Slow Transit Constipation: Pathophysiological Perspectives and Management Updates

Slow transit constipation (STC) is a chronic colonic motility disorder characterized by markedly delayed transit, leading to reduced bowel movements, abdominal discomfort, and significant quality-of-life impairment. It predominantly affects women and is associated with abnormalities in enteric neuronal signaling, smooth muscle contractility, interstitial cells of Cajal, gut peptides, bile acid homeostasis, and autonomic regulation. Secondary causes of constipation and structural lesions must be excluded before the diagnosis of STC, with colonic transit studies serving as the gold standard. Complementary investigations such as anorectal manometry and defecography help detect coexisting outlet obstruction, which can alter management. The treatment of STC should follow a stepwise approach, beginning with dietary and lifestyle modification, osmotic and stimulant laxatives, and prokinetics such as prucalopride. Secretagogues and bile acid modulators may offer additional benefit. Biofeedback therapy is primarily indicated for overlapping dyssynergic defecation. For refractory STC, interventional therapies, such as fecal microbiota transplantation, acupuncture, sacral nerve stimulation, and transanal irrigation, are found to have equivocal outcomes. Antegrade continence enema procedures can be an alternative for patients unsuitable for colectomy. Surgical options, including subtotal colectomy with ileosigmoid or cecorectal anastomosis, and total colectomy with ileorectal anastomosis, are reserved for carefully selected patients with medically intractable symptoms, following thorough physiological evaluation. Although advances in understanding STC pathophysiology are guiding novel therapeutic development, robust randomized controlled trials remain scarce. Optimal care requires multidisciplinary collaboration between gastroenterologists, colorectal surgeons, and pelvic floor specialists to ensure accurate diagnosis, tailored treatment, and improved long-term outcomes.