Data on treatment satisfaction in European men and women with chronic constipation are limited.
Data on treatment satisfaction in European men and women with chronic constipation are limited.
To assess satisfaction with current treatment among European men and women with chronic constipation.
An internet-based survey was conducted in 2009 in 10 European countries: Austria, Germany, France, Ireland, Italy, Spain, Switzerland, the UK, Belgium and the Netherlands. Participants had self-reported chronic constipation (<3 bowel movements/week and ≥1 symptoms for ≥6 months of: pain during defecation; lumpy/hard faeces; and feeling of incomplete evacuation). Demographic data and disease history were collected. For participants using laxatives, drug name/class, satisfaction with treatment and interest in other treatments were collected.
Of the 1941 participants screened, 1355 had chronic constipation and met the inclusion criteria (chronic constipation population). The majority of the chronic constipation population who disclosed their sex (n = 811) were women (82%). Sixty-eight per cent of respondents (n = 855/1255) reported using laxatives, with the proportion of laxative users differing between subsets. Twenty-eight per cent (n = 225/793) were (very) satisfied with their treatment, whereas 44% (n = 345/793) were neutral and 28% (n = 223/793) (very) dissatisfied. There was no relationship between type of laxative and degree of (dis)satisfaction. Interest in other treatments was high with 83% (n = 686/827) of respondents ‘absolutely’ or ‘probably’ interested. Respondents dissatisfied with their treatment were more likely to be interested in other treatments.
Laxative-use is common for chronic constipation. In this large survey, 28% of participants were dissatisfied with their treatment, with the majority interested in other treatments.
The true prevalence of constipation is difficult to ascertain, with reports of approximately 17% in European populations and estimates ranging between 2% and 27% in US populations.[3, 4] Systematic reviews found most estimates of constipation prevalence to be in the range of 12–19%.[3, 4] Constipation is more common in women than men, and the likelihood of suffering from constipation increases with age.[5-7] Constipation is often a chronic, long-standing problem. Indeed, a survey conducted in a US population showed that, of 557 participants with chronic constipation, 43% reported a history of chronic constipation of 4 years or more, and 21% reported having chronic constipation for ≥10 years.
The management of chronic constipation can be difficult, and there are various aetiologies. Therefore, treatment should aim to address the underlying pathophysiology while relieving the multiple symptoms associated with the disease. Currently, lifestyle and dietary modifications are recommended before the use of laxatives in the treatment of chronic constipation[9, 10]; however, there are only limited data available on the effectiveness of these modifications. When lifestyle and dietary modifications fail to provide an adequate effect, laxatives are considered the first-line pharmacological intervention. Laxatives are generally classed by their mode of action and include bulking agents (e.g. fibre), stimulant laxatives (e.g. bisacodyl and sodium picosulphate), stool softeners (e.g. docusate) and osmotic laxatives (e.g. polyethylene glycol and lactulose). Numerous studies have shown that laxatives increase the number of bowel movements, with some reporting an improvement in specific symptoms; however, these studies are often small and may not always have clinically meaningful endpoints.
Clinical trial endpoints are unlikely to capture the whole picture, and surveys of patient satisfaction with chronic constipation treatments can reveal useful information about the real-life effectiveness of these agents. In a US survey of people with chronic constipation, 72% of the 533 respondents stated that they were currently taking medication to treat their chronic constipation symptoms, and 47% of these were not completely satisfied with the treatment they were receiving. Dissatisfaction with treatment potentially has an impact on quality of life, which is already affected by chronic constipation irrespective of treatment. Indeed, in a National Health and Wellness survey, patients with chronic constipation had significantly lower health-related quality of life than matched controls, in both the physical and mental components of the SF-12 questionnaire. Thus, such a high dissatisfaction rate for a common affliction like chronic constipation could carry a considerable burden for the population.
Currently, there are limited data on treatment satisfaction in European men and women with chronic constipation. Therefore, this internet survey was developed, with the aim of assessing satisfaction with current treatment options among a sample of European men and women suffering from chronic constipation.
An internet survey on chronic constipation treatments and satisfaction with treatment was conducted from 19 January 2009 until 1 April 2009 in 10 European Countries: Austria, Germany, France, Ireland, Italy, Spain, Switzerland, the UK, Belgium and the Netherlands (BNL).
