Constipation is a symptom with many causes.

These causes are of two types: obstructed defecation and colonic slow transit (or hypomobility). About 50% of patients evaluated for constipation at tertiary referral hospitals have obstructed defecation. !" This type of constipation has mechanical and functional causes. Causes of colonic slow transit constipation include diet# hormones# side effects of medications# and heavy metal to$icity.

Children
Constipation in children usually occurs at three distinct points in time: after startin% formula or processed foods (while an infant)# durin% toilet trainin% in toddlerhood# and soon after startin% school (as in a &inder%arten) '" After birth# most infants pass ()5 soft li*uid bowel movements (+,) a day. +reast)fed infants usually tend to have more +, compared to formula)fed infants. -ome breast)fed infants have a +, after each feed# whereas others have only one +, every ./! days. 0nfants who are breast)fed rarely develop constipation. 10" +y the a%e of two years# a child will usually have 1/. bowel movements per day and by four years of a%e# a child will have one bowel movement per day. 11"

Causes
The causes of constipation can be divided into con%enital# primary# and secondary. ." The most common cause is primary and not life threatenin%. 1." 0n the elderly# causes include: insufficient dietary fiber inta&e# inade*uate fluid inta&e# decreased physical activity# side effects of medications# hypothyroidism# and obstruction by colorectal cancer. 1!" Constipation with no &nown or%anic cause# i.e. no medical e$planation# e$hibits %ender differences in prevalence: females are more often affected than males. 1("

Primary
2rimary or functional constipation is on%oin% symptoms for %reater than si$ months not due to any underlyin% cause such as medication side effects or an underlyin% medical condition. ." 15" 0t is not associated with abdominal pain thus distin%uishin% it from irritable bowel syndrome. ." 0t is the most common cause of constipation. ."

Diet
Constipation can be caused or e$acerbated by a low fiber diet# low li*uid inta&e# or dietin%. 5" 3"

Medication
,any medications have constipation as a side effect. -ome include (but are not limited to)4 opioids (e.%. common pain &illers)# diuretics# antidepressants# antihistamines# antispasmodics# anticonvulsants# and aluminum antacids 5" 5"

Metabolic & muscular

,etabolic and endocrine problems which may lead to constipation include: hypercalcemia# hypothyroidism# diabetes mellitus# cystic fibrosis# and celiac disease. 5" 1." Constipation is also common in individuals with muscular and myotonic dystrophy. 5"

Structural and functional abnormalities

Constipation has a number of structural (mechanical# morpholo%ical# anatomical) causes# includin%: spinal cord lesions# 2ar&insons# colon cancer# anal fissures# proctitis# and pelvic floor dysfunction. 1." Constipation also has functional (neurolo%ical) causes# includin% anismus# descendin% perineum syndrome# and 6irschsprun%7s disease. !" 0n infants# 6irschsprun%7s disease is the most common medical disorder associated with constipation. Anismus occurs in a small minority of persons with chronic constipation or obstructed defecation. 13"

Psychological

8oluntary withholdin% of the stool is a common cause of constipation. 5" The choice to withhold can be due to factors such as fear of pain# fear of public restrooms# or la9iness. 5" :hen a child holds in the stool a combination of encoura%ement# fluids# fiber# and la$atives may be useful to overcome the problem. 1;"

Prevention
Constipation is usually easier to prevent than to treat. <ollowin% the relief of constipation# maintenance with ade*uate e$ercise# fluid inta&e# and hi%h fiber diet is recommended. 5" Children benefit from scheduled toilet brea&s# once early in the mornin% and !0 minutes after meals. 5" .!"

Treatment
The main treatment of constipation involves the increased inta&e of water and fiber (either dietary or as supplements). 1." The routine use of la$atives is discoura%ed# as havin% bowel movements may come to be dependent upon their use. =nemas can be used to provide a form of mechanical stimulation. 6owever# enemas are %enerally useful only for stool in the rectum# not in the intestinal tract.

Laxatives
0f la$atives are used# mil& of ma%nesia is recommended as a first)line a%ent due to its low cost and safety. 1." -timulants should only be used if this is not effective. 1." 0n cases of chronic constipation# pro&inetics may be used to improve %astrointestinal motility. A number of new a%ents have shown positive outcomes in chronic constipation4 these include prucalopride# .(" andlubiprostone. .5"

Physical intervention
Constipation that resists the above measures may re*uire physical intervention such as manual disimpaction (the physical removal of impacted stool usin% the hands4 see <ecal impaction).

Pediatric
>actulose and mil& of ma%nesia have been compared with polyethylene %lycol (2=?) in children. All had similar side effects# but 2=? was more effective at treatin% constipation. .3" .;" @smotic la$atives are recommended over stimulant la$atives. .5"