia, unintentional weight loss, iron-deficiency anemia, new or progressive constipation in an older adult, rapid progression, or first-degree family history of colorectal cancer or inflammatory bowel disease.[1][5]

A medication review is mandatory; medications are a common, reversible contributor.

Physical examination includes abdominal exam and a digital rectal examination with dynamic maneuvers (squeeze, simulated defecation). Paradoxical contraction of the puborectalis or failure of perineal descent on bearing down strongly suggests a defecatory disorder.[1][6]

TestIndication
Basic labs (CBC, TSH, calcium, glucose, creatinine)Selected patients with short history, alarm features, or suspected metabolic cause
ColonoscopyAlarm features, or due for age-appropriate colorectal cancer screening
Anorectal manometry + balloon expulsion testRefractory constipation, suspicion for defecatory disorder, or pre-surgical assessment. Workflow and interpretation → see Defecatory Dysfunction
Colonic transit (radiopaque markers or scintigraphy)Refractory constipation after excluding or treating an outlet disorder; guides subtype and surgical candidacy
Defecography (fluoroscopic or MR)Consider in refractory constipation, particularly when ARM/BET is inconclusive, or for suspected structural outlet obstruction (rectocele, intussusception, enterocele or perineal descent).[1][13]

Evaluation sequence. ASCRS 2024 recommends evaluating for outlet dysfunction in patients who fail diet, fiber and osmotic laxatives , using anorectal physiology testing or dynamic imaging (fluoroscopic or MR defecography, dynamic ultrasound).[5] It recommends measuring colonic motility and transit before surgical intervention is considered .[5] In refractory patients, anorectal manometry with balloon expulsion testing comes first, and transit testing is interpreted after outlet obstruction has been excluded or treated.[1][5] The balloon expulsion test is highly specific but only about 50% sensitive, and radiopaque markers remain the most widely used transit test.[5]

Management​

Management proceeds in a stepwise fashion: lifestyle and fiber, then osmotic laxatives, then stimulants as rescue or an individualized adjunct, then prescription secretagogues or prokinetics for OTC failures, with biofeedback promptly when a defecatory disorder is identified, then surgery in carefully selected refractory cases.[4][5]

Lifestyle and Dietary Measures​

  • Diet, fluid and fiber. ASCRS 2024 makes dietary change, adequate fluid and fiber supplementation the initial step . Fiber helps least in slow transit and outlet obstruction: about 80% of patients with slow transit and 63% with outlet obstruction may not respond adequately, versus about 85% improvement in patients without an underlying pathologic finding (as reported by ASCRS).[5]
  • Toileting routine. Post-prandial attempts leveraging the gastrocolic response; knees-above-hips positioning (e.g., footstool); avoidance of prolonged straining.
  • Hydration. Adequate fluid intake, particularly with fiber.
  • Physical activity. Modest evidence for benefit; reasonable first-line adjunct.

Pharmacologic Therapy — AGA/ACG 2023 Recommendations​

The 2023 AGA–ACG guideline on pharmacologic management of chronic idiopathic constipation provides graded recommendations for adult chronic idiopathic constipation.[4]

