What is constipation?
Constipation is a symptom, not a disease, associated with hard, dry bowel movements or when you go longer than usual in between bowel movements. It is defined as having a bowel movement fewer than three times per week. With constipation stools are usually hard, dry, small in size, and difficult to eliminate. Some people may find it painful to have a bowel movement and often experience straining, bloating, and the sensation of a full bowel. Others assume they are constipated if they do not have a bowel movement every day. However, normal stool elimination may be three times a day or three times a week, depending on the person. Almost everyone experiences constipation at some point in their life, and a poor diet usually is the cause. Most constipation is temporary and not serious. Understanding its causes, prevention, and treatment will help most people find relief.
Lower Digestive System
- Difficulty pushing out bowel movement
- Pain or bleeding during bowel movement
- A feeling that you did not finish having your bowel movement
- Nausea
- Full feeling
- Headache
What causes constipation?
- Not eating enough high-fiber foods: Fiber is important in maintaining a soft, bulky stool. Diets low in fiber and/or high in fat can cause constipation. The best natural sources of fiber are fresh fruits and vegetables, bran, whole-grain cereals, legumes (beans, peas, and lentils), nuts and seeds.
- Not drinking enough water
- Lack of physical activity
- Pain medicine, medicine used to treat depression or high blood pressure, and others (see below).
- Medical conditions, such as hemorrhoids, diabetes, or a stroke
- Habit: Bowel movements are under voluntary control. Therefore, the normal urge people feel when they need to have a bowel movement can be suppressed. Occasionally, it is appropriate to suppress an urge to defecate (for example, when a bathroom is not available), but doing this too frequently can reduce the natural urge and result in constipation.
- Laxatives: One suspected cause of severe constipation is the over-use of stimulant laxatives (for example, senna [Senokot], castor oil, and certain herbs). An association has been shown between chronic use of stimulant laxatives and damage to nerves and muscles of the colon. Some researchers believe that the damage is responsible for constipation. It is not clear, however, whether laxatives initiated the damage or whether the damage existed prior to the use of laxatives and caused the laxatives to be used. Nevertheless, because of the possibility that stimulant laxatives can damage the colon, most experts recommend that stimulant laxatives be used as a last resort after non-stimulant treatments have failed.
- Hormones and hormonal disorders can affect bowel movements: Too little thyroid hormone (hypothyroidism) and too much parathyroid hormone (raising calcium levels in the blood) can cause constipation; At the time of a woman’s menstrual periods, estrogen and progesterone levels are high and may cause constipation (this is rarely a prolonged problem); High levels of estrogen and progesterone during pregnancy can cause constipation.
- Diseases affecting muscle and/or nerve function of the colon, such as diabetes, scleroderma, intestinal pseudo-obstruction, Hirschsprung’s disease, Chagas disease, cancer or a narrowing (stricture) of the colon that blocks it, can all cause a decrease in the flow of stool.
- Central nervous system diseases: Some diseases of the brain and spinal cord may cause constipation, including Parkinson’s disease, multiple sclerosis, and spinal cord injuries.
- Colonic inertia: A condition in which the nerves and/or muscles of the colon do not work normally. As a result, the contents of the colon are not propelled through the colon easily. The cause of colonic inertia is unclear. In some cases, the muscles or nerves of the colon are diseased. Colonic inertia may also result from chronic use of stimulant laxatives, as described above. In most cases, however, there is no clear cause for the constipation.
- Pelvic floor dysfunction (“outlet obstruction or outlet delay”): A condition in which muscles of the lower pelvis that surround the rectum (pelvic floor muscles) do not work normally. These muscles are critical for a bowel movement. It is unknown why these muscles fail to work properly in some people, but they can make the passage of stools difficult, even when everything else is normal.
Cheese, ice cream, and other dairy products have a reputation of being “binding” or constipating foods, due to the high-fat and low-fiber content of many of these products. Dairy products made from milk can constipate many individuals, particularly toddlers.