Participants aged >18 years were recruited through targeted advertising on Google (using Adwords) and patient health websites (see Appendix S1) using keywords related to constipation and treatments. The aim of the study was to recruit 100 participants per country for participation in the survey; patients were given an incentive of being entered into a draw with the chance of winning a gift voucher worth €125 (£110 in the UK). Inclusion criteria for the survey were a self-report of chronic constipation, which was defined as <3 bowel movements/week as well as ≥1 of the following symptoms for at least 6 months: pain during defecation; lumpy/hard faeces; and a feeling of incomplete evacuation.
Do you suffer from chronic constipation? Specifically: Do you have FEWER THAN 3 bowel movements per week and do you suffer from AT LEAST 1 of the following symptoms?
(1) Pain during bowel movement
(2) Lumpy or hard feces
(3) The feeling of incomplete bowel movement, ‘that you aren't yet finished’
|How long have you been suffering from chronic constipation?||(Categorical answers from months to years)|
|Which of the following products are you currently using for chronic constipation?||(A list of proprietary products)|
|For how long have you been using this product?||(Categorical answers from months to years)|
|How satisfied are you with your CURRENT medication for chronic constipation?|| |
Neither satisfied nor dissatisfied
|Would you be interested in OTHER products for chronic constipation that can relieve you of the symptoms quicker?|| |
No, absolutely not
|Have you already used COMPLEMENTARY or ALTERNATIVE treatment for chronic constipation?|| |
Which COMPLEMENTARY or ALTERNATIVE treatments have you already used?
You can tick more than one answer.
|(Categorical answers from a list)|
|How old are you?||(Categorical answers starting from 10 to 18 years old)|
|Are you?|| |
For the majority of questions in the survey, the participants selected from predefined answers; however, some questions allowed participants to insert free text. Participants were not required to answer all questions; responses from participants who answered all questions as well as those who answered only a subset of the questions were included in the analysis.
Data were collected and categorised according to language and therefore were divided into six subsets: English speaking (including the UK and Ireland), German speaking (including Germany, Austria and German-speaking Switzerland), French speaking (France and French-speaking Switzerland), Italian speaking, Spanish speaking [Spain but also including data for a respondent not residing in Spain (respondent's country of residence unknown)] and Dutch speaking (including BNL). Participants indicated current laxative use by either selecting from a list of proprietary products or selecting ‘other’ and entering the drug name. Products were categorised into the following pharmacological groups: macrogol, diphenolic laxatives (bisacodyl or sodium picosulphate), anthraquinones, fibre (dietary), sugars, osmotic salts and rectal (rectally administered products, such as enemas and suppositories); any products that could not be categorised were grouped as ‘other’. Summary statistics were used, including mean values and percentages. Correlations between categorical variables were analysed using the Chi-squared test.
A total of 1941 participants were screened, of whom 284 (15%) did not have constipation according to the specified criteria. Of the 1657 (85%) participants with constipation, 1611 (97%) disclosed the duration of their constipation. A total of 1355 (84%) respondents had experienced constipation for ≥6 months duration (therefore defined as chronic constipation), and hence fulfilled the inclusion criteria of the survey (referred to as the chronic constipation population). The majority of the chronic constipation population had experienced constipation for more than 3 years [n = 940 (69%); Table 2]. Of the chronic constipation population, 811 (60%) provided details about their sex; the majority were women (82%), without major differences between the six subsets (Table 3). Seven hundred and ninety-four (59%) of the chronic constipation population provided their age category: age categories ranged from 19 to >65 years; the most common age group represented was between 41 years and 45 years [n = 109 (14%)].
