Clinical recommendation Evidence rating Comments
A history and physical examination should be performed in patients with constipation to identify alarm symptoms, including unintentional weight loss, fatigue, rectal bleeding, change in bowel habits, or narrowing of the stool.6,7,10 C Expert opinion and clinical practice guidelines, with limited observational studies or case series available, but benefits clearly outweigh risks
Routine use of blood tests, imaging, or colonoscopy in patients with constipation who do not have alarm symptoms is not recommended.6,7,10 C Expert opinion and clinical practice guidelines
Patients with alarm symptoms clinically concerning for malignancy should be referred for colonoscopy.17,22 C Expert opinion and clinical practice guidelines
Pelvic floor therapy with biofeedback is superior to laxatives, sham therapy, and placebo in RCTs for defecatory dysfunction.36,37 B Prospective RCT supported by clinical practice guidelines
Polyethylene glycol (Miralax) is preferred over lactulose for the treatment of constipation because it is more effective and has fewer adverse effects.39,42 A Cochrane review involving RCTs with strong evidence to support the superiority of polyethylene glycol over lactulose
Linaclotide (Linzess) and lubiprostone (Amitiza) are more effective than placebo for chronic constipation.4346 B Evidence from RCTs (comparisons with over-the-counter laxatives and head-to-head trials are lacking)