CONSTIPATION

Constipation occurs when bowel movements become less frequent and stools become difficult to pass. It happens most often due to changes in diet or routine, or due to inadequate intake of fiber. You should call your doctor if you have severe pain, blood in your stools, or constipation that lasts longer than three weeks.

OVERVIEW:

What is constipation?

Having fewer than three bowel movements a week is, technically, the definition of constipation. However, how often you “go” varies widely from person to person. Some people have bowel movements several times a day while others have them only one to two times a week. Whatever your bowel movement pattern is, it’s unique and normal for you – as long as you don’t stray too far from your pattern.

Regardless of your bowel pattern, one fact is certain: the longer you go before you “go,” the more difficult it becomes for stool/poop to pass. Other key features that usually define constipation include:

• Your stools are dry and hard.
• Your bowel movement is painful and stools are difficult to pass.
• You have a feeling that you have not fully emptied your bowels.     

How common is constipation?

You are not alone if you have constipation. Constipation is one of the most frequent gastrointestinal complaints in the United States. At least 2.5 million people see their doctor each year due to constipation.

People of all ages can have an occasional bout of constipation. There are also certain people and situations that are more likely to lead to becoming more consistently constipated (“chronic constipation”). These include:

• Older age. Older people tend to be less active, have a slower metabolism and less muscle contraction strength along their digestive tract than when they were younger.
• Being a woman, especially while you are pregnant and after childbirth. Changes in a woman’s hormones make them more prone to constipation. The baby inside the uterus squishes the intestines, slowing down the passage of stool.
• Not eating enough high-fiber foods. High-fiber foods keep food moving through the digestive system.
• Taking certain medications (see causes).
• Having certain neurological (diseases of the brain and spinal cord) and digestive disorders (see causes).

How does constipation happen?

Constipation happens because your colon absorbs too much water from waste (stool/poop), which dries out the stool making it hard in consistency and difficult to push out of the body.

To back up a bit, as food normally moves through the digestive tract, nutrients are absorbed. The partially digested food (waste) that remains moves from the small intestine to the large intestine, also called the colon. The colon absorbs water from this waste, which creates a solid matter called stool. If you have constipation, food may move too slowly through the digestive tract. This gives the colon more time – too much time – to absorb water from the waste. The stool becomes dry, hard, and difficult to push out.

Pathway of food waste through colon, rectum and anus.

Can constipation cause internal damage or lead to other health problems?

There are a few complications that could happen if you don’t have soft, regular bowel movements. Some complications include:

• Swollen, inflamed veins in your rectum (a condition called hemorrhoids).
• Tears in the lining of your anus from hardened stool trying to pass through (called anal fissures).
• An infection in pouches that sometimes form off the colon wall from stool that has become trapped and infected (a condition called diverticulitis)
• A pile-up of too much stool/poop in the rectum and anus (a condition called fecal impaction).
• Damage to your pelvic floor muscles from straining to move your bowels. These muscles help control your bladder. Too much straining for too long a period of time may cause urine to leak from the bladder (a condition called stress urinary incontinence).

Does not having regular bowel movements cause toxins to build up in my body and make me sick?

Don’t worry, this usually isn’t the case. Although your colon holds on to stool longer when you are constipated and you may feel uncomfortable, the colon is an expandable container for your waste. There is possibly a slight risk of a bacterial infection if waste gets into an existing wound in the colon or rectum.

SYMPTOMS AND CAUSES

What causes constipation?

There are many causes of constipation – lifestyle choices, medications, medical conditions, and pregnancy.

Common lifestyle causes of constipation include:

• Eating foods low in fiber.
• Not drinking enough water (dehydration).
• Not getting enough exercise.
• Changes in your regular routine, such as traveling or eating or going to bed at different times.
• Eating large amounts of milk or cheese.
• Stress.
• Resisting the urge to have a bowel movement.

