Constipation is a common complaint which most people have suffered from at some time during their life. Constipation affects all ranges of age groups including the Plus Fifty age group with a greater prevalence amongst women. It is a common misconception that it is only a problem to frail immobile, elderly people. Constipation can be attributed to a combination of factors or only one or two. Bowel motility problems, bowel surgery or anatomic irregularities also play a significant part. Age does not seem to be a major factor although as the population ages the bowel problems can appear to become more prevalent as it can be a cumulative factor. Years of on and off constipation may cause haemorrhoids, which may be the reason for seeking help form your GP rather than the contributing constipation problem.
In this article bowel evacuations or poo may be referred to as, faeces, bowel motions, faecal matter, excrement or stools.
Constipation can be attributed to many situations psychological, as well as physical, both of which can affect your digestive system and therefore your bowels.
The physical effects of constipation are
Stool consistency – hard, solid, lacking in moisture, lumpy,
Physical effects – painful to evacuate, straining, incomplete emptying
Regularity – Less than two stool per week,
The condition can be an on-going (Chronic) or sudden (Acute) situation. Chronic constipation assessment as defined by the Rome II criteria means that if you have been suffering from these symptoms 25% of the time over a period of three months or more you will need to consult your doctor for advice. Many people have suffered for years with poor bowel habits as they have not been aware of any different
It is important to state that if you have experienced a change in bowel habits and your symptoms have come on suddenly you will need to visit your doctor for a thorough investigation urgently.
There are two types of constipation
Idiopathic constipation – this means it is of unknown origin which does not respond to conventional treatment
Functional constipation- the bowel is working properly but there is a problem
The problems can include
Pelvic floor muscle dysfunction
Delayed stool transit
What does the bowel do?
The bowel is where all the food and fluids you consume is utilised by the body. All the nutrients, carbohydrate, vitamins and minerals are extracted and converted into fuel for the body to use as energy.
This refers to the transit time of food travelling through your digestive system to evacuation. When Your GP refers to low motility or transit time this is what they are referring to. You may become constipated due to a physical cause which causes a lack of motility in your bowel this may be attributed to change of diet or environment.
This refers to what you personally consider regular bowel movements for you. This can mean anything from opening your bowels three times a day to only four times a week. It directly relates to what you eat, drink, your level of fitness and your digestive transit time. Food tends to travels through the colon within 12 – 48 hours.
Sometimes referred to in the UK as the “Meyers Scale”, it was developed by Dr. Ken Heaton at the University of Bristol
Looking at the stool chart you will be able to assess your faeces and the degree of constipation you may be experiencing. If you regularly evacuate your bowels and it is either type 3/4 then the consistency is fine. Types 1/2 indicate constipation and likewise 6/7 diarrhoea.
Psychological links to constipation
The psychological aspect of constipation is an important and significant factor; many people do not like to have their bowels open in public toilets as it is often considered something which should be done only at home.
In Roman times communal toilets were accepted as the hygienic way to visit the toilet, sitting side by side. If this sounds unthinkable to you, you are not alone; the thought of someone hearing you evacuating your bowels let alone sitting next to you is often aberrant.
These problems with where you can or can’t go to the toilet can begin in early childhood with innocent comments from parents becoming learned experiences. Children often need to go to the toilet when they are out shopping but are often told “hang on” or told “you should have gone before we left home” these are akin to subliminal messages, setting up a pattern of bowel habits for the future. Being teased as a child after having an accident can also have a significant effect, the embarrassment will be remembered and have a life style impact on toileting behaviour.
Anxiety can have an effect on the body’s digestive system. It can occur when you have an incident where you are unable to successfully evacuate your bowels due to apprehension. If this occurs on a regular basis you will either learn to wait until you return home or to avoid social situations. Many can relate to the queue for the toilet being a stressful situation, either the thought of being listened to, the odour which will emanate from the cubical once you have left or the time restriction of the people waiting.
Emotional distress, and depression, has an effect on how we behave. This emotional behaviour then affects our choices regarding our intake of food types, and the amount of liquids and what type of liquids. Junk food does not contain any nutrients to aid motility in the gut and alcohol actively acts as a diuretic diverting fluid away from the bowel and out of the body.
Causes of constipation
Lack of exercise
Lack of fluids
Lack of fibre
Change in your daily routine
Ignoring the urge to have your bowels open
Stress related to anxiety, depression or lack of privacy
Medication and their side effects
Symptoms of constipation
The symptoms below are not always associated with constipation and are often dismissed as linked to other conditions such as menstrual period pain, over eating, eating too many vegetables, thirst or general tiredness. These symptoms are relevant and when giving your medical account of your condition to your doctor should be included.
Bloating or bloated stomach
Medicines and Constipation
Medicines can directly affect your bowels, so be aware that if you do suffer from constipation mention it to the GP at the time they will often be able to substitute an alternative or prescribe a laxative to maintain your bowel habit. If your doctor is aware you suffer from constipation on a regular basis they will be able to monitor and advise or refer you to someone who could offer help and advice.
Medications known to affect the bowel causing constipation
Analgesics/opiates – pain relief medicines
Antacids (calcium and magnesium) – for the relief of heart burn
Anticholinergic - These block the activity of a substance in the body called acetylcholine which carries messages between nerve cells.
