What is refractory constipation?
Constipation is when you have infrequent or hard-to-pass bowel movements (meaning they are painful or you have to strain), have hard stools, or feel like your bowel movements are incomplete. Infrequent means less than three bowel movements a week. Most of the time, constipation can be treated medically.
Refractory, or hard-to-treat, constipation happens when you have ongoing trouble with bowel movements even after trying lifestyle changes, diet, medications, and other therapies, like pelvic floor biofeedback. It can happen in people with chronic constipation or irritable bowel syndrome with constipation (IBS-C).
Sometimes, constipation is caused by things like medications, eating disorders, or nerve problems. These need to be checked and treated first. Another common cause is a problem with how the muscles and nerves in your pelvic area work together to expel stool (called a “defecatory disorder”).
Chronic constipation is often a lifelong condition requiring ongoing treatment. It is important to work with your health care providers to set goals, understand what “normal” bowel habits look like, and manage ongoing treatment.
Getting tested for refractory constipation
Your health care provider will ask for your medical history to identify potential causes making your constipation harder to treat, such as medications, poor nutritional habits, or disordered eating.
There are a few tests your health care provider might order to determine if you have refractory constipation.
- Your health care provider will do a gentle rectal exam to check for dyssynergic defecation, which is caused by muscle or nerve problems.
- Dyssynergic defecation is when you have constipation and have trouble having a bowel movement due to an inability to use your rectal muscles to expel stool and/or an inability to relax your anal sphincter to allow stool to pass.
- Anorectal manometry is a test that measures how well the muscles and nerves in your rectum and anus work together.
- The balloon expulsion test checks how easily you can push out a small balloon from your rectum.
- When done together, these tests help your health care provider understand why you might have constipation, trouble passing stool, or other bowel problems.
- Learn more about this test and how to prepare.
- Colonic transit testing helps diagnose slow-transit constipation or other conditions that affect bowel movement.
- This test helps your health care provider understand how quickly food moves through your large intestine (colon).
- You will need to stop using laxatives for at least 7 days and stop medications that slow down movement in your colon for at least 2 weeks before this test.
- Learn more about this test and how to prepare for colonic transit testing.
- This test helps your health care provider see if there are structural or functional problems in your anus, rectum, or pelvic floor.
- Defecography is performed using either barium or magnetic resonance.
- Barium is used to help measure rectal evacuation while you’re sitting up.
- Magnetic resonance defecography is performed while you’re lying down, but it is less widely available and more expensive.
- Both tests can help your health care provider see pelvic floor prolapse (weak pelvic muscles that can cause organs to sag) and pelvic floor motion.
How to treat refractory constipation
Many patients with chronic constipation are unsure what it means to have “normal” bowel habits. In the U.S., roughly 95% of individuals have between 3 bowel movements per day and 3 per week.
Since chronic constipation is a long-term condition, you will require ongoing medical treatment. Talk with your health care provider about treatment goals, expectations, and expected outcomes so you understand what to expect and the need to maintain ongoing therapy.
Lifestyle and nutrition
A healthy lifestyle is important when living with chronic constipation. Eating fresh fruits and veggies, drinking a lot of water, and exercising regularly help most people with constipation or irregular bowel habits. Every day you should:
- Eat a well-balanced diet with fiber, including whole grains, fresh fruits, and veggies.
- Drink plenty of fluids (especially water).
- Exercise regularly.
- Set aside time after breakfast or dinner to go to the bathroom.
- Go to the bathroom when you feel like you have to. Don’t ignore the urge to have a bowel movement.
However, even those following a very healthy diet can still struggle with chronic constipation, and medical treatment is often needed.
Medications
There are many medication options to help treat chronic constipation — along with the daily habits above — that can be found over-the-counter, without a prescription. Sometimes, combining different types of medications works better. Talk with your health care provider about the treatment options that are best for you.
- Over-the-counter options: Osmotic laxatives (like polyethylene glycol), stimulant laxatives (like bisacodyl or senna), and others. If over-the-counter medicines don’t work, talk with your health care provider about prescription medications.
- Prescription medications: Drugs like prucalopride, linaclotide, plecanatide, or tenapanor (for IBS-C) may be tried.
Non-medication treatment
Non-medication treatments can provide relief for patients with refractory constipation, especially when used with medicine.
Physical therapy that uses sensors and a computer for visual feedback to help retrain your muscles and nerves for better bowel movements.
Uses water to help empty the bowel, especially for people with nerve-related problems.
Has shown in clinical trials to work for patients with severe symptoms who have experienced more severe constipation.
Combines traditional acupuncture with electrical stimulation and been shown to help some patients.
Surgery
- Surgery is only considered if all other treatments fail and tests show your colon moves food too slowly (slow transit constipation), and you don’t have pelvic muscle problems.
- The most common surgery is removing part of the colon and connecting the small intestine to the rectum (colectomy with ileorectal anastomosis).
- Sometimes, a temporary stoma (loop ileostomy) is used first to see if surgery will help.
- Not everyone is a good candidate: Surgery may not be right for people with severe psychiatric illness, unresolved trauma, or if bloating and pain are the main symptoms.
Questions to ask your health care provider
- What tests will I need to find out the cause of my constipation?
- What lifestyle changes or medications should I try first?
- Is pelvic floor therapy right for me?
- What are the risks and benefits of surgery?
- How will my mental health be supported during treatment?
Reviewed by
Kyle Staller, MD, MPH
Director, Gastrointestinal Mobility Laboratory, Massachusetts General Hospital, Boston
Written November 2025