Medications that can cause constipation include:

• Strong pain medicines, like the narcotics containing codeine, oxycodone (Oxycontin) and hydromorphone (Dilaudid).
• Nonsteroidal anti-inflammatory drugs, like ibuprofen (Advil, Motrin) and naproxen (Aleve).
• Antidepressants, including the selective serotonin reuptake inhibitors (like fluoxetine [Prozac]) or tricyclic antidepressants (like amitriptyline [Elavil]).
• Antacids containing calcium or aluminum, such as Tums.
• Iron pills.
• Allergy medications, such as antihistamines (like diphenhydramine [Benadryl]).
• Certain blood pressure medicines, including calcium channel blockers (like verapamil [Calan SR], diltiazem [Cardizem] and nifedipine [Procardia]) and beta-blockers (like atenolol [Tenormin]).
• Psychiatric medications, like clozapine (Clozaril) and olanzapine (Zyprexa).
• Anticonvulsant/seizure medications, such as phenytoin and gabapentin.
• Antinausea medications, like ondansetron (Zofran).

Many drugs can cause constipation. Ask your doctor or pharmacist if you have any questions or concerns.

Medical and health conditions that can cause constipation include:

• Endocrine conditions, like underactive thyroid gland (hypothyroidism), diabetes, uremia and hypercalcemia.
• Colorectal cancer.
• Irritable bowel syndrome (IBS).
• Diverticular disease.
• Outlet dysfunction constipation. (A defect in the coordination of pelvic floor muscles. These muscles support the organs within the pelvis and lower abdomen. They are needed to help release stool.)
• Neurologic disorders, including spinal cord injury, multiple sclerosis, Parkinson’s disease, and stroke.
• Lazy bowel syndrome. The colon contracts poorly and retains stool.
• Intestinal obstruction.
• Structural defects in the digestive tract (like fistula, colonic atresia, volvulus, intussusception, imperforate anus or malrotation.)
• Multiple organ diseases, such as amyloidosis, lupus and scleroderma.
• Pregnancy.

What are the symptoms of constipation?

Symptoms of constipation include:

• You have fewer than three bowel movements a week.
• Your stools are dry, hard and/or lumpy.
• Your stools are difficult or painful to pass.
• You have a stomach ache or cramps.
• You feel bloated and nauseous.
• You feel that you haven’t completely emptied your bowels after a movement.

DIAGNOSIS AND TESTS

What should I expect when I talk to my doctor about my constipation?

Talking to your doctor – or anyone – about your bowel movements (or lack of them) is not the most pleasant of topics. Know that your doctor is there for you. Doctors are trained health professionals who have discussed just about every health topic you can think of with their patients.

Your doctor will first ask you questions about your medical history, bowel movements, and your lifestyle and routines.

Medical history

These questions may include:

• What are your current and past diseases/health conditions?
• Have you lost or gained any weight recently?
• Have you had any previous digestive tract surgeries?
• What medications and supplements do you take for other disorders and for the relief of constipation?
• Does anyone in your family have constipation or diseases of the digestive tract or a history of colon cancer?
• Have you had a colonoscopy?

Bowel movement history

These questions may include:

• What food and beverages do you eat and drink?
• What is your exercise routine?

Your doctor will also perform a physical exam, which includes a check of your vital signs (temperature, pulse, blood pressure). He or she will use a stethoscope to listen to the sounds in your abdomen. Your abdomen will also be touched to check for pain, tenderness, swelling, and lumps.

Be aware that your doctor will also perform a rectal exam. This is a finger exam of the inside of your rectum. It’s a quick check for any masses or problems that can be felt by finger.

What lab tests and other medical tests may be done to find the cause of my constipation?

Your doctor can order no tests or many types of tests and procedures. The decision of which ones your doctor might order for you depends on your symptoms, medical history, and overall health.

Lab tests: Blood and urine tests reveal signs of hypothyroidism, anemia, and diabetes. A stool sample checks for signs of infection, inflammation, and cancer.

Imaging tests: Computed tomography (CT), magnetic resonance imaging (MRI) or lower gastrointestinal tract series may be ordered to identify other problems that could be causing your constipation.

Colonoscopy: A colonoscopy or sigmoidoscopy– an internal view of your colon with a scope – may be performed. During this procedure, a small sample of tissue (biopsy) may be taken to test for cancer or other problems and any found polyps will be removed.

Colorectal transit studies: These tests involve consuming a small dose of a radioactive substance, either in pill form or in a meal, and then tracking both the amount of time and how the substance moves through your intestines.