|Language subset||Participants screened, N||Participants with constipation, n||Duration of constipation||Participants not answering the question, n|
|Less than 6 months, n (%)||6–12 months, n (%)||1–2 years, n (%)||2–3 years, n (%)||More than 3 years, n (%)|
|Dutch speaking||494||391||64 (17%)||37 (10%)||44 (12%)||29 (8%)||201 (54%)||16|
|French speaking||316||263||38 (15%)||27 (10%)||16 (6%)||19 (7%)||158 (61%)||5|
|German speaking||287||246||48 (20%)||28 (12%)||26 (11%)||19 (8%)||116 (49%)||9|
|Italian speaking||307||273||37 (14%)||23 (9%)||21 (8%)||13 (5%)||173 (65%)||6|
|Spanish speaking||312||279||36 (13%)||18 (7%)||21 (8%)||12 (4%)||186 (68%)||6|
|English speaking||225||205||33 (16%)||25 (12%)||24 (12%)||13 (6%)||106 (53%)||4|
|Total||1941||1657||256 (16%)||158 (10%)||152 (9%)||105 (7%)||940 (58%)||46|
|Language subset||Participants with chronic constipationa, n||Sex||Total unanswered, n|
|Male, n (%)||Female, n (%)|
|Dutch speaking||311||35 (19%)||151 (81%)||125|
|French speaking||220||20 (15%)||111 (85%)||89|
|German speaking||189||26 (28%)||68 (72%)||95|
|Italian speaking||230||28 (20%)||113 (80%)||89|
|Spanish speaking||237||18 (13%)||121 (87%)||98|
|English speaking||168||18 (15%)||102 (85%)||48|
|Total||1355||145 (18%)||666 (82%)||544|
Of the chronic constipation population, 1255 (93%) disclosed whether they used laxatives or not: 400 (32%) answered that they did not use laxatives, with the remaining 855 (68%) reporting laxative use. The proportion of laxative users differed between the subsets [Dutch speaking: n = 191 (67%); French speaking: n = 148 (73%); German speaking: n = 116 (66%); Italian speaking: n = 126 (59%); Spanish speaking: n = 146 (67%); English speaking: n = 128 (81%); Chi-squared 21.2, P = 0.001]. Seven hundred and ninety-three (93%) laxative users disclosed the duration of laxative use: laxative use categories ranged from less than 1 month to more than 2 years; the most common group for duration of laxative use was more than 2 years (n = 288; 36%) (Table 4). Of the 855 respondents using laxatives, 793 (93%) answered whether they were satisfied with their treatment or not; 225 (28%) were very satisfied or satisfied with their treatment, 345 (44%) were neutral and 223 (28%) were dissatisfied or very dissatisfied with their treatment. The individual data from the six subsets are shown in Figure 1. Satisfaction was lowest in the English-speaking and Spanish-speaking subsets, and highest in the Italian-speaking subset (Chi-squared 25.6, P = 0.004) (Figure 1). Diphenolic laxatives (bisacodyl or sodium picosulphate) were the most commonly used laxatives, followed by macrogol, anthraquinones and sugars (Figure 2). There was no relationship between the type of laxative and the degree of satisfaction or dissatisfaction (Chi-squared 18.0, P = 0.117) (Figure 3). Interestingly, the class of laxatives used by the chronic constipation population differed between the six subsets (Chi-squared 229, P < 0.001) (Figure 2). Macrogol was the most common laxative used in the French-speaking subset and Dutch-speaking subset while it was not widely used in the Spanish-speaking subset. Although diphenolic laxatives were used by nearly half of the German-speaking subset, their use was quite uncommon in the Italian-speaking subset. Anthraquinones were the most common laxatives used in the English-speaking subset, Spanish-speaking subset and Italian-speaking subset, but were uncommon in the French-speaking, German-speaking and Dutch-speaking subsets. Osmotic salts were the least widely used laxatives across all subsets except the Spanish speaking, where macrogol was the least widely used laxative.
|Language subset||Participants with chronic constipationa, n||Participants using laxatives, n||Duration of laxative use||Participants answering the question, n||Participants not answering the question, n|
|Less than 1 month, n (%)||1–3 months, n (%)||3–6 months, n (%)||6–12 months, n (%)||1–2 years, n (%)||More than 2 years, n (%)|
|Dutch speaking||311||191||30 (17%)||26 (15%)||21 (12%)||26 (15%)||25 (14%)||50 (28%)||178||13|
|French speaking||220||148||20 (15%)||17 (13%)||15 (11%)||10 (7%)||16 (12%)||57 (42%)||135||13|
|German speaking||189||116||20 (20%)||8 (8%)||14 (14%)||12 (12%)||11 (11%)||37 (36%)||102||14|
|Italian speaking||230||126||15 (13%)||9 (8%)||12 (10%)||13 (11%)||15 (13%)||51 (44%)||115||11|
|Spanish speaking||237||146||21 (15%)||15 (11%)||16 (12%)||16 (12%)||17 (12%)||53 (38%)||138||8|
|English speaking||168||128||23 (18%)||15 (12%)||13 (10%)||19 (15%)||15 (12%)||40 (32%)||125||3|
|Total||1355||855||129 (16%)||90 (11%)||91 (11%)||96 (12%)||99 (12%)||288 (36%)||793||62|
When the laxative users were asked whether they would be interested in other treatments for constipation, 827 of participants responded: 484 (59%) voted ‘yes, absolutely’, 202 (24%) ‘probably’, 96 (12%) ‘don't know’, 23 (3%) ‘probably not’, 22 (3%) ‘no, absolutely not’. There were no appreciable differences between the six subsets (P > 0.2). Respondents dissatisfied with their laxative treatment were more likely to be interested in other treatment options (Chi-squared 34.9, P < 0.001) (Table 5).
