Table 2.

Summary of the Seoul Consensus on Functional Constipation

		Level of evidence	Strength of recommendation
Definition and epidemiology
1	Constipation is defined as the occurrence of symptoms of infrequent bowel movements, hard stools, a feeling of incomplete evacuation, straining at defecation, a sense of anorectal blockage during defecation, and use of digital maneuvers to assist defecation.	NA	NA
2	The prevalence of constipation is higher in the elderly population.	Moderate	NA
3	The prevalence of constipation is higher in females than in males.	High	NA
Diagnosis
4	Type 1 and 2 stools (according to the Bristol Stool Form Scale) can be used to predict slow-transit constipation in patients with chronic constipation.	Moderate	Conditional
5	Digital rectal examination is useful for identifying organic anorectal causes of constipation (such as anorectal masses, rectal prolapse, and rectoceles).	Moderate	Strong
6	Abnormal findings on digital rectal examination, suggesting defecatory disorders, can prompt the referral for physiological tests.	Moderate	Strong
7	Colonoscopy should be performed in patients with constipation who have alarm symptoms or have not undergone appropriate colon cancer screening.	Low	Strong
8	Physiological tests are recommended for patients with functional constipation who have failed to respond to treatment with available laxatives (for a minimum of 12 weeks and under a recommended therapeutic regimen) or who are strongly suspected of having a defecatory disorder.	Very low	Strong
9	Although poorly standardized, the balloon expulsion test may be useful for screening for defecatory disorders.	Moderate	Conditional
10	Anorectal manometry is useful for diagnosing defecatory disorders in patients with constipation. However, it should be performed alongside other anorectal physiological tests to confirm the diagnosis.	Moderate	Strong
11	Defecography is useful for assessing structural abnormality of the pelvic floor or pelvic dyssynergia in patients with chronic constipation who are suspected of having an evacuation disorder.	Moderate	Strong
12	Segmental colon transit time is useful for differentiating slow-transit constipation from defecatory disorder in patients with chronic constipation.	Low	Strong
Management
13	Dietary fiber is effective in improving the symptoms of chronic constipation by reducing the colon transit time and increasing the bowel frequency.	Moderate	Strong
14	Exercises can be recommended since they may improve symptoms in some patients with chronic constipation. Besides, exercises confer health benefits to people of all age groups.	Low	Conditional
15	Bulking agents increase the frequency of defecation and are effective and safe for the management of chronic constipation.	Moderate	Strong
16	The use of bulking agents, especially insoluble fiber, in patients with chronic constipation is limited by adverse events, particularly abdominal pain, bloating, flatulence, and nausea.	Low	Conditional
17	Magnesium salts improve stool frequency and consistency.	High	Strong
18	Magnesium salts can cause hypermagnesemia in patients with an impaired renal function.	Low	Strong
19	Non-absorbable carbohydrates are effective in patients with chronic constipation.	Low	Strong
20	Long-term administration and use in elderly patients of non-absorbable carbohydrates may be considered as serious side effects are rare.	Low	Conditional
21	Polyethylene glycol is effective in the management of chronic constipation.	High	Strong
22	Polyethylene glycol is safe and tolerable for long-term treatment in patients with chronic constipation and can be considered for use in the elderly.	Moderate	Conditional
23	The administration of stimulant laxatives is recommended to relieve symptoms in patients with chronic constipation.	Moderate	Strong
24	The use of stimulant laxatives in patients with chronic constipation should be recommended for a short-term period due to limited evidence on the long-term safety of these laxatives.	Low	Conditional
25	Probiotics can be used to relieve constipation symptoms in patients with chronic constipation. However, because the effects of probiotics vary depending on their species/strains and because the results between studies are inconsistent, it is recommended to use probiotics as a supplementary treatment.	Low	Conditional
26	Prucalopride is a highly selective serotonin (5-hydroxytryptamine)-4 agonist that accelerates the whole gut motility. It is effective in the management of chronic constipation, even in patients who exhibit an inadequate response to conventional laxatives.	High	Strong
27	Lubiprostone, the chloride channel activator, is effective and safe for the management of chronic constipation. It does not cause clinically significant adverse effects, such as electrolyte imbalance and renal dysfunction.	High	Strong
28	Linaclotide, an intestinal secretagogue, is effective and safe for the management of chronic constipation.	High	Strong
29	Biofeedback therapy is effective and safe for treating patients with defecatory disorders.	Moderate	Strong
30	Biofeedback therapy has long-term therapeutic effects and improves the quality of life in patients with defecatory disorders.	Moderate	Strong
31	Enemas can be effective in the subset of patients with refractory defecatory disorders.	Low	Conditional
32	Enemas should be used with caution because there are no standardized guidelines on their use and they may cause adverse events, such as electrolyte imbalance and rectal mucosal injury.	Low	Conditional
33	Colectomy can be considered in highly selected patients with medically intractable (non-responsive) slow-transit constipation who do not have defecatory disorders and other gastrointestinal motility disorders.	Moderate	Conditional
34	Surgery for obstructed defecation syndrome can be indicated in patients with reparable structural abnormalities (such as rectocele, rectal intussusception, or rectal prolapse).	Low	Conditional

NA, not applicable.