Publication Date: January 1, 2013
Last Updated: September 2, 2022


  • If feasible, discontinue medications that can cause constipation before further testing.
( Very Low , Strong )

  • A careful digital rectal examination that includes assessment of pelvic floor motion during simulated evacuation is preferable to a cursory examination without these maneuvers and should be performed before referral for anorectal manometry. However, a normal digital rectal examination does not exclude defecatory disorders.
( Moderate , Strong )

The key components of the rectal examination include:

  • In the left lateral position, with the buttocks separated, observe the descent of the perineum during simulated evacuation and the elevation during a squeeze aimed at retention. The perianal skin can be observed for evidence of fecal soiling and the anal reflex tested by a light pinprick or scratch.
  • During simulated defecation, the anal verge should be observed for any patulous opening (suspect neurogenic constipation with or without incontinence) or prolapse of anorectal mucosa.
  • The digital examination should evaluate resting tone of the sphincter segment and its augmentation by a squeezing effort. Above the internal sphincter is the puborectalis muscle, which should also contract during squeeze. Acute localized tenderness to palpation along the puborectalis is a feature of the levator ani syndrome. Finally, the patient should be instructed to integrate the expulsionary forces by requesting that she or he "expel my finger."
  • An examination should then be conducted to evaluate for a rectocele or consideration be given to gynecologic consultation.

Testing for Medical Causes

In the absence of other symptoms and signs, only a complete blood cell count is necessary. ( Low , Strong )
Unless other clinical features warrant otherwise, metabolic tests (glucose, calcium, sensitive thyroid-stimulating hormone) are not recommended for chronic constipation. ( Moderate , Strong )
A colonoscopy should not be performed in patients without alarm features (eg, blood in stools, anemia, weight loss) unless age-appropriate colon cancer screening has not been performed. ( Moderate , Strong )
Anorectal manometry and a rectal balloon expulsion should be performed in patients who fail to respond to laxatives. ( Moderate , Strong )
Defecography should not be performed before anorectal manometry and a rectal balloon expulsion test. ( Low , Strong )
Defecography should be considered when results of anorectal manometry and rectal balloon expulsion are inconclusive for defecatory disorders. ( Low , Strong )
Colonic transit should be evaluated if anorectal test results do not show a defecatory disorder or if symptoms persist despite treatment of a defecatory disorder. ( Low , Strong )


After discontinuing medications that can cause constipation and performing blood and other tests as guided by clinical features, a therapeutic trial (ie, fiber supplementation and/or osmotic or stimulant laxatives) is recommended before anorectal testing. ( Moderate , Strong )

Anorectal tests should be performed in patients who do not respond to these measures. ( High , Strong )

Pelvic floor retraining by biofeedback therapy rather than laxatives is recommended for defecatory disorders. ( High , Strong )

Surgical Treatment

When bowel symptoms are refractory to simple laxatives, newer agents should be considered in patients with NTC or STC. ( Moderate , Conditional (weak) )
Anorectal tests and colonic transit should be reevaluated when symptoms persist despite an adequate trial of biofeedback therapy. ( Low , Strong )
A subtotal colectomy rather than continuing therapy with chronic laxatives should be considered for patients with symptomatic STC without a defecatory disorder. ( Moderate , Conditional (weak) )
Colonic intraluminal testing (manometry, barostat) should be considered to document colonic motor dysfunction before colectomy. ( Moderate , Conditional (weak) )
Suppositories or enemas rather than oral laxatives alone should be considered in patients with refractory pelvic floor dysfunction. ( Low , Conditional (weak) )

Recommendation Grading





Authoring Organization

Publication Month/Year

January 1, 2013

Last Updated Month/Year

December 1, 2022

Document Type


External Publication Status


Country of Publication


Target Patient Population

Adults with constipation

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings


Intended Users

Nurse, nurse practitioner, physician, physician assistant


Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D003248 - Constipation



Source Citation

American Gastroenterological Association, Bharucha AE, Dorn SD, Lembo A, Pressman A. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013 Jan;144(1):211-7. doi: 10.1053/j.gastro.2012.10.029. PMID: 23261064.

Supplemental Methodology Resources

Technical Review