|Satisfaction with treatment||Interest in other products to treat chronic constipation||Total answered, n|
|Yes, absolutely/probably, n (%)||Don't know, n (%)||No, absolutely not/probably not, n (%)|
|Very satisfied/satisfied||169 (72%)||38 (16%)||27 (12%)||234 (100%)|
|Neither satisfied nor dissatisfied||304 (86%)||40 (11%)||10 (3%)||354 (100%)|
|Dissatisfied/very dissatisfied||213 (89%)||18 (8%)||8 (3%)||239 (100%)|
|Total answeredc||686 (83%)||96 (12%)||45 (5%)||827 (100%)|
Of the chronic constipation population answering the question (n = 1138), 490 (43%) stated they had already used complementary or alternative treatment for their constipation [Dutch speaking: 105/259 (41%); French speaking: 92/183 (50%); German speaking: 76/153 (50%); Italian speaking: 62/194 (32%); Spanish speaking: 95/205 (46%); and English speaking: 60/144 (42%)]. Homeopathy was the most common complementary or alternative treatment used by the chronic constipation population, followed by massage (Figure 4).
This multinational survey aimed to determine the level of satisfaction with current treatment options among a sample of European women and men suffering from chronic constipation. The majority of the chronic constipation population who disclosed their sex in this European survey were women, a result that is consistent with the available literature.[3, 13] Chronic constipation is often of long duration and, of the chronic constipation population (defined as constipation for ≥6 months duration) in this survey, the majority had experienced constipation for more than 3 years. It is well documented that the prevalence of constipation increases with age[5-7]; however, in the chronic constipation population in this survey, the age group with the highest number of respondents was between 41 years and 45 years. A limitation of this survey was its selection bias towards subjects with chronic constipation; certain keywords relating to constipation causes and treatments, when input into Google (an online search engine), were used to direct subjects to the survey (via Google Adwords). The questions in the survey were not validated, but they were not complex and were similar to questions that have been used in other constipation surveys in the past. As this survey had selection bias towards individuals who have access to the internet, the age category of the chronic constipation population could have been influenced, resulting in more young and middle-aged subjects completing the survey compared to elderly subjects. However, this result is similar to that observed in a multinational survey conducted by Wald et al. in which interviews were conducted in Italy, Germany and the UK (nationwide), France (27 major towns only), South Korea (Seoul, Incheon and Kyungi only), Brazil (Greater Sao Paulo and Greater Rio de Janeiro) and the USA (10 major towns only). In the survey conducted by Wald et al., approximately half of the subjects with constipation (self-reported constipation assessed using the Rome III criteria) fell within the 30–59 years old age category.
The medical management of chronic constipation with traditional laxatives generally begins after failure of dietary and lifestyle modifications; however, without high-quality randomised controlled trials, it is difficult to ascertain the benefit of increasing dietary fibre intake in patients with chronic idiopathic constipation. Laxative use is usually high among chronic constipation sufferers. Indeed, in our European survey, 68% of the chronic constipation population confirmed that they used laxatives to treat their constipation. This result is consistent with a randomised, web-based US survey conducted by Johanson and Kralstein, in which 72% (385/533) of respondents with constipation (defined using the Rome II criteria) reported taking medication to treat their constipation symptoms.
The different pharmacologic classes of laxatives vary in their use across different countries; however, the reason for this is not apparent. The proportion of laxative users ranged from 59% in the Italian-speaking subset to 81% in the English-speaking subset. It remains unclear, however, whether this is due to cultural differences or other reasons. Our survey identified macrogol as the most common laxative used in the French-speaking and Dutch-speaking subsets, compared with anthraquinones in the Italian-speaking, Spanish-speaking and English-speaking subsets, and diphenolic laxatives in the German-speaking subset. Currently, only few published data are available on the type of laxative use across different countries; therefore, more data are required to make a comparison with our findings.