Other bowel function tests: Your doctor may order tests that check how well your anus and rectum hold and release stool. These tests include a certain type of x-ray (defecography), done to rule out causes of outlet dysfunction constipation, and the insertion of a small balloon into the rectum (balloon expulsion test and anorectal manometry).

MANAGEMENT AND TREATMENT

How is constipation treated?

Self-care

Most cases of mild to moderate constipation can be managed by you at home. Self-care starts by taking an inventory of what you eat and drink and then making changes.

Some recommendations to help relieve your constipation include:

• Drink two to four extra glasses of water a day. Avoid caffeine-containing drinks and alcohol, which can cause dehydration.
• Add fruits, vegetables whole grains and other high-fiber foods to your diet. Eat fewer high-fat foods, like meat, eggs and cheese.
• Eat prunes and/or bran cereal.
• Keep a food diary and single out foods that constipate you.
• Get moving, exercise.
• Check how you sit on the toilet. Raising your feet, leaning back or squatting may make having a bowel movement easier.
• Add an over-the-counter supplemental fiber to your diet (like Metamucil, Citrucel, and Benefiber).
• If needed, take a very mild over-the-counter stool softener or laxative (such as docusate [Colace] or Milk of Magnesia). Mineral oil enemas, like Fleet, and stimulant laxatives, like bisacodyl (Dulcolax) or senna (Senokot), are other options. There are many laxative choices. Ask your pharmacist or doctor for help in making a choice. Do not use laxatives for more than two weeks without calling your doctor. Overuse of laxatives can worsen your symptoms.
• Do not read, use your phone or other devices while trying to move your bowels.

Medication/supplement review

In addition to self-care methods, your doctor will review your medications and supplements (if you take any). Some of these products can cause constipation. If they do, your doctor may change the dose, switch to another drug and/or ask that you stop taking the supplement. Never stop taking your medications or supplements before talking with your doctor first.

Prescription medications

A few prescription drugs are available to treat constipation. These include lubiprostone (Amitiza), prucalopride (Prudac, Motegrity), plecanatide (Trulance), lactulose (Cephulac, Kristalose) and linaclotide (Linzess). Your doctor will pick the drug that might work best for you based on the results of your tests.

Surgery

Surgery is rarely needed to treat constipation. Your doctor may, however, recommend surgery if constipation is caused by a structural problem in the colon. Examples of these problems include a blockage in the colon (intestinal obstruction), a narrowing in a portion of the intestine (intestinal stricture), tear in the anus (anal fissure) or the collapse of part of the rectum into the vagina (rectal prolapse). Some causes of outlet dysfunction constipation may be treated with surgery. This is best discussed after testing. You may also need surgery if cancer was found in your colon, rectum or anus.

PREVENTION

How can I prevent constipation?

Use the same home-based methods you used to treat constipation to prevent it from becoming a chronic problem:

• Eat a well-balanced diet with plenty of fiber. Good sources of fiber are fruits, vegetables, legumes, and whole-grain breads and cereals. Fiber and water help the colon pass stool. Most of the fiber in fruits is found in the skins, such as in apples. Fruits with seeds you can eat, like strawberries, have the most fiber. Bran is a great source of fiber. Eat bran cereal or add bran cereal to other foods, like soup and yogurt. People with constipation should eat between 18 and 30 grams of fiber every day.
• Drink eight 8-ounce glasses of water a day. (Note: Milk can cause constipation in some people.) Liquids that contain caffeine, such as coffee and soft drinks, can dehydrate you. You may need to stop drinking these products until your bowel habits return to normal.
• Exercise regularly.
• Treat mild constipation with a dietary supplement like magnesium. (Not everyone should take magnesium. Check with your doctor before taking.)
• Move your bowels when you feel the urge. Do not wait.

When should I call my doctor?

Call your healthcare provider if:

• Constipation is a new problem for you.
• You see blood in your stool.
• You are losing weight unintentionally.
• You have severe pain with bowel movements.
• Your constipation has lasted more than three weeks.
• You have symptoms of outlet dysfunction constipation.

Remember, talk openly and honestly with your doctor about your bowel movements and any questions or concerns you may have. Pooping is something we all should be doing. Constipation may be a temporary situation, a long-term problem or a sign of a more serious condition. Be safe. See your doctor, especially if you’ve noticed a change in your bowel pattern or if your life is being ruled by your bowels. 

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