ClassAgentRecommendationCertaintyKey Implementation Notes
FiberPsylliumConditional (suggest)LowFirst-line for patients with low dietary fiber intake; encourage hydration; flatulence is common; evidence for bran and inulin is very limited[4]
OsmoticPEGStrong (recommend)ModerateDurable response at 6 months; well tolerated; combine with fiber as needed
Magnesium oxideConditional (suggest)Very lowStart low, titrate; avoid in renal insufficiency (hypermagnesemia risk)
LactuloseConditional (suggest)Very lowReserve for OTC failures; bloating and flatulence are dose-limiting
StimulantBisacodyl / sodium picosulfateStrong (recommend)ModerateShort-term (≤4 wk) or rescue therapy; start low to limit cramping and diarrhea. Sodium picosulfate is not marketed in the United States
SennaConditional (suggest)LowTrials used higher doses than are common in practice; start low and titrate
SecretagogueLubiprostoneConditional (suggest)LowFor OTC failures; CIC dose is 24 mcg twice daily with food and water (food may reduce nausea), reduced to 16 mcg twice daily for Child-Pugh B or 8 mcg twice daily for Child-Pugh C hepatic impairment. Stop for severe diarrhea or syncope/hypotension and assess dyspnea. Contraindicated in known or suspected mechanical GI obstruction.[4][33]
LinaclotideStrong (recommend)ModerateFor OTC failures; label CIC dose 145 mcg daily (72 mcg if tolerability is limiting), on an empty stomach; diarrhea is the main adverse effect; contraindicated under age 2 years and in mechanical obstruction[4][31]
PlecanatideStrong (recommend)ModerateFor OTC failures; label CIC dose 3 mg daily; diarrhea is a principal adverse effect; contraindicated under age 6 years and in mechanical obstruction; avoid use from age 6 to under 18 years; no head-to-head equivalence with linaclotide implied[4][30]
5-HT4 agonistPrucaloprideStrong (recommend)ModerateFor OTC failures; adult dose 2 mg daily (1 mg daily if creatinine clearance is below 30 mL/min); avoid use in end-stage renal disease requiring dialysis. Contraindicated with prior hypersensitivity, intestinal perforation or obstruction due to structural or functional gut-wall disease, obstructive ileus, severe inflammatory intestinal disease such as Crohn disease or ulcerative colitis, or toxic megacolon/megarectum. Monitor for suicidal thoughts or behavior and new or worsening depression; stop immediately for these or unusual mood changes, although causation is unestablished. Headache, abdominal pain, nausea and diarrhea are the most common adverse effects.[4][20]

ASCRS 2024 rates osmotic laxatives as appropriate first-line medical therapy , with bisacodyl or other stimulants for rescue or second-line use.[5] It cites limited randomized data for anthraquinone stimulants (senna, cascara, aloe) in chronic constipation.

Practical sequencing. A reasonable first-line regimen for most adults is fiber (psyllium) plus PEG, with bisacodyl or sodium picosulfate reserved for rescue. Patients who fail or cannot tolerate OTC therapy should advance to a secretagogue (linaclotide, plecanatide, or lubiprostone) or the 5-HT4 agonist prucalopride; choice is driven largely by payer formulary, comorbidity (e.g., avoid magnesium oxide in CKD), and side-effect profile.[4]

Tenapanor (an NHE3 inhibitor, 50 mg twice daily) is US-labeled for IBS-C, not chronic idiopathic constipation, and is not part of the 2023 CIC guideline.[32]

Opioid-Induced Constipation​

Opioid-induced constipation (OIC) is the commonest medication-related secondary cause and is managed on a separate track. AGA strongly recommends traditional laxatives, including stimulant and osmotic agents, as first-line therapy (moderate-quality evidence); for laxative-refractory OIC it strongly recommends naldemedine (high-quality evidence) or naloxegol (moderate-quality evidence), and conditionally suggests methylnaltrexone (low-quality evidence).[14] Lubiprostone is labeled at 24 mcg twice daily for OIC in adults with chronic noncancer pain, including prior-cancer pain without frequent opioid dose escalation; use lower doses for Child-Pugh B or C hepatic impairment, and effectiveness during methadone therapy has not been established.[33]

PAMORALabel notes
Naloxegol (Movantik)Contraindicated in patients with known or suspected GI obstruction or at risk of recurrent obstruction, and with strong CYP3A4 inhibitors[24]
Naldemedine (Symproic)Contraindicated in known or suspected GI obstruction or risk of recurrent obstruction[25]
Methylnaltrexone (Relistor; tablet and injection)Contraindicated in known or suspected mechanical GI obstruction or increased risk of recurrent obstruction[26]

Perforation is the reason for the obstruction contraindication. Agent-specific PAMORA labels warn about impaired GI-wall integrity, including GI malignancy, GI surgery, diverticular disease, or Crohn disease; review the chosen label and discontinue treatment for severe, persistent, or worsening abdominal pain.[24][25][26]