Despite the high rate of laxative use and the wide variety available, patients with chronic constipation can be dissatisfied with their treatment. As previously mentioned, in a US survey conducted by Johanson and Kralstein, 72% of respondents with constipation stated that they were taking medication to treat their symptoms. Of these, 47% were not completely satisfied with their current treatment. In our European survey, only 28% of the chronic constipation population were satisfied or very satisfied with their current treatment. As this survey had selection bias towards individuals searching for constipation treatments, it is possible that the percentage of subjects satisfied with their treatment could have been influenced, as more patients dissatisfied with their treatment could have completed the survey than those satisfied with their treatment. Our survey did not identify the cause of dissatisfaction with current treatment options for chronic constipation. However, Johanson and Kralstein reported in their survey that the majority of respondents identified efficacy-related reasons, including ‘does not work well’ or ‘inconsistent results’, as the cause of their treatment dissatisfaction. Safety-related and adverse-effect concerns were also among the reasons reported for dissatisfaction with current treatment options. In addition to these causes for dissatisfaction, when Johanson and Kralstein further divided dissatisfaction according to type of laxative (over-the-counter or prescription), it was noted that, for the 146 respondents taking over-the-counter laxatives, 71% were not completely satisfied with the predictability of the treatment, 60% did not think the laxatives completely relieved the multiple symptoms of constipation and 44% believed the products did not completely relieve their constipation. The results for prescription laxatives were similar to those reported for over-the-counter laxatives. A pharmacy-based survey showed that customers buying sodium picosulphate were satisfied to a high degree with this drug. Hence, it appears that many patients with constipation have difficulty in finding the product/laxative that suits them; however, those who have found it are highly satisfied.
With the current level of dissatisfaction with laxatives, it is conceivable that patients would seek alternative methods to relieve their chronic constipation. In our survey, almost half of the chronic constipation population confirmed that they had already used complementary or alternative treatments. When asked whether they would be interested in other treatment options for chronic constipation, the majority of respondents (484/827; 59%) answered that they would ‘absolutely’ be interested. However, a minority of patients (45/827; 5%) answered that they would not be or would probably not be interested in other treatment options. Although more dissatisfied respondents were interested in other treatment options (89%), the proportion of satisfied participants with interest in other treatments was still remarkably high (72%).
Patients with chronic constipation have been reported to have lower levels of health-related quality of life compared with matched controls. It has also been reported that chronic constipation causes an economic burden on society, with higher levels of loss of work productivity, including absenteeism and overall work impairment, as well as more healthcare-provider and emergency-room visits in the last 6 months in chronically constipated subjects compared with healthy subjects. This economic burden could, at least in part, be contributed to by the lack of satisfaction with laxatives that a number of patients with chronic constipation experience, as highlighted in our survey. Our survey has identified a need for newer treatment options for those patients that are currently dissatisfied with their treatment.
Guarantor of the article: Stefan Müller-Lissner accepts responsibility for the integrity of the work as a whole, from inception to published article.
Author contributions: FS and RSG were involved in the concept and design of the survey; SML wrote sections of the manuscript; YF was involved in the collection and assembling of the data; SML, JT, YF, FS, RSG performed/supervised the analysis, interpreted the results of the survey and critically reviewed the manuscript. All authors have approved the final version of the article, including the authorship list.
Declaration of personal interests: Stefan Müller-Lissner has served as a speaker, a consultant and an advisory board member for Boehringer Ingelheim, Falk Foundation, Janssen, Mundipharma GmbH and Shire-Movetis NV. Jan Tack has acted as an advisor to Addex, Almirall, AstraZeneca, Danone, Ironwood, Menarini, Novartis, Sanofi-Aventis, Shire-Movetis NV, SK Life Sciences, Takeda, Theravance, Tranzyme Pharma, XenoPort and Zeria, and has undertaken speaking engagements for Abbott, Alfa Wasserman, Almirall, AstraZeneca, Janssen, Menarini, Novartis, Nycomed, Shire-Movetis NV, and Takeda. Yue Feng has served as a consultant for Shire-Movetis NV and is an employee of Across Health. Fonny Schenck has served as a consultant for Shire-Movetis NV and is the CEO of Across Health. Renate Specht Gryp is an employee of and owns stock in Shire.
Declaration of funding interests: The data reported in this manuscript are the results of a survey conducted by Across Health, Ghent, Belgium and funded by Shire-Movetis NV. Writing support was provided by Kerri Bridgwater of Choice Healthcare Solutions and funded by Shire-Movetis NV. Support in data analysis was provided by Across Health and funded by Shire-Movetis NV. Editorial assistance was provided by Slavka Baronikova of Shire-Movetis NV.