low cost and safety. stimulants should only be used if this is not effective. in cases of chronic constipation, polyethylene glycol appears superior to lactulose. prokinetics may be used to improve gastrointestinal motility. a number of new agents have shown positive outcomes in chronic constipation; these include prucalopride and lubiprostone. cisapride is widely available in third world countries, but has been withdrawn in most of the west. it has not been shown to have a benefit on constipation, while potentially causing cardiac arrhythmias and deaths. enemas enemas can be used to provide a form of mechanical stimulation. a large volume or high enema can be given to cleanse as much of the colon as possible of feces, and the solution administered commonly contains castile soap which irritates the colon's lining resulting in increased urgency to defecate. however, a low enema is generally useful only for stool in the rectum, not in the intestinal tract. physical intervention constipation that resists the above measures may require physical intervention such as manual disimpaction (the physical removal of impacted stool using the hands; see fecal impaction). regular exercise regular exercise can help improve chronic constipation. surgical intervention in refractory cases, procedures can be performed to help relieve constipation. sacral nerve stimulation has been demonstrated to be effective in a minority of cases. colectomy with ileorectal anastomosis is another intervention performed only in patients known to have a slow colonic transit time and in whom a defecation disorder has either been treated or is not present. because this is a major operation, side effects can include considerable abdominal pain, small bowel obstruction, and post-surgical infections. furthermore, it has a very variable rate of success and is very case dependent. prognosis complications that can arise from constipation include hemorrhoids, anal fissures, rectal prolapse, and fecal impaction. straining to pass stool may lead to hemorrhoids. in later stages of constipation, the abdomen may become distended, hard and diffusely tender. severe cases ("fecal impaction" or malignant constipation) may exhibit symptoms of bowel obstruction (nausea, vomiting, tender abdomen) and encopresis, where soft stool from the small intestine bypasses the mass of impacted fecal matter in the colon. epidemiology constipation is the most common chronic gastrointestinal disorder in adults. depending on the definition employed, it occurs in 2% to 20% of the population. it is more common in women, the elderly and children. specifically constipation with no known cause affects females more often affected than males. the reasons it occurs more frequently in the elderly is felt to be due to an increasing number of health problems as humans age and decreased physical activity. 12% of the population worldwide reports having constipation. chronic constipation accounts for 3% of all visits annually to pediatric outpatient clinics. constipation-related health care costs total $6.9 billion in the us annually. more than four million americans have frequent constipation, accounting for 2.5 million physician visits a year. around $725 million is spent on laxative products each year in america. history 19th century satirical cartoon of a monkey rejecting an old style clyster for a new design, filled with marshmallow and opium since ancient times different societies have published medical opinions about how health care providers should respond to constipation in patients. in various times and places, doctors have made claims that constipation has all sorts of medical or social causes. doctors in history have treated constipation in reasonable and unreasonable ways, including use of a spatula mundani. after the advent of the germ theory of disease then the idea of "auto-intoxication" entered popular western thought in a fresh way. enema as a scientific medical treatment and colon cleansing as alternative medical treatment became more common in medical practice. since the 1700s in the west there has been some popular thought that people with constipation have some moral failing with gluttony or laziness. special populations children main article: constipation in children approximately 3% of children have constipation, with girls and boys being equally affected. with constipation accounting for approximately 5% of general pediatrician visits and 25% of pediatric gastroenterologist visits, the symptom carries a significant financial impact upon the healthcare system. while it is difficult to assess an exact age at which constipation most commonly arises, children frequently experience constipation in conjunction with life-changes. examples include: toilet training, starting or transferring to a new school, and changes in diet. especially in infants, changes in formula or transitioning from breast milk to formula can cause constipation. the majority of constipation cases are not tied to a medical disease, and treatment can be focused on simply relieving the symptoms. postpartum women the six-week period after pregnancy is called the postpartum stage. during this time, women are at increased risk of being constipated. multiple studies estimate the prevalence of constipation to be around 25% during the first 3 months. constipation can cause discomfort for women, as they are still recovering from the delivery process especially if they have had a perineal tear or underwent an episiotomy. risk factors that increase the risk of constipation in this population include: damage to the levator ani muscles (pelvic floor muscles) during childbirth forceps-assisted delivery lengthy second stage of labor delivering a large child hemorrhoids hemorrhoids are common in pregnancy and also may get exacerbated when constipated. anything that can cause pain with stooling (hemorrhoids, perineal tear, episiotomy) can lead to constipation because patients may withhold from having a bowel movement so as to avoid pain. the pelvic floor muscles play an important role in helping pass a bowel movement. injury to those muscles by some of the above risk factors (examples- delivering a large child, lengthy second stage of labor, forceps delivery) can result in constipation. enemas may be administered during labor and these can also alter bowel movements in the days after giving birth. however, there is insufficient evidence to make conclusions about the effectiveness and safety of laxatives in this group of people.