CONSTIPATION

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It’s defined as having hard, dry bowel movements, or going fewer than three times a week.

Chronic constipation is infrequent bowel movements or difficult passage of stools that persists for several weeks or longer.

Constipation is generally described as having fewer than three bowel movements a week.

Though occasional constipation is very common, some people experience chronic constipation that can interfere with their ability to go about their daily tasks. Chronic constipation may also cause people to strain excessively in order to have a bowel movement.

Symptoms

Signs and symptoms of chronic constipation include:

1. Passing fewer than three stools a week
2. Having lumpy or hard stools
3. Straining to have bowel movements
4. Feeling as though there’s a blockage in your rectum that prevents bowel movements
5. Feeling as though you can’t completely empty the stool from your rectum
6. Needing help to empty your rectum, such as using your hands to press on your abdomen and using a finger to remove stool from your rectum
7. low-fiber diet, particularly diets high in meat, milk, or cheese
8. dehydration
9. lack of exercise
10. delaying the impulse to have a bowel movement
11. travel or other changes in routine
12. certain medications, such as high calcium antacids and pain medications
13. pregnancy

Causes

Constipation most commonly occurs when waste or stool moves too slowly through the digestive tract or cannot be eliminated effectively from the rectum, which may cause the stool to become hard and dry. Chronic constipation has many possible causes.

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Blockages in the colon or rectum

Blockages in the colon or rectum may slow or stop stool movement. Causes include:

1. Tiny tears in the skin around the anus (anal fissure)
2. A blockage in the intestines (bowel obstruction)
3. Colon cancer
4. Narrowing of the colon (bowel stricture)
5. Other abdominal cancer that presses on the colon
6. Rectal cancer
7. Rectum bulge through the back wall of the vagina (rectocele)

Problems with the nerves around the colon and rectum

Neurological problems can affect the nerves that cause muscles in the colon and rectum to contract and move stool through the intestines. Causes include:

1. Damage to the nerves that control bodily functions (autonomic neuropathy)
2. Multiple sclerosis
3. Parkinson’s disease
4. Spinal cord injury
5. Stroke

Difficulty with the muscles involved in elimination

Problems with the pelvic muscles involved in having a bowel movement may cause chronic constipation. These problems may include:

1. The inability to relax the pelvic muscles to allow for a bowel movement (anismus)
2. Pelvic muscles that don’t coordinate relaxation and contraction correctly (dyssynergia)
3. Weakened pelvic muscle.

Who is at risk for constipation?

Eating a poor diet and not exercising are major risk factors for constipation. You may also be at greater risk if you’re:

1. Age 65 or older. Older adults tend to be less physically active, have underlying diseases, and eat poorer diets.
2. Confined to bed. Those who have certain medical conditions, such as spinal cord injuries, often have difficulty with bowel movements.
3. A woman or child. Women have more frequent episodes of constipation than men, and children are affected more often than adults.
4. Pregnant. Hormonal changes and pressure on your intestines from your growing baby can lead to constipation.

Treatment

Treatment for chronic constipation usually begins with diet and lifestyle changes meant to increase the speed at which stool moves through your intestines. If those changes don’t help, your doctor may recommend medications or surgery.

Diet and lifestyle changes

Your doctor may recommend the following changes to relieve your constipation:

• Increase your fiber intake. Adding fiber to your diet increases the weight of your stool and speeds its passage through your intestines. Slowly begin to eat more fresh fruits and vegetables each day. Choose whole-grain breads and cereals. Your doctor may recommend a specific number of grams of fiber to consume each day. In general, aim for 14 grams of fiber for every 1,000 calories in your daily diet. A sudden increase in the amount of fiber you eat can cause bloating and gas, so start slowly and work your way up to your goal over a few weeks.
• Exercise most days of the week. Physical activity increases muscle activity in your intestines. Try to fit in exercise most days of the week. If you do not already exercise, talk to your doctor about whether you are healthy enough to start an exercise program.
• Don’t ignore the urge to have a bowel movement. Take your time in the bathroom, allowing yourself enough time to have a bowel movement without distractions and without feeling rushed.

Laxatives

Several types of laxatives exist. Each works somewhat differently to make it easier to have a bowel movement. The following are available over the counter:

• Fiber supplements. Fiber supplements add bulk to your stool. Bulky stools are softer and easier to pass. Fiber supplements include psyllium (Metamucil, Konsyl, others), calcium polycarbophil (FiberCon, Equalactin, others) and methylcellulose (Citrucel).
• Stimulants. Stimulants including bisacodyl (Correctol, Dulcolax, others) and sennosides (Senokot, Ex-Lax, Perdiem) cause your intestines to contract.
• Osmotics. Osmotic laxatives help stool move through the colon by increasing secretion of fluid from the intestines and helping to stimulate bowel movements. Examples include oral magnesium hydroxide (Phillips’ Milk of Magnesia, Dulcolax Milk of Magnesia, others), magnesium citrate, lactulose (Cholac, Constilac, others), polyethylene glycol (Miralax, Glycolax).
• Lubricants. Lubricants such as mineral oil enable stool to move through your colon more easily.
• Stool softeners. Stool softeners such as docusate sodium (Colace) and docusate calcium (Surfak) moisten the stool by drawing water from the intestines.
• Enemas and suppositories. Tap water enemas with or without soapsuds can be useful to soften stool and produce a bowel movement. Glycerin or bisacodyl suppositories also aid in moving stool out of the body by providing lubrication and stimulation.

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Other medications

If over-the-counter medications don’t help your chronic constipation, your doctor may recommend a prescription medication, especially if you have irritable bowel syndrome.

• Medications that draw water into your intestines. A number of prescription medications are available to treat chronic constipation. Lubiprostone (Amitiza), linaclotide (Linzess) and plecanatide (Trulance) work by drawing water into your intestines and speeding up the movement of stool.
• Serotonin 5-hydroxytryptamine 4 receptors. Prucalopride (Motegrity) helps move stool through the colon.
• Peripherally acting mu-opioid receptor antagonists (PAMORAs). If constipation is caused by opioid pain medications, PAMORAs such as naloxegol (Movantik) and methylnaltrexone (Relistor) reverse the effect of opioids on the intestine to keep the bowel moving.

Training your pelvic muscles

Biofeedback training involves working with a therapist who uses devices to help you learn to relax and tighten the muscles in your pelvis. Relaxing your pelvic floor muscles at the right time during defecation can help you pass stool more easily.

During a biofeedback session, a special tube (catheter) to measure muscle tension is inserted into your rectum. The therapist guides you through exercises to alternately relax and tighten your pelvic muscles. A machine will gauge your muscle tension and use sounds or lights to help you understand when you’ve relaxed your muscles.

Surgery

Surgery may be an option if you have tried other treatments and your chronic constipation is caused by a blockage, rectocele or stricture.

For people who have tried other treatments without success and who have abnormally slow movement of stool through the colon, surgical removal of part of the colon may be an option. Surgery to remove the entire colon is rarely necessary.

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