AAPA: Constipation: It's Not Quantity That Counts

PHILADELPHIA, May 31 -- Infrequent bowel movements are not the most common symptom in patients with constipation.

In fact, frequency ranked next-to-last on a list of seven symptoms ordered according to the percentage of patients who suffer them, said Richard H. Davis Jr., P.A.-C., of the University of Florida in Gainesville at an industry-sponsored symposium held here conjunction with the American Academy of Physician Assistants meeting.

Straining was the most common symptom, experienced by 81% of patients, Mr. Davis said. In contrast, only 36% of patients reported fewer than three bowel movements per week, he said, citing a study published in the November 2001 issue of the American Journal of Gastroenterology.

The complete ranking is as follows:

• Straining, 81%
• Hard or lumpy stools, 72%
• A feeling of incomplete emptying, 54%
• Stool cannot be passed, 39%
• Abdominal fullness or bloating, 37%
• Fewer than three bowel movements per week, 36%
• Need to press on the anus, 28%

This ranking suggests that primary care clinicians should broaden their definition of constipation beyond the strictly quantitative criterion, Mr. Davis said. A better, more qualitative, definition might be "unsatisfactory defecation characterized by infrequent stools, difficult stool passage, or both," he said.

Difficult stool passage includes straining, incomplete evacuation, hard/lumpy stools, and the need for manual maneuvers to pass stool, he said.

When assessing a patient's constipation, clinicians should ask about these symptoms as well as asking about frequency of bowel movements, he suggested. One important question: "What is your most distressing symptom?" he said.

Adequate evaluation and treatment of chronic constipation is important, because the condition can have a negative effect on a patient's psychological health and overall quality of life, said Satish S. Rao, M.D., Ph.D., of the University of Iowa in Iowa City. Constipation also has a significant economic impact, Dr. Satish said.

It's estimated that from 2% to 28% of the U.S. population suffers from chronic constipation, Dr. Rao said. And each year, 1.2% of the population seeks medical help to find relief, according to the CDC's National Center for Health Statistics, he added.

Chronic constipation accounts for 2.7 million ambulatory office visits and more than 500,000 trips to the emergency room each year, Dr. Rao said. Nearly 11 million laxative prescriptions were written in 1995, more than were written for antihypertensives or birth control pills, he noted. In addition, Americans spend about million dollars on over-the-counter laxatives each year.

Recent evidence has also linked chronic constipation to psychological distress and disorders, including depression, obsessive-compulsive behavior, anxiety, hostility, and paranoid ideation, Dr. Rao said.