Criteria
Rome IV criteria of functional bowel disorders[6][7]
Diagnostic criteria for functional constipation (criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis):
Must include two or more of the following:
Straining during at least 25% of defecations
Lumpy or hard stools at least 25% of defecations
Sensation of incomplete evacuation at least 25% of defecations
Sensation of anorectal obstruction/blockage at least 25% of defecations
Manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic floor)
Less than three defecations per week.
Loose stools are rarely present without the use of laxatives.
There are insufficient criteria for irritable bowel syndrome (IBS).
Diagnostic criteria for IBS-constipation (criteria fulfilled for the past 3 months with symptom onset 6 months prior to diagnosis):
Recurrent abdominal pain, on average, at least 1 day per week in the past 3 months associated with two or more of the following:
Related to defecation.
Associated with a change in frequency of stool.
Associated with a change in form (appearance) of stool
More than one-fourth (25%) of bowel movements with Bristol stool form types 1 and 2
Less than one-fourth (25%) of bowel movements with Bristol stool form types 6 and 7.
Diagnostic criteria for functional defecation disorders (criteria fulfilled for the past 3 months with symptom onset at least 6 months prior to diagnosis):
The patient must satisfy diagnostic criteria for functional constipation.
During repeated attempts to defecate, must have at least 2 of the following:
Evidence of impaired evacuation, based on balloon expulsion test or imaging
Inappropriate contraction of the pelvic floor muscles (i.e., anal sphincter or puborectalis) or <20% relaxation of basal resting sphincter pressure by manometry, imaging, or electromyography (EMG)
Inadequate propulsive forces, assessed by manometry or imaging.
i) Dyssynergic defecation
Inappropriate contraction of the pelvic floor or <20% relaxation of basal resting sphincter pressure with adequate propulsive forces during attempted defecation.
ii) Inadequate defecatory propulsion
Inadequate propulsive forces with or without inappropriate contraction or <20% relaxation of the anal sphincter during attempted defecation.
Diagnostic criteria for opioid-induced constipation:
New or worsening symptoms of constipation when initiating, changing, or increasing opioid therapy that must include 2 or more of the following:
Straining during at least 25% of defecations
Lumpy or hard stools (Bristol stool form score 1-2) in at least 25% of defecations
Sensation of incomplete evacuation for at least 25% of defecations
Sensation of anorectal obstruction/blockage for at least 25% of defecations
Manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic floor)
Less than three spontaneous bowel movements per week.
Loose stools are rarely present without the use of laxatives.
Occasional constipation[50]
A panel of experts from five countries has defined occasional constipation as intermittent or occasional symptomatic alterations in bowel habit (which include bothersome reduction in the frequency of bowel movements and/or difficulty with passage of stool), in the absence of warning signs for more serious conditions. Symptoms may last a few days or a few weeks and may require modification of lifestyle, dietary habit, and/or use of over-the-counter laxatives to restore satisfactory bowel habit. It is often difficult to have an algorithmic approach for occasional constipation as most patients will not see a physician. Management includes lifestyle modification (diet, exercise) and fiber supplements. However, these measures take time to show effect, so most patients with persistent symptoms will require nonprescription drugs including osmotic and stimulant laxatives. If the patient requires prescription drugs, this suggests a diagnosis of chronic constipation instead.
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