Defecatory Disorders — handled separately​

Anorectal biofeedback may be used for defecatory disorders with dyssynergia or inadequate propulsion identified on ARM and BET; ASCRS 2024 specifically considers it first-line for symptomatic pelvic floor dyssynergia .[5][10] In a randomized trial of 109 patients with normal-transit constipation due to dyssynergia who had not responded to fiber plus enemas or suppositories, five weekly biofeedback sessions gave major improvement in 80% at 6 months versus 22% with polyethylene glycol plus counseling, with benefit sustained to 24 months in the biofeedback arm (the PEG group was assessed through 12 months).[15] A sham-controlled trial (n = 77) showed greater correction of dyssynergia and more complete spontaneous bowel movements with biofeedback than with sham or standard therapy.[16] Its one-year extension enrolled 26/44 eligible patients; 13/13 biofeedback and 7/13 standard-care patients completed follow-up, with sustained improvement among biofeedback completers.[17] The full diagnostic workflow and treatment algorithm (biofeedback, botulinum toxin, selected structural surgery) lives on the Defecatory Dysfunction page.[6][10]

The relevant point for constipation management: treat confirmed dyssynergia while continuing appropriate stool-form treatment. Slow-transit constipation commonly improves once evacuation is restored.[1][6]

Surgical Considerations​

Colectomy for isolated refractory slow-transit constipation is reserved for carefully selected patients after adequate medical treatment and, when indicated, pelvic floor therapy; delayed transit and absence of an ongoing defecatory disorder must be objectively confirmed.[5][13] ASCRS 2024 grades the operations as follows, all from low-quality evidence except rectocele repair and STARR:[5]

ASCRS 2024 statementStrengthEvidence
Total abdominal colectomy with ileorectal anastomosis may benefit isolated refractory slow-transit constipationConditionalLow
Rectocele repair may be considered for significant outlet dysfunction after concomitant functional causes such as a nonrelaxing puborectalis are addressedConditionalModerate
STARR is not recommended for rectocele or internal intussusception because of high complication ratesStrongModerate
Repair of rectal intussusception may be considered for severe obstructed defecation after nonoperative treatment failsConditionalLow
Fecal diversion may be considered for intractable constipation refractory to other treatmentConditionalLow
IndicationOperationNotes
Medically refractory slow-transit constipation; no ongoing defecatory disorder (normal ARM/BET or corrected dyssynergia); assess severe symptomatic upper-gut delayTotal abdominal colectomy with ileorectal anastomosis (TAC-IRA)Symptom satisfaction can be high, but perioperative risks include anastomotic leak and prolonged ileus; persistent abdominal pain, bloating, small-bowel obstruction, diarrhea and fecal incontinence remain possible. Clinically significant upper-gut dysmotility is a relative contraindication.[5][13]
Symptomatic rectocele causing significant outlet dysfunction after functional causes are addressedFor women with stage 2 or greater clinically evident rectocele and obstructed defecation, IUGA favors native-tissue transvaginal rectocele repair first ; transanal or transperineal repair may suit selected patientsDefecography can clarify rectocele emptying and coexisting outlet lesions; treat dyssynergia before repair.[5][34]
High-grade internal rectal intussusception with severe obstructed defecation after failed nonoperative treatment[5][35]Ventral mesh rectopexy (or selected abdominal/perineal alternative)Offer pelvic floor PT before surgery and consider it afterward if symptoms persist.[35]
Symptomatic external full-thickness rectal prolapse (procidentia)Timely colorectal repair, including ventral mesh rectopexy or another abdominal/perineal approach as appropriatePreoperative pelvic floor PT may be considered if it does not delay surgery; consider combined apical repair only when apical prolapse independently warrants it.[35]
Enterocele / sigmoidocele contributing to obstructed defecationEnterocele repair, often as part of apical suspensionAddress concurrent apical defects