Antidepressants – these work by increasing the levels of chemicals called neurotransmitters in the brain
Anti-hypertensives – These are medicines which lower your blood pressure
Anti-Parkinson agents – These are used to treat a condition known as Parkinson’s which affects nerve cells
Barium – This is used in x-ray examinations to outline the digestive tract
Calcium channel blockers -These are used to in the treatment of stable angina patients
Diuretics – These are often called water tablets they increase the amount of urine which is excreted
Iron supplements – These are used for the prevention and treatment of anaemia
Non-steroidal anti-inflammatory agents – NSAIDs – used to ease pain in many conditions
Sucralfate – These are used for the treatment of ulcers in the stomach and upper intestine as well as chronic gastritis
This is where you have experienced constipation for many months even years on and off, the term chronic means of long duration. If you have suffered from constipation for a long time it will not need urgent investigations and many simple measures can be taken which may improve the motility and consistency of your faeces. It is a good idea to try looking at your lifestyle with specific consideration to:-
Fibre – Do you eat the recommended 5 portions per day?
Fluids – Are you drinking enough?
Exercise – Are you taking regular exercise?
Psychological – Are you under stress which is affecting your digestion?
The term acute means that the condition has come on rapidly. This is a more situation as it may be the result of a medical condition. If you suddenly begin to suffer from any, or a combination of the following you will need to seek medical help.
If your bowel habits have altered noticeably over a period of three to four weeks
You have symptoms of unexplained tiredness
You have lost weight without dieting
You are experiencing vomiting
You have noticed a lump on your stomach
You are experiencing bleeding when you do have your bowels open.
Constipation Relief and Treatment
If you have only recently been suffering you will often look for the quick solution to immediately relieve your symptoms. Usually the first stop will be the chemist and laxatives, but which type is appropriate for you? It is advisable to speak to the pharmacist for advice if you are concerned about which to use, especially if this is an unusual episode for you.
Constipation treatment can often seem conflicting as information is sought by many people but may not be in line with your lifestyle or just not be put into practice. Treatment then becomes totally ineffective and the cycle of constipation continues. If your symptoms are related to functional constipation, making a choice to address the problem is a long term decision there is no choice but to make a lifestyle change. If it is idiopathic constipation your bowel management will require thorough investigation by the continence team and a bowel management plan designed to fit in with your lifestyle.
If constipation is functional then constipation treatment needs a commitment from the sufferer to actively help themselves. A record in a food diary over an average week period can give a good indication of your fibre intake and it will provide ideas where you can increase it. A good diet for the relief of constipation requires between 18-30 grams on a daily basis. The majority of western society does not reach this on a daily basis some not on a weekly basis! Increasing fibre into your diet should be a gradual process otherwise you could suffer from bloating, flatulence and abdominal discomfort. Ideally the increase of fibre should occur over a two to four week period the results will become increasingly better as the weeks continue. Increase in fibre goes hand in hand with increasing fluid intake and exercise. You never know you could really become quite healthy so no downside really.
It is recommended that you eat between 18- 30 grams of fibre each day that fibre can be found in many foods.
Beans and pulses
Fruit, apricots, prunes, raisins apples, citrus fruits
Vegetables – beans, broccoli, cabbage, cauliflower
Wholemeal/ whole grain bread
Whole wheat breakfast cereals
Diet for Constipation Recommendations
Whole grain cereals
At least 3 times a week
3 or 4 times per week
Fruit or nuts
1 to 3 times a weeks
Fruit or nuts Daily
4 to 5 times a week
Brown rice or pasta
More than 5 times a week
If you are unable to actually consume the recommended amount of fibre you may need to discuss with your doctor the possibility of taking a regular laxative. However, this should not be your first step, lifestyle changes are by far more preferable.
What is a laxative?
A laxative is a remedy for constipation which is used as short term solution to the immediate problem. It is a resolution to improve both the amount of times you have your bowels open on a regular basis and the consistency of the bowel motions.
Adjustments in lifestyle and diet are the long term remedy for constipation.
The most natural laxative you can take is a bulk forming one – fruit and vegetables this one is clinically proven to work wonders on your bowels. If you are normally healthy, fit and have not had bowel surgery, if you eat five portions every day ,drink enough fluids, exercise you won’t suffer from constipation.
What type of laxative do I need?
There are a variety of different laxatives available on the market they have differing actions to promote bowel actions. It is important that all laxatives are taken as directed on the packaging.
Laxatives may be either
Oral – taken by mouth
Rectal – this includes enemas and suppository
Some are oral laxatives are taken at night to facilitate a bowel motion in the morning others must not be. Laxatives work in different ways, some act faster than others and have implications for the absorption of medicines you may be taking for other ailments. Please consult with your doctor prior to taking any oral laxatives if you are taking other medication.
Caution always needs to be mentioned prior to beginning to take laxatives as there are thoughts in the medical profession that over use of laxatives can cause constipation, due to nerves and muscle damage in the bowel. The question being posed is was the bowel causing the problem initiating the use of laxatives or the laxatives?
Bulk forming laxatives
This increases the size of the stool, by doing this it can stimulate the natural peristaltic action of the bowel to move the motion on. The way the stool is increased is by eating substances such as bran in your diet. Ispaghula or pysllium husk and can be taken as a supplement if you are not able to eat enough fibre but it must not be taken before bedtime and you must increase the amount of water you take each day.
Side effects can include - constipation if not enough water/fluids are taken, flatulence and bloating
Emollient or lubricant laxatives
These are stool softeners; they prevent the hardening of the faeces by adding moisture. These are often used for patients who are recovering form bowel surgery or haