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 Chronic constipation is described as a common complication determined by difficult and/or rare passage of stool or both. The difference in definition of constipation has led to a wide range of reported prevalence (i.e., between 1% and 80%). Various reasons are involved in the pathogenesis of the disease, including type of diet, genetic predisposition, colonic motility, absorption, social economic status, daily behaviours, and biological and pharmaceutical factors. Diagnostic and therapeutic options play a key role in the treatment of chronic constipation. There are still debates about the timing of these diagnostic and therapeutic algorithms.

Constipation is a disorder in the gastrointestinal tract, which can result in the infrequent stools, difficult stool passage with pain and stiffness. Acute constipation may cause closure of the intestine, which may even require surgery.

It is worth noting that there is currently no ideal definition for constipation. Thus, history and physical examination can be considered the main initial approaches. Many definitions are described by using a self-reported constipation and the formal criteria. Many definitions of chronic constipation are related to scientific considerations such as secondary causes (medications), neurological, or systemic diseases. However, it is considered primary or idiopathic.

Pathogenesis is multifactorial with focus on genetic predisposition, socioeconomic status, low fiber consumption, lack of adequate fluid intake, lack of mobility, disturbance in the hormone balance, side effects of medications, or anatomy of the body. 

Chronic constipation is a complicated condition usually among older individuals, which is characterized by difficult stool passage.In this regard, this condition has a close relationship with the patients’ quality of life, and consuming health resources.

Age and gender distribution

Constipation among older people is far more common than in younger people. Common causes of constipation in the elderly are linked to several factors including lack of normal bowel movements or aging, lack of proper diet, lack of adequate fluid intake, lack of adequate physical activity, illness or the use of drugs. The prevalence of this condition is higher in adults over 65 years of age due to a loose-fitting dentures or tooth loss, resulting in chewing difficulty, which forces the patient to select soft and soft fiber materials. Low-fiber foods are consumed by those who have lost their interest or are having difficulty swallowing.
 
The prevalence of anatomic abnormalities such as rectocele, pelvic floor dyssynergia, and prolapse, was reported to be higher in the elderly. On the other hand, constipation is more common in women than in men. Moreover, severe constipation is markedly seen in elderly women as compared with that of male individuals.During pregnancy, especially in the last trimester, the risk of constipation is high due to a significant increase of sex hormones, a decrease in intestinal movement and delayed intestinal emptying because of mechanical pressure from the carrying fetus.

It has been reported that women are more likely to suffer from constipation in the premenopausal period, where it may be related to fluctuations in female sexual hormones and feelings. Furthermore, the use of laxatives is much more likely in women when they are seeking more health care for constipation.
 

Causes of constipation

Pathogenesis is multifactorial with focusing on the type of diet, genetic predisposition, colonic motility, and absorption, as well as behavioral, biological, and pharmaceutical factors.Furthermore, low fiber dietary intake, inadequate water intake, sedentary lifestyle, irritable bowel syndrome (IBS), failure to respond to urge to defecate, and slow transit have been revealed to be associated with predisposition.

Overall, a number of factors contribute to constipation including lower social economic status, lower parental education, physical activity, medications, depression, physical and sexual abuse, and everyday life events. 

The long list and heterogeneity of related factors indicate which many pathophysiological factors cause the same symptoms, and are often undetectable from early forms. Regarding the complex interactions of various pathophysiological factors, caution should be used in applying therapeutic strategies based on only one of them.

Different studies have investigated the effects of 1 factor on constipation, while their multiplicity, mutual interaction, and overlapping nature should be considered for avoiding oversimplification. The lack of a diet containing vegetables and low consumption of fluids can lead to constipation.

Some medications and physiological conditions (e.g., pregnancy and age) have been revealed to increase the risk of consumption. Moreover, a number of diseases are also associated with reduced movement, such as spinal cord injury or musculoskeletal disorders (muscular dystrophy), which are also common causes of this condition. Furthermore, some diseases of the large intestine have appeared to interfere with the movements of the colon, such as IBS, pelvic floor dysfunction, and depression disorders. It is worth noting that the following sections have provided the causes of constipation and other aspects.

Diet

Common causes of chronic constipation include a lack of fiber (inadequate consumption of fruits, vegetables, and other foods containing fibers), no sufficient drinking water or liquids. In these cases, constipation is usually not a serious problem and can be controlled and treated by correcting nutritional habits and lifestyles.

Studies have indicated that a high-fiber diet can increase stool weight, resulting in a decreased colon transit time, while poor-fiber diet induces constipation. Moreover, it has been revealed that increased fiber diet could improve symptoms in patients with normal colonic transit and anorectal function, while constipated patients with delayed colonic transit patients have not improved by increasing dietary fiber. Increasing fiber consumption does not make colonic transit normal, and may even worsen their symptoms through the fiber's metabolism as a result of the gas produced. On the other hand, it has been demonstrated that diets with soluble fiber (i.e., psyllium or ispaghula), but not fiber insoluble diet (wheat Bran), can be associated with the improvement of the symptoms in chronic constipation. A systematic review showed that soluble fiber improved constipation symptoms in IBS with varying effects on abdominal pain.
 

Diseases and conditions as secondary cause of constipation

Mechanical cause of constipation: colon, rectal, or anal stricture, megacolon rectocele, intestinal pseudo obstruction, injured tissues, diverticulosis, and abnormal narrowing of the intestine or rectum.

Organic stenosis: cancer or cancer-related causes (e.g., colorectal cancer and tumor, intestinal radiation, etc.), diverticulitis, sigmoid or cecal volvulus, intestinal masses, inflammatory, and ischemic or surgical stenosis.

Psychological conditions: depression, anxiety, eating disease.

Enteric neuropathies: people with Hirschsprung disease are more susceptible to constipation, as well as to chronic intestinal pseudo-obstruction.
Neurological disorders: multiple sclerosis, Parkinson disease, stroke, spinal cord injury, paraplegia, spina bifida, and autonomic neuropathy.
Endocrine and metabolic conditions: diabetes mellitus, hypercalcemia, porphyria, hypothyroidism, hyperthyroidism, and pregnancy.
Myopathic disorders: scleroderma and amyloidosis.

Anorectal disorders: anal strictures, anal fissures, and hemorrhoids are anal diseases that delay the removal of stool and exacerbate chronic constipation due to pain during fecal excretion.

Connective tissue disorders: lupus.

Uncertain cause: idiopathic chronic constipation.

Medications

Several constipation-causing medications are indicated as causative agents of constipation including antipyretic drugs (e.g., morphine and codeine), anticholinergic drugs (Hyoscine), antidepressants (Imipramine and fluoxetine), antiepileptic drugs (e.g., phenytoin and carbamazepine), antipsychotics (haloperidol and clozapine), food supplements containing iron and calcium.

On the other hand, some blood pressure-lowering drugs, lipid-lowering drugs, muscle relaxant drugs, anti-ulcer drugs, antihistamines, and antioxidants (i.e., drugs containing aluminium and calcium) are commonly associated with constipation. Continuous consumption of opioids leads to chronic constipation in addicts. Opiate combinations weaken gastrointestinal motility movements and the susceptibility of rectal dilation to stimulation, whereas these increase the ileocecal tone and internal anal sphincter tone; thus prolonging the duration of excretion in the intestine, causing constipation.

Rectal sensorimotor dysfunction

Evidence suggests the role for rectal sensorimotor dysfunction as a factor in the symptoms in a proportion of patients who suffered from chronic constipation including sensation, motility, and biomechanical components. This condition is markedly related to functional evacuatory disorders and constipation. Most patients with preventable constipation complain of an evacuatory disorder.

A number of factors are also involved in functional disorders of defecation and defined in patients with constipation including rectal hyposensitivity, altered rectoanal reflex activity, increased rectal duct capacity, and rectal motor dysfunction.The role of abnormal visceral sensation is currently considered to be involved in the development of functional bowel disorders with considerable attention to visceral hypersensitivity,whereas hyposensitivity was relatively considered. Hyposensitivity may occur in 1 quarter of adults with constipation, while one-third of these patients are involved in impairment of sensation due to a primary disorder of the afferent pathway. Attenuated sensory perception seems to be secondary factor in compliance/capacity change in adults. These mentioned dysfunctions may be present together, which may vary depending on the degree of participation of the subject. How to get rid of hemorrhoids using a squat stool has also be extensively debated.

Psychoaffective disorders

Patients with constipation often have psychological disorders in a variety of stressful life events such as anxiety, depression, physical and sexual abuse, and anorexia nervosa, as well as a concomitant eating disorder.It has been indicated that patients with chronic constipation, especially those with dyssynergic defecation, had had an important psychological disorder.

In contrast, a study has reported that there is no relationship between psychological distress and stool frequency in patients with slow transit constipation. However, it is complicated to determine how constipation is influenced by these factors.

Socioeconomic status

The impacts of socioeconomic status and educational level on the prevalence of constipation have been reported in most studies. Low-income people are more likely to suffer from constipation than their richer counterparts.On the other hand, a reverse correlation between parental education and the incidence of constipation has been demonstrated in a number of investigations.The socioeconomic status and educational level seem to be associated with these conditions in Iran.

Other risk factors for constipation have also been reported in some studies, including a positive family history of constipation and living in a densely populated society.However, there is a lack of consensus on some of the relevant factors in the literature.

Economic impact and the health-related quality of life

Constipation causes many physical and mental problems for many patients and can significantly affect the daily life and well-being of constipated individuals. Although a small proportion of constipated patients seek medical care, but most patients are taking medications to improve their condition. 

Healthcare costs among patients is significantly considerable, indicating that hundreds of millions dollars are annually spent on laxatives use. General health, mental health, and social function in people with constipation are lower than healthy subjects and are very low in hospitalized patients compared with the community.Diagnosis and treatment of constipation impose a significant cost to the individual and the healthcare system, while constipation prevention programs will lead to cost savings.
 
 
 
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