Sacral neuromodulation is sometimes offered before colectomy. Evidence is mixed. In an open-label randomized trial of refractory idiopathic slow-transit constipation without outlet obstruction, 22/41 assigned to sacral neuromodulation versus 1/26 to personalized conservative care averaged at least three defecations per week at six months; the trial also reported 68 versus 10 adverse events and 6 versus 2 serious adverse events, respectively.[21] A 2025 meta-analysis of five RCTs (187 patients) found no statistically significant pooled advantage over sham or conservative controls (OR 1.92, 95% CI 0.68–5.42).[22] In the earlier tined-lead test study, a reduction of at least 0.5 in constipation symptom score at six months occurred in 60% of discriminate versus 57% of indiscriminate test responders (P = 0.76); investigators suggested a placebo response. Infection occurred in 10/45 patients during the six-week test phase, and the study ended early.[18]

Do not operate without objective workup. Colectomy should be considered only for documented slow transit with no ongoing defecatory disorder (normal ARM/BET or corrected dyssynergia). Evaluate severe, symptomatic gastric or small-bowel dysmotility; clinically significant upper-gut dysmotility is a relative contraindication.[5][13] Outcomes of colectomy performed in unselected patients are poor.[5]

Refractory constipation: AGA 2026​

Before labeling constipation refractory, reassess secondary causes and complete anorectal testing and biofeedback when indicated. For patients who remain refractory, the AGA 2026 expert update considers a vibrating capsule a reasonable adjunct.[13] In a separate eight-week sham-controlled randomized trial of chronic constipation (n = 312), at least one additional complete spontaneous bowel movement per week for at least six of eight weeks occurred in 39.3% with the capsule versus 22.1% with sham.[28] Confirm transit off therapy and, ideally, on maximal therapy. Colectomy requires documented slow transit without an ongoing defecatory disorder, regional gut-transit assessment and psychological evaluation; when expected benefit is uncertain or relative contraindications exist, a diverting loop ileostomy can test symptom response before resection.[13] Pain- or bloating-dominant illness and untreated severe psychiatric disease are relative contraindications.[13]

Outcomes and Follow-Up​

  • PEG. In a six-month randomized trial (n = 304), PEG 17 g daily relieved modified Rome criteria for at least half of treatment weeks in 52% of patients versus 11% on placebo.[4][27]
  • Linaclotide 9-of-12-week CSBM response (≥3 per week and ≥1 above baseline) was 16–21% (145 µg) and 19–21% (290 µg) versus 3–6% with placebo across two 12-week trials.[8] In a 12-week CIC trial, plecanatide 3 mg met the durable overall CSBM endpoint in 20.1% of 443 adults versus 12.8% of 445 on placebo (≥3 complete spontaneous bowel movements and ≥1 over baseline in the same week for ≥9 of 12 weeks, including ≥3 of the final 4).[9]
  • Prucalopride. In a 12-week trial of 620 patients with severe chronic constipation (no more than two spontaneous complete bowel movements weekly at baseline), 30.9% receiving 2 mg daily versus 12.0% receiving placebo averaged at least three spontaneous complete bowel movements weekly; headache and abdominal pain were the most frequent adverse events.[7]
  • Biofeedback for dyssynergia yielded adequate relief in 70% at 3 months in one controlled trial and major improvement in 80% at 6 months in another; the latter reported 81.5% major improvement at 24 months, while a separate one-year extension followed 13 biofeedback completers.[10][15][17]
  • Colectomy for STC. ASCRS reports clinical improvement in 50–100% after total colectomy with ileorectal anastomosis, whereas segmental colectomy has failed in up to 100%.[5] Satisfaction is high in carefully selected series, but long-term morbidity is substantial. Among 42 of 102 original subtotal-colectomy patients available at a mean 15.9-year follow-up, half reported fewer than four bowel movements daily, 21% reported severe fecal incontinence, and eight had converted to ileostomy.[23] In a separate survey, 75 of 112 subtotal-colectomy patients returned questionnaires; among respondents, 46% reported diarrhea at least some of the time, yet 93% would have the operation again.[5][29] In a postal survey at a mean 15.3 years after total colectomy with ileorectal anastomosis, 32/71 contacted patients (45%) responded.[19] Most respondents were satisfied, yet 72% reported abdominal pain, 53% fecal incontinence and 44% a later admission for bowel obstruction.[5][19]

Follow-up intervals are typically 4–8 weeks during initial titration and 3–6 months once a stable regimen is established. Patients on long-term laxatives should be reassessed periodically for efficacy and for the emergence of alarm features.

