Constipation 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 who are constipated find it painful to have a bowel movement and often experience straining, bloating, and the sensation of a full bowel.

Some people think 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.

Constipation is a symptom, not a disease. Almost everyone experiences constipation at some point in their life, and a poor diet typically is the cause. Most constipation is temporary and not serious. Understanding its causes, prevention, and treatment will help most people find relief.

Who gets constipated?

Constipation is one of the most common gastrointestinal complaints in the United States. More than four million Americans have frequent constipation, accounting for two and a half million physician visits a year. Those reporting constipation most often are women and adults ages sixty-five and older. Pregnant women may have constipation, and it is a common problem following childbirth or surgery.

Self-treatment of constipation with over-the-counter (OTC) laxatives is by far the most common aid. Around $725 million is spent on laxative products each year in America.

What causes constipation?

To understand constipation, it helps to know how the colon, or large intestine, works. As food moves through the colon, the colon absorbs water from the food while it forms waste products, or stool. Muscle contractions in the colon then push the stool toward the rectum. By the time stool reaches the rectum it is solid, because most of the water has been absorbed.

Constipation occurs when the colon absorbs too much water or if the colon’s muscle contractions are slow or sluggish, causing the stool to move through the colon too slowly. As a result, stools can become hard and dry. Common causes of constipation are:

• not enough fiber in the diet
• lack of physical activity (especially in the elderly)
• medications
• irritable bowel syndrome
• changes in life or routine such as pregnancy, aging, and travel
• abuse of laxatives
• ignoring the urge to have a bowel movement
• dehydration
• specific diseases or conditions, such as stroke (most common)
• problems with the colon and rectum
• problems with intestinal function (chronic idiopathic constipation)

Not Enough Fiber in the Diet

People who eat a high-fiber diet are less likely to become constipated. The most common causes of constipation are a diet low in fiber or a diet high in fats, such as cheese, eggs, and meats.

Fiber—both soluble and insoluble—is the part of fruits, vegetables, and grains that the body cannot digest. Soluble fiber dissolves easily in water and takes on a soft, gel-like texture in the intestines. Insoluble fiber passes through the intestines almost unchanged. The bulk and soft texture of fiber help prevent hard, dry stools which are difficult to pass.

Americans eat an average of five to fourteen grams of fiber daily, which is short of the twenty to thirty-five grams recommended by the American Dietetic Association. People often eat too many refined and processed foods from which the natural fiber has been removed.

A low-fiber diet also plays a key role in constipation among older adults, who may lose interest in eating and choose foods that are quick to make or buy, such as fast foods, or prepared foods, both of which are usually low in fiber. Also, difficulties with chewing or swallowing may cause older people to eat soft foods that are processed and low in fiber.

Lack of Physical Activity

A lack of physical activity can lead to constipation. For example, constipation often occurs after an accident or during an illness when one must stay in bed and cannot exercise. Lack of physical activity is thought to be one of the reasons constipation is common in older people.

Medications

Some medications can cause constipation, including:

• pain medications (especially narcotics)
• antacids that contain aluminum and calcium
• blood pressure medications (calcium channel blockers)
• antiparkinson drugs
• antispasmodics
• antidepressants
• iron supplements
• diuretics
• anticonvulsants

Changes in Life or Routine

During pregnancy, women may be constipated because of hormonal changes or because the uterus compresses the intestine. Aging may also affect bowel regularity, because a slower metabolism results in less intestinal activity and muscle tone. In addition, people often become constipated when traveling, because their normal diet and daily routine are disrupted.

Abuse of Laxatives

The common belief that people must have a daily bowel movement has led to self-medicating with OTC laxative products. Although people may feel relief when they use laxatives, typically they must increase the dose over time because the body grows reliant on laxatives in order to have a bowel movement. As a result, laxatives may become habit-forming.

Ignoring the Urge to Have a Bowel Movement

People who ignore the urge to have a bowel movement may eventually stop feeling the need to have one, which can lead to constipation. Some people delay having a bowel movement because they do not want to use toilets outside the home. Others ignore the urge because of emotional stress or because they are too busy.

Not Enough Liquids

Research shows that although increased fluid intake does not necessarily help relieve constipation, many people report some relief from their constipation if they drink fluids such as water and juice and avoid dehydration. Liquids add fluid to the colon and bulk to stools, making bowel movements softer and easier to pass. Some beverages, such as ones containing alcohol or caffeine, can actually dehydrate the body, so it is important to drink fluids that hydrate the body, such as water and juice.

Specific Diseases

Diseases that cause constipation include neurological disorders, metabolic and endocrine disorders, and systemic conditions that affect organ systems. These disorders can slow the movement of stool through the colon, rectum, or anus.

Conditions that can cause constipation are found below.

• Neurological disorders, such as multiple sclerosis, Parkinson’s disease, chronic idiopathic intestinal pseudo-obstruction, stroke, and spinal cord injuries

• Metabolic and endocrine conditions, such as diabetes, uremia, hypercalcemia, and hypothyroidism

• Systemic disorders, such as amyloidosis, lupus, scleroderma

Problems with the Colon and Rectum

Intestinal obstruction, scar tissue—also called adhesions— tumors, colorectal stricture, Hirschsprung disease, or cancer can compress, squeeze, or narrow the intestine and rectum and cause constipation.

Problems with Intestinal Function

The two types of constipation are idiopathic constipation and functional constipation. Irritable bowel syndrome (IBS) with predominant symptoms of constipation is categorized separately.

Idiopathic—of unknown origin—constipation usually does not respond to standard treatment.

Functional constipation means that the bowel is healthy but not working properly and is often the result of poor dietary habits and lifestyle. It occurs in both children and adults and is most common in women. Colonic inertia, delayed transit, and pelvic floor dysfunction are three types of functional constipation. Colonic inertia and delayed transit are caused by a decrease in muscle activity in the colon. These syndromes may affect the entire colon or may be confined to the lower, or sigmoid, colon.

