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Behavioural and new pharmacological treatments for constipation: getting the balance right
  1. Michael Camilleri,
  2. Adil E Bharucha
  1. Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Dr Michael Camilleri, Mayo Clinic, Charlton 8-110, 200 First St. S.W., Rochester, MN 55905, USA; camilleri.michael{at}


Chronic constipation affects almost one in six adults and is even more frequent in the elderly. In the vast majority of patients, there is no obstructive mucosal or structural cause for constipation and, after excluding relatively rare systemic diseases (commonest of which is hypothyroidism), the differential diagnosis is quickly narrowed down to three processes: evacuation disorder of the spastic (pelvic floor dyssynergia, anismus) or flaccid (descending perineum syndrome) varieties, and normal or slow transit constipation. Treatment of chronic constipation based on identifying the underlying pathophysiology is generally successful with targeted therapy. The aims of this review are to discuss targeted therapy for chronic constipation: behavioural treatment for outlet dysfunction and pharmacological treatment for constipation not associated with outlet dysfunction. In particular, we shall review the evidence that behavioural treatment works for evacuation disorders, describe the new treatment options for constipation not associated with evacuation disorder, and demonstrate how ‘targeting therapy’ to the underlying diagnosis results in a balanced approach to patients with these common disorders.

  • Constipation
  • rectal evacuation disorder
  • anal and pelvic floor biofeedback therapy
  • colonic diseases
  • pharmacotherapy

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  • Funding AEB is supported by NIH RO1 DK 78924, and MC by NIH R01-DK079866 and NIH 1RC1-DK086182 for studies in lower gastrointestinal motility disorders.

  • Competing interests MC has received research grants from Aryx (for ATI-7505), Johnson and Johnson (for prucalopride), Microbia (for linaclotide), Takeda/Sucampo (for lubiprostone), and Theravance (for velusetrag); honoraria below the US federal threshold for significant COI from Theravance, Takeda, and Ironwood; and CDA with no personal remuneration from Movetis. AEB has received research grants from Pfizer, and honoraria below the US federal threshold for significant COI from American Medical Systems, and Helsinn HealthCare.

  • Provenance and peer review Commissioned; externally peer reviewed.