See Also​

References​

1. Bharucha AE, Lacy BE. "Mechanisms, Evaluation, and Management of Chronic Constipation." Gastroenterology. 2020;158(5):1232-1249.e3. doi:10.1053/j.gastro.2019.12.034

2. Suares NC, Ford AC. "Prevalence of, and Risk Factors for, Chronic Idiopathic Constipation in the Community: Systematic Review and Meta-analysis." Am J Gastroenterol. 2011;106(9):1582-1591. doi:10.1038/ajg.2011.164

3. Lacy BE, Mearin F, Chang L, et al. "Bowel Disorders." Gastroenterology. 2016;150(6):1393-1407. doi:10.1053/j.gastro.2016.02.031

4. Chang L, Chey WD, Imdad A, et al. "American Gastroenterological Association–American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation." Gastroenterology. 2023;164(7):1086-1106. doi:10.1053/j.gastro.2023.03.214

5. Alavi K, Thorsen AJ, Fang SH, et al. "The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Evaluation and Management of Chronic Constipation." Dis Colon Rectum. 2024;67(10):1244-1257. doi:10.1097/DCR.0000000000003430

6. Rao SSC, Bharucha AE, Chiarioni G, et al. "Anorectal Disorders." Gastroenterology. 2016;150(6):1430-1442. doi:10.1053/j.gastro.2016.02.009

7. Camilleri M, Kerstens R, Rykx A, Vandeplassche L. "A Placebo-Controlled Trial of Prucalopride for Severe Chronic Constipation." N Engl J Med. 2008;358(22):2344-2354. doi:10.1056/NEJMoa0800670

8. Lembo AJ, Schneier HA, Shiff SJ, et al. "Two randomized trials of linaclotide for chronic constipation." N Engl J Med. 2011;365(6):527-536. doi:10.1056/NEJMoa1010863

9. DeMicco M, Barrow L, Hickey B, et al. "Randomized clinical trial: efficacy and safety of plecanatide in the treatment of chronic idiopathic constipation." Therap Adv Gastroenterol. 2017;10(11):837-851. doi:10.1177/1756283X17734697

10. Rao SS, Benninga MA, Bharucha AE, et al. "ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders." Neurogastroenterol Motil. 2015;27(5):594-609. doi:10.1111/nmo.12520

11. Corsetti M, Shin A, Lacy BE, et al. Bowel disorders. Gastroenterology. 2026;170:1261–1282. doi:10.1053/j.gastro.2026.02.003.

12. Palsson OS, Lacy BE, Benninga MA, et al. Development of the Rome V diagnostic questionnaires. Gastroenterology. 2026;170:1408–1416. doi:10.1053/j.gastro.2026.01.041.

13. Staller K, Neshatian L, Lembo A, Bharucha AE. AGA clinical practice update on evaluation and management of refractory constipation: expert review. Clin Gastroenterol Hepatol. 2026;24:296–305. doi:10.1016/j.cgh.2025.09.031.

14. Crockett SD, Greer KB, Heidelbaugh JJ, et al. American Gastroenterological Association Institute Guideline on the Medical Management of Opioid-Induced Constipation. Gastroenterology. 2019;156(1):218-226. doi:10.1053/j.gastro.2018.07.016

15. 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(3):657-664. doi:10.1053/j.gastro.2005.11.014

16. Rao SS, 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):331-338. doi:10.1016/j.cgh.2006.12.023

17. Rao SS, Valestin J, Brown CK, et al. Long-term efficacy of biofeedback therapy for dyssynergic defecation: randomized controlled trial. Am J Gastroenterol. 2010;105(4):890-896. doi:10.1038/ajg.2010.53

18. Yiannakou Y, Etherson K, Close H, et al. A randomized double-blinded sham-controlled cross-over trial of tined-lead sacral nerve stimulation testing for chronic constipation. Eur J Gastroenterol Hepatol. 2019;31(6):653-660. doi:10.1097/MEG.0000000000001379