Foods to avoid to reduce constipation:
- Red meat
- Full-fat dairy products
- Fried foods
- Cakes, cookies, chips
- Frozen dinners (Low in fiber, high in fat and salt)
- Unripened green bananas (However, ripe bananas are very high in soluble fiber, which can help to push waste through the bowels and relieve constipation.)
Medications which can cause constipation:
- Pain medications (especially narcotics)
- Antacids that contain aluminum and calcium
- Blood pressure medications (calcium channel blockers)
- Antiparkinson drugs
- Antispasmodics
- Antidepressants
- Iron supplements
- Diuretics
- Anticonvulsants
Lifestyle changes may help reduce constipation:
- Get plenty of exercise each day: Regular physical activity can help stimulate your intestines. Brisk walks, dancing, swimming, taking stairs instead of elevators, bicycling, etc.). Set yourself an achievable goal such as a 30-minute walk each day and stick to it. Being more active will increase general health and should make the gut work more effectively. Studies show that exercise increases nitric oxide levels, which may alleviate constipation. Low nitric oxide levels may explain both constipation and hypertension in pregnant women and the elderly. Talk to your caregiver about the best exercise plan for you.
- Drink plenty of water and increase your consumption of liquids: Constipation occurs when too much moisture is reabsorbed from feces. Adults should drink between 9-13 eight-ounce cups of liquid every day. Ask your doctor what amount is best for you if you have a health problem. For most people, good liquids to drink are water, juice, milk, and herbal teas.
- Eat a variety of high-fiber foods: Fiber provides bulk and softness to your bowel movement. It also accelerates the movement of food through the GI tract. Both insoluble and soluble fiber will benefit constipation. Healthy foods include fruit, vegetables, whole-grain breads, low-fat dairy products, beans, lean meat, and fish. Figs and prunes are an option and are high in fiber. Ask your caregiver for more information about a high-fiber diet. Increase dietary fiber slowly to reduce bloating and gas, and drink more water to help flush the fiber through your digestive tract.
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Select breakfast cereals with approximately 10 grams of fiber per 100 grams: But do watch cereal salt content.
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Eat more legumes (beans, peas, lentils), nuts, seeds, and green leafy vegetables on a daily basis: They are rich in fiber and nutrients, including magnesium, which help alleviate constipation.
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Avoid refined carbohydrates, such as white bread, pasta, and rice, and select whole-meal or whole-grain varieties instead: Whole grains provide more fiber and nutrients which not only help protect against constipation but may also prevent insulin surges and reduce the risk of diabetes.
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Aim for at least 5 portions of fruit and vegetables per day: A variety of fruits and vegetables provides different kinds of fibers and enhances the body’s ability to fight free radicals by providing a variety of different antioxidants with different roles to play in the body. Remember that those dried and canned count too.
- Try to have a bowel movement at the same time each day: The best time is 15-45 minutes after breakfast, because eating helps to stimulate the colon. This may help train your body to have regular bowel movements.
- Always allow enough time to have a bowel movement and don’t ignore the urge to have one: Bend forward while you are on the toilet to help move the bowel movement out. Sit on the toilet at least 10 minutes, even if you do not have a bowel movement.
- Cut down on caffeine and alcohol: Both are diuretics that can dehydrate you. Caffeine is a stimulant which normally promotes muscle contraction needed for a bowel movement, but drinking too much in place of water and other liquids can lead to dehydration. Sometimes switching to decaffeinated coffee helps. Drink more water instead.
- Do not overeat: Smaller meals are easier to digest and may benefit digestive health more than larger meals. Try eating more than three “petite” meals a day and see how you feel. Avoid eating late at night, since the body has more trouble digesting food while you are sleeping.
- Use over-the-counter remedies with caution: If you do try them and they work but constipation returns, do not continue using them as a long-term solution. Consult your family physician first.
- Eat more natural probiotics to help balance the good and bad bacteria in your digestive system: Active cultures in yogurt and kefir may help assuage constipation and even reduce the risk of colon cancer. If you are magnesium-deficient, consider a magnesium supplement as well.
