Side-By-Side: Diagnosis and Management of Chronic Constipation (AGA, WHO, & ASCRS)

Chronic constipation is usually defined as fewer than three bowel movements per week. Symptoms of constipation include straining, hard stools, and a feeling of incomplete evacuation. It’s one of the most common GI disorders seen in primary care, but it's often underdiagnosed. 

In this guidelines side-by-side comparison, we compare the latest clinical practice guidelines from the American Gastroenterological Association (AGA), the American Society of Colon and Rectal Surgeons (ASCRS), and the World Gastroenterology Organisation (WGO) on chronic constipation. This comparison is not exhaustive of all of the recommendations made by these organizations. For complete details, we encourage you to review the full guidelines available at the links below.

Guidelines for Comparison

	American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation	The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Evaluation and Management of Chronic Constipation	A Global Cascade Approach to Diagnosis and Management of Chronic Constipation
Authoring Society	American Gastroenterology Association	American Society of Colon and Rectal Surgeons	World Gastroenterology Organization
Publication Date	May 2023	September 2024	August 2025
Graded Recommendations	Yes	Yes	No
Uses GRADE	Yes	Yes	No
Links	Pocket Guide / Full Text	Summary / Full Text	Summary / Full Text

Key Takeaways

The WGO provides guidance meant to be adapted globally, based on the resources available in a given region. Its guidance includes cascades of care from level 1, which can be implemented in areas with limited resources, up to level 3 interventions, which require extensive resources. The WGO addresses both evaluation and treatment, and presents information on emerging device-based interventions which were not included in this article.

The ASCRS guideline also includes recommendations for both evaluation and treatment, with more focus on surgical interventions, and no recommendations regarding advanced pharmacotherapy.

The AGA guideline is for patients with chronic idiopathic constipation and includes only recommendations for pharmacologic management.

Some of the key takeaways, similarities, and differences between the guidelines published by the WGO, ASCRS, and AGA are reviewed below. 

Fiber Intake

• All three articles support increased dietary/supplemental fiber intake as a first-line therapy for the treatment of chronic constipation.

Other Non-Pharmacologic Interventions

• Both the ASCRS and WGO recommend increased fluid intake.
• The WGO goes further, advising regular exercise, especially aerobic activity, proper toileting habits, and identifying and discontinuing medications that contribute to constipation.

Osmotic Laxatives

• Osmotic laxatives are recommended as a first-line therapy by all three guidelines. 
• The AGA recommended polyethylene glycol (PEG), magnesium oxide (MgO), and lactulose. 
• WGO recommended PEG and lactulose, and recognized that in some regions MgO may be used.

Stimulant Laxatives

• All three articles recommend stimulant laxative bisacodyl for short term use or as a rescue or second-line agent for chronic constipation.
• The AGA and ASCRS also recommend sodium picosulfate for short-term use or as a rescue medicine.
• Stimulant laxative senna is suggested for idiopathic chronic constipation by the AGA.

Surgical Intervention

• Surgical interventions were not addressed by the AGA.
• The WGO recommends considering surgical interventions for carefully selected patients with medically refractory constipation.
• ASCRS suggests considering surgical intervention for patients to repair a rectocele or rectal intussusception that’s causing severe obstructed defecation. They also make recommendations for colectomy in patients with refractory slow-transit constipation and fecal diversion for intractable constipation that does not respond to other treatment options.

Advanced Pharmaceuticals

• WGO recommends the use of advanced pharmaceuticals in their level 3 cascade for the treatment of chronic constipation. 
• The AGA recommends advanced pharmaceuticals: lubiprostone, linaclotide, plecanatide, and prucalopride for chronic idiopathic constipation not amenable to over-the-counter agents.
• The ASCRS does not address the use of advanced pharmaceuticals for the treatment of chronic constipation.

Advanced Surgical Interventions

• Advanced surgical interventions were not addressed by the AGA.
• Stapled trans-anal rectal resection (STARR) was addressed by both the ASCRS and WGO. 
• The ASCRS does not recommend STARR for repair of a rectocele or internal rectal intussusception because of high complication rates. 
• WGO on the other hand, considers STARR as a treatment option to repair internal rectal prolapse or rectocele, but recognizes the high rate of complications from this procedure.