Pelvic floor dysfunction is caused by a weakness of the muscles in the pelvis surrounding the anus and rectum. However, because this group of muscles is voluntarily controlled to some extent, biofeedback training is somewhat successful in retraining the muscles to function normally and improving the ability to have a bowel movement.

How is the cause of constipation identified?

The tests the doctor performs depend on the duration and severity of the constipation, the person’s age, presence of blood in the stool, recent changes in bowel habits or if weight loss have occurred. Most people with constipation do not need extensive testing and can be treated with changes in diet and exercise. For example, in young people with mild symptoms, a medical history and physical exam may be all that is needed for diagnosis and treatment.

Medical History

The doctor may ask a patient to describe his or her constipation, including duration of symptoms, frequency of bowel movements, consistency of stools, presence of blood in the stool, and how often and where one has bowel movements. A record of eating habits, medication, and level of physical activity will also help the doctor determine the cause of constipation.

The clinical definition of constipation is having any two of the following symptoms for at least twelve weeks—not always consecutive—in the previous twelve months:

• straining during bowel movements
• lumpy or hard stool
• sensation of incomplete evacuation
• sensation of rectal blockage/obstruction
• fewer than three bowel movements per week

Testing

In some cases, blood tests may be necessary to look for thyroid disease or serum calcium levels or to rule out inflammatory, metabolic, and other disorders. Testing may also include a colonoscopy which is an examination of the rectum and entire colon.

Extensive testing usually is reserved for people with severe symptoms, for those with sudden changes in the number and consistency of bowel movements or blood in the stool, and older adults.

How is constipation treated?

Although treatment depends on the cause, severity, and duration of the constipation, in most cases dietary and lifestyle changes will help relieve symptoms and help prevent them from recurring.

Diet

A diet with enough fiber (twenty to thirty-five grams each day) helps the body form soft, bulky stools. A doctor or dietitian can help plan an appropriate diet. High-fiber foods include beans, whole grains and bran cereals, fresh fruits, and vegetables such as asparagus, brussels sprouts, cabbage, and carrots. For people prone to constipation, limiting foods that have little or no fiber, such as ice cream, cheese, meat, and processed foods, is also important.

Lifestyle Changes

Other changes that may help treat and prevent constipation include drinking enough water and other liquids, such as fruit and vegetable juices and clear soups, so as not to become dehydrated, engaging in daily exercise, and reserving enough time to have a bowel movement. In addition, the urge to have a bowel movement should not be ignored.

Laxatives

Most people who are mildly constipated do not need laxatives. However, for those who have made diet and lifestyle changes and are still constipated, a doctor may recommend laxatives for a limited time.

A doctor should determine when a patient needs a laxative and which form is best. Laxatives taken by mouth are available in liquid, tablet, gum powder, and granule forms. They work in various ways:

• Bulk-forming laxatives generally are considered the safest, but they can interfere with absorption of some medicines. These laxatives, also known as fiber supplements, are taken with water. They absorb water in the intestine and make the stool softer. Brand names† include Metamucil, Fiberall, Citrucel, Konsyl, and Serutan. These agents must be taken with an adequate amount of water or they can cause obstruction. Some people report no relief after taking bulking agents and suffer from a worsening in bloating and abdominal pain.
• Stimulants cause rhythmic muscle contractions in the intestines. Brand names† include Correctol, Dulcolax, Purge, and Senokot. These may cause increased abdominal cramping and are generally not recommended.
• Osmotics cause fluids to flow in a special way through the colon, resulting in bowel distention. This class of drugs is useful for people with idiopathic constipation. Brand names† include Cephulac, Sorbitol, and Miralax. These are generally considered safe when used in moderation.
• Stool softeners moisten the stool. These laxatives are often recommended after childbirth or surgery. Brand names† include Colace and Surfak. These products are suggested for people who should avoid straining in order to pass a bowel movement.
• Lubricants grease the stool, enabling it to move through the intestine more easily. Mineral oil is the most common example. Brand names† include Fleet and Zymenol. Lubricants typically stimulate a bowel movement within eight hours.
• Saline laxatives act like a sponge to draw water into the colon for easier passage of stool. Brand names† include Milk of Magnesia and Haley’s M-O. Saline laxatives are used to treat acute constipation if there is no indication of bowel obstruction. Electrolyte imbalances have been reported with extended use.
• Chloride channel activators increase intestinal fluid and motility to help stool pass, thereby reducing the symptoms of constipation. One such agent is Amitiza†, which is available by prescription only. Pregnancy should be avoided while taking this medication.

Can constipation be serious?

Sometimes constipation can lead to complications. These complications include hemorrhoids, caused by straining to have a bowel movement; diverticulosis or anal fissures. As a result, rectal bleeding may occur, appearing as bright red streaks on the surface of the stool, on the toilet tissue or in the toilet water.  Medical attention should be sought if this occurs.

Points to Remember

• Constipation affects almost everyone at one time or another.
• Many people think they are constipated when, in fact, their bowel movements are regular.
• The most common causes of constipation are poor diet and lack of exercise.
• Other causes of constipation include medications, irritable bowel syndrome, abuse of laxatives, and specific diseases.
• A medical history and physical exam may be the only diagnostic tests needed before the doctor suggests treatment.
• In most cases, making minor dietary and lifestyle changes will help relieve symptoms and prevent recurrence of constipation

Disclaimer: The contents of this site are for informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this site.

†Medical Associates of Middletown, Inc, does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this document are used only because they are considered necessary in the context of the information provided. If a product is not mentioned, the omission does not mean or imply that the product is unsatisfactory.