Refractory constipation

Refractory constipation (RC) represents a complex clinical challenge that requires a systematic, pathophysiology-centered approach in order to avoid overclassification and the premature use of invasive interventions. Despite multiple therapeutic options, a significant proportion of patients remain dissatisfied with available treatments. RC is defined as the persistence of infrequent and/or unsatisfactory bowel habits, with or without abdominal discomfort, despite appropriate lifestyle interventions, optimization of medical therapy, and pelvic floor biofeedback therapy when indicated. Before considering a patient as refractory, it is essential to confirm the correct clinical phenotype – functional constipation, irritable bowel syndrome with constipation predominance, or dyssynergic defecation – and to exclude secondary causes such as medications or neurological comorbidities. Physiological evaluation is fundamental. Anorectal manometry and the balloon expulsion test constitute first-line diagnostic tools to identify defecatory disorders, which are present in up to one-third of these patients. Colonic transit studies allow the diagnosis of slow-transit constipation and help guide management. Defecography is reserved for inconclusive cases or when structural abnormalities are suspected. Treatment should prioritize pharmacological optimization with laxatives, secretagogues, and prokinetic agents, considering individualized combination regimens. Non-pharmacological options such as biofeedback therapy and the vibrating capsule may be useful. Surgery should be restricted to carefully selected cases, after excluding pelvic floor dysfunction, diffuse gastrointestinal dysmotility, and adverse psychological factors. An integrated and individualized approach improves clinical outcomes and quality of life.