Comparison of Recommendations (for Patients Without Defecatory Disorders)

Treatment Recommendations	AGA	ASCRS	WGO
Non-pharmacologic Interventions	In adults with chronic idiopathic constipation (CIC), the panel suggests the use of fiber supplementation over management without fiber supplements.	The initial management of patients with symptomatic constipation involves dietary modifications and ensuring adequate fluid intake and fiber supplementation.	Fiber in diet and or supplementation is considered as the first-line treatment for patients with chronic constipation (In patients with obstructive diseases of the intestine, a high-fiber diet should be avoided).
			Besides fiber: • Increased fluid intake should be used to enhance colonic transit and minimize bloating. • Regular exercise is strongly recommended; in particular, aerobic activities such as brisk walking, jogging, cycling, and swimming have been shown to stimulate gut motility and reduce colonic transit time. •Proper toilet habits, such as responding promptly to the urge to defecate and adopting a squatting position, can also facilitate bowel movements. •Identifying and discontinuing medications that contribute to constipation is essential for optimal symptom control.
Pharmacological Interventions – Osmotic Laxatives	In adults with CIC, the panel recommends the use of PEG compared with management without PEG. In adults with CIC, the panel suggests the use of MgO over management without MgO. In adults with CIC who fail or are intolerant to over the counter (OTC) therapies, the panel suggests the use of lactulose over management without lactulose.	Osmotic laxatives are an appropriate first-line medical therapy to manage chronic constipation.	Osmotic laxatives are the recommended first-line pharmacologic agents. Polyethylene glycol (PEG) and lactulose have strong clinical evidence supporting their effectiveness in treating constipation. However, lactulose is associated with a higher incidence of gastrointestinal side effects, such as bloating, flatulence, and abdominal discomfort. In some regions, magnesium oxide is also used.
Pharmacologic Interventions- Stimulant Laxatives	In adults with CIC, the panel recommends the use of bisacodyl or sodium picosulfate (SPS) short term or as rescue therapy over management without bisacodyl or SPS. In adults with CIC, the panel suggests the use of senna over management without Senna.	Stimulant laxatives, such as bisacodyl, can be considered for rescue therapy or as second-line therapy, if needed.	Stimulant laxatives such as bisacodyl can be used as rescue therapy. Although effective for short-term symptom relief, their use should generally be limited to intermittent or as-needed administration to avoid potential adverse effects such as electrolyte imbalances, abdominal cramping, and the theoretical risk of colonic neuromuscular dysfunction with long-term use.
Surgical Intervention	Not Addressed	Patients with significant outlet dysfunction from a rectocele may be considered for surgical repair after addressing any concomitant functional causes, such as nonrelaxing puborectalis muscle. Repair of rectal intussusception may be considered in patients with severe obstructed defecation in whom nonoperative treatments were unsuccessful. Patients with isolated refractory colonic slow-transit constipation may benefit from total abdominal colectomy with ileorectal anastomosis. Fecal diversion may be considered in patients with intractable constipation refractory to other treatment options.	Level 2 and 3 interventions when first-level is ineffective: Surgery may be considered in carefully selected patients with medically refractory constipation, particularly those with confirmed slow transit constipation (STC), where subtotal colectomy (with ileorectal or cecorectal anastomosis) may provide symptom relief. However, adverse outcomes including postoperative incontinence, diarrhea, small bowel obstruction, or stoma requirement can occur in a minority⁠. Long‑term data remain variable, reflecting heterogeneity in patient selection and surgical techniques⁠. For anatomical causes such as external rectal prolapse or internal prolapse, resection rectopexy and mesh or suture rectopexy (e.g., laparoscopic ventral mesh rectopexy) demonstrate robust functional outcomes.
Advanced Pharmaceuticals	In adults with CIC who do not respond to OTC agents, the panel suggests the use of lubiprostone over management without lubiprostone.  In adults with CIC who do not respond to OTC agents, the panel recommends the use of linaclotide over management without linaclotide.   In adults with CIC who do not respond to OTC agents, the panel recommends the use of plecanatide over management without plecanatide.   In adults with CIC who do not respond to OTC agents, the panel recommends the use of prucalopride over management without prucalopride.	Not Addressed	For third-level cascade interventions, which typically apply to regions with extensive resources, treatment incorporates advanced pharmacologic agents alongside cutting-edge device-based or neuromodulation therapies. Among advanced pharmaceuticals agents such as linaclotide, lubiprostone, elobixibat, and guanylate cyclase-c (GC-C) receptor agonists are well-established in current guidelines. These medications enhance intestinal secretion, reduce transit time, or modulate bile acid signaling to increase spontaneous bowel movement frequency in patients unresponsive to bulk-forming or osmotic laxatives.
Advanced Surgical Interventions	Not Addressed	STARR is not recommended for the repair of a rectocele or internal rectal intussusception because of the high complication rates associated with this procedure.	When less-invasive and device-based treatments fail or prove unfeasible, advanced surgical interventions may be considered. Such procedures carry significant risks and should be reserved for highly selected patients within multidisciplinary expert centers. Stapled Trans-Anal Rectal Resection (STARR) is a minimally invasive, transanal procedure targeting obstructed defecation secondary to internal rectal prolapse or rectocele. A systematic review emphasized that STARR is safe and effective in managing constipation due to obstructed defecation syndrome and improves patients’ quality of life⁠. However, STARR carries notable complication rates up to 36% in some cohorts, including bleeding, fecal urgency, flatus incontinence, and symptom recurrence over time.

This concludes our chronic constipation guidelines side-by-side comparison. Don’t forget to sign up for alerts to stay informed on the latest published clinical guidelines and guideline updates.