Exclude bowel obstruction, clinical features might include:

• nausea
• vomiting
• colicky abdominal pain
• abdominal distension

Correct reversible causes if appropriate.

An understanding of the patient's normal, accepted bowel habit is essential when planning treatment.

Constipation is best managed by empowering patients to adjust their doses according to response.

Almost all patients on opioids require a laxative prescribed regularly.

A combination of stimulant and softener is usually required. Modify food and fluid intake if appropriate.

See also section 1.6 Laxatives for preparations

Is the stool hard or soft?

Soft stools:

• Consider stimulant laxative e.g. senna
• Titrate dose

Hard stools:

• Consider laxative with softening e.g. sodium docusate
• Titrate dose

Then consider combination of softener and stimulant laxative or change to alternative then titrate.

Alternatives include:

• Osmotic laxatives e.g. Macrogol compound oral powder, sachets
• Co-danthramer or co-danthrusate (only licensed in terminal illness)

Following rectal examination consider:

Soft or hard impacted stools:

• Stimulant suppositories and/or enemas

No stools:

• Abdominal x-ray to aid diagnosis
• high phosphate enema or impaction dose macrogol compound

Aim for a comfortable, regular passage of stool.

Continue regular laxatives to retain this unless the cause has been reversed.