Treatments to discuss with your doctor:
- Dietary fiber or fiber supplements (add bulk and softness to your bowel movement). Drink more water whenever you increase dietary fiber or take such supplements.
- Bowel movement softeners.
- Laxatives help intestines relax and loosen.
- When a medication is causing constipation, your health care provider may suggest that you stop taking the medication or switch to a different medication.
Laxative medications and enemas may be recommended for people who have made diet and lifestyle changes and are still constipated. Laxatives taken by mouth are available in liquid, tablet, powder, and granule forms:
- Bulk-forming agents: Brand names include Metamucil, FiberCon, Citrucel, Konsyl, and Serutan. Bulk-forming agents absorb fluid in the intestines, making stools bulkier, which helps trigger the bowel to contract and push stool out. These supplements should be taken with water or they can cause obstruction. Bulk-forming agents are generally considered the safest laxative, but they can interfere with the absorption of some medications. Many people also report no relief after taking bulk-forming agents and suffer from bloating and abdominal pain.
- Osmotic agents: Brand names include Milk of Magnesia, Fleet Phospho-Soda, Cephulac, Sorbitol, and Miralax. Osmotic agents help stool retain fluid, increasing the number of bowel movements and softening the stool. These laxatives are usually used by people who are bedridden or cannot take bulk-forming agents. Older adults and people with heart or kidney failure should be careful when taking osmotic agents, because they can cause dehydration or a mineral imbalance.
- Stool softeners: Brand names include Colace, Docusate, and Surfak. Stool softeners help mix fluid into stools to soften them. Stool softeners may be suggested for people who should avoid straining in order to pass a bowel movement; they are often recommended after childbirth or surgery.
- Lubricants: Brand names include Fleet and Zymenol. Lubricants coat the surface of stool and help the stool hold in fluid and pass more easily. Lubricants are simple, inexpensive laxatives that may be recommended for people with anorectal blockage.
Other types of laxatives include:
- Stimulants: Brand names include Correctol, Dulcolax, Purge, and Senokot. Stimulant laxatives cause the intestines to contract, which moves stool. Stimulants should be reserved for constipation that is severe or has not responded to other treatments. People should not use stimulant laxatives containing phenolphthalein, as phenolphthalein may increase the likelihood of cancer. Most laxatives sold in the United States do not contain phenolphthalein.
- Chloride channel activators: Lubiprostone (Amitiza) is a chloride channel activator available with a prescription. This type of laxative increases fluid in the GI tract. Lubiprostone has been shown to be safe when used for 6-12 months.
People who depend on laxatives to have a bowel movement need to talk with their health care provider about how to slowly stop using them. For most people, stopping laxatives restores the colon’s natural ability to contract.
Biofeedback:
People with chronic constipation caused by problems with the anorectal muscles can use biofeedback to retrain the muscles. Biofeedback uses special sensors to measure bodily functions. The measurements are displayed on a video screen as line graphs and sounds indicate when the person is using the correct muscles. A health care provider uses the information to help the person modify or change abnormal function. The person practices at home and may need to continue practicing for 3 months to get the most benefit from the training.
Surgery may be needed to correct an anorectal blockage caused by rectal prolapse. Surgical removal of the colon may be an option for people whose colon muscles do not work properly, causing severe symptoms that do not respond to treatment. However, the benefits of this surgery should be weighed against possible complications, which include abdominal pain and diarrhea.
Contact your health caregiver if:
- Your constipation is getting worse.
- You have fever and abdominal pain with the constipation.
- You start vomiting.
- You have questions or concerns about your condition or care.
- Seek care immediately or call 911 if you have blood in your bowel movements.
Please note that regular screening, beginning at age 50, is a key to preventing colorectal cancer. The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer using high-sensitivity fecal occult blood testing, sigmoidoscopy, or colonoscopy beginning at age 50 years and continuing until age 75 years.
People at higher risk of developing colorectal cancer should begin screening at a younger age, and may need to be tested more frequently. The decision to be screened after age 75 should be made on an individual basis. If you are older than 75, ask your doctor if you should be screened.
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