19. Johnston BJ, Clark DA, Warwick AM. Long-term outcomes of total colectomy for severe constipation. Colorectal Dis. 2023;25(6):1194-1201. doi:10.1111/codi.16517

20. Takeda Pharmaceuticals America, Inc. "MOTEGRITY (prucalopride) tablets: prescribing information." Revised July 2025. DailyMed

21. Heemskerk SCM, Dirksen CD, van Kuijk SMJ, et al. "Sacral Neuromodulation Versus Conservative Treatment for Refractory Idiopathic Slow-transit Constipation: The Randomized Clinical No.2-Trial." Ann Surg. 2024;279(5):746-754. doi:10.1097/SLA.0000000000006158

22. Emile SH, Dourado J, Wignakumar A, et al. "Meta-analysis of Randomized Controlled Trials on the Efficacy of Sacral Neuromodulation in Chronic Constipation." Neuromodulation. 2025;28(5):737-745. doi:10.1016/j.neurom.2025.03.001

23. Patton V, Balakrishnan V, Pieri C, et al. "Subtotal colectomy and ileorectal anastomosis for slow transit constipation: clinical follow-up at median of 15 years." Tech Coloproctol. 2020;24(2):173-179. doi:10.1007/s10151-019-02140-5

24. Averitas Pharma, Inc. "MOVANTIK (naloxegol) tablets: prescribing information." Revised August 2026. DailyMed

25. BioDelivery Sciences International, Inc. "SYMPROIC (naldemedine) tablets: prescribing information." Revised July 2025. DailyMed

26. Salix Pharmaceuticals, Inc. "RELISTOR (methylnaltrexone bromide) tablets and injection: prescribing information." Revised May 2024. DailyMed

27. DiPalma JA, Cleveland MVB, McGowan J, Herrera JL. "A randomized, multicenter, placebo-controlled trial of polyethylene glycol laxative for chronic treatment of chronic constipation." Am J Gastroenterol. 2007;102(7):1436-1441. doi:10.1111/j.1572-0241.2007.01199.x

28. Rao SSC, Quigley EMM, Chey WD, Sharma A, Lembo AJ. "Randomized Placebo-Controlled Phase 3 Trial of Vibrating Capsule for Chronic Constipation." Gastroenterology. 2023;164(7):1202-1210.e6. doi:10.1053/j.gastro.2023.02.013

29. FitzHarris GP, Garcia-Aguilar J, Parker SC, et al. "Quality of life after subtotal colectomy for slow-transit constipation: both quality and quantity count." Dis Colon Rectum. 2003;46(4):433-440. doi:10.1007/s10350-004-6576-3

30. Salix Pharmaceuticals Inc. "TRULANCE (plecanatide) tablets: prescribing information." Revised April 2024. DailyMed

31. Allergan, Inc. "LINZESS (linaclotide) capsules: prescribing information." Revised May 2026. DailyMed

32. Ardelyx. "IBSRELA (tenapanor) prescribing information." Revised May 2025. DailyMed.

33. Golden State Medical Supply, Inc. "Lubiprostone capsules prescribing information." Updated July 28, 2026. DailyMed.

34. Rachaneni S, Dietz HP, Latthe P, Sirany A, Spivak A, Dua A. "IUGA Opinion Paper on Obstructed Defecation: Management of Clinical and Proctographic Rectoceles." Int Urogynecol J. 2026;37(1):75-85. doi:10.1007/s00192-025-06288-7

35. Traugott AL, Barten J, Bordeianou L, et al. "Incorporating Pelvic Floor Physical Therapy in the Treatment of Obstructed Defecation Syndrome and Posterior Compartment Pelvic Organ and Rectal Prolapse: Proceedings of the Consensus Meeting of the Pelvic Floor Consortium of the American Society of Colon and Rectal Surgeons, the International Continence Society, the International Urogynecological Association, the American Urogynecologic Society, and the American Physical Therapy Association." Dis Colon Rectum. 2026;69(3):346-359. doi:10.1097/DCR.0000000000003993