A Multinational Survey of Prevalence and Patterns of Laxative Use Among Adults with Self-Defined Constipation

A. Wald; C. Scarpignato; S. Mueller-Lissner; M. A. Kamm; U. Hinkel; I. Helfrich; C. Schuijt; K. G. Mandel

Disclosures

Aliment Pharmacol Ther. 2008;28(7):917-930. 

In This Article

Abstract and Introduction

Abstract

Background. While numerous studies report prevalence of constipation, use of laxatives is poorly understood.
Aim. To conduct a survey in seven countries evaluating prevalence of constipation and laxative use in its treatment.
Methods. Thirteen thousand eight hundred seventy-nine adults [approximately 2000 each from US, UK, Germany (GE), France (FR), Italy (IT), Brazil (BR) and South Korea (SK)] completed questionnaires assessing occurrence, frequency, duration and laxative use for treating constipation.
Results. Overall, 12.3% of adults had constipation [range: 5% (GE) to 18% (US)] in the prior year. A greater percent of women from all countries and elderly from all except SK and BR reported constipation; odds ratios for constipation among women and elderly were 2.43 (95% CI: 2.18-2.71) and 1.5 (95% CI: 1.25-1.73) vs. men and young subjects. Among those with constipation, 16% (SK) to 40% (US) used laxatives. Laxative use was generally associated with increasing age, symptom frequency and lower income and education. A similar percentage of men and women with constipation reported using laxatives; a greater percentage of women used laxatives for a longer time.
Conclusions. Prevalence of self-defined constipation and laxative use varies among countries. Prevalence is generally related to gender and age, whereas laxative use is related to age, but not to gender.

Introduction

Constipation is a common disorder, which patients usually define as straining, difficulty in passing stool, hard stool, infrequent bowel movements, discomfort with defecation and feeling of incomplete evacuation. In contrast, constipation is often clinically defined by healthcare professionals based only on bowel frequency, specifically, having fewer than three bowel movements per week.[1] The Rome Criteria provide a clinical definition of constipation based on objective (stool frequency, requiring manual manoeuvres for defecation) and subjective (straining, hard stool, incomplete bowel movements, sensing anorectal blockage) symptoms.[2] These criteria provide a means to standardize diagnostic evaluation and are useful for identifying patients for research studies and clinical trials.

Several studies report population prevalence of constipation to range from 2% to 28%.[3,4,5,6,7,8,9,10,11] This wide range, in part, reflects how constipation is defined and the populations surveyed. In general, estimates of prevalence rates are lower in studies, which use more restricted definitions for constipation. For example, defining constipation solely as having a stool frequency of fewer than three bowel movements per week results in lower prevalence rates ranging from <1% to 5.4%. In contrast, higher prevalence rates are reported when constipation is defined using combinations of subjective (straining, passing hard stool, having unsatisfactory or incomplete defecation) and objective (stool frequency) measures.[9,12,13,14] Drossman et al.[9] reported prevalence rates of 17.2% and 4.2% when constipation was defined as straining on >25% of bowel movements, or <3 bowel movements per week respectively. Similarly, studies defining constipation, based on a combination of objective and subjective symptoms or using the Rome Criteria, report prevalence rates ranging from 8.0% to 18.3% and higher prevalence in women than in men.[13,15,16]

Other studies have measured prevalence based on self-defined constipation, where participants are free to consider themselves to have constipation without any constraint on definition. The estimation of the community prevalence of constipation based on self-definition relies on the finding that most sufferers do not seek healthcare intervention. As expected, the prevalence of self-defined constipation is greater than that reported using restricted definitions, such as stool frequency alone.[8,11,17,18,19] For example, Curtin et al.[8] reported prevalence rates of 6.4%, 5.1% and 2% in Swiss adult males when constipation was self-defined, defined as straining and/or difficulty in evacuation, or as having <3 bowel movements per week respectively. Another study from Sweden reported a 14.3% prevalence when constipation was self-defined, but only 3.1% when defined as <3 bowel movements per week.[11] Surveys conducted in representative US population samples reported prevalence of self-reported constipation to range from 12.8% to 20.8%.[17,18]

Most studies also demonstrate that individuals define constipation primarily as symptoms of straining, hard stool, discomfort and difficulty in passing stool, in contrast to a clinical definition based solely on infrequent stool frequency. In addition, most epidemiologic studies support evidence that constipation occurs with greater frequency in women than in men and that prevalence generally increases with age.[1,3,5,15,17,20,21,22] Some studies also support an association between increased prevalence of constipation, lower education and lower socioeconomic status. Population-based studies from the US suggest higher prevalence among women than among men and African-Americans compared with Caucasians.[17,18]

In contrast to the large amount of data concerning the prevalence of constipation and its association with age and gender, relatively little is known about laxative use among constipation sufferers. In the mid-1960s, Connell et al.[1] reported a constipation prevalence of <1%, but laxative use of almost 20% in a UK population sample. This suggests a large discrepancy between laxative use and reported constipation. To our knowledge, no study to date has been published, which compares prevalence of constipation and use of laxatives amongst various countries using the same survey methodology. This study compares prevalence rates of self-reported constipation and use of laxatives by constipation sufferers in seven countries, namely the United States (US), United Kingdom (UK), France (FR), Germany (GE), Italy (IT), Brazil (BR) and South Korea (SK). Participants from each country were interviewed using an appropriately translated standardized questionnaire. Results of the present investigation clearly show similarities and differences across geographies for this common gastrointestinal (GI) disorder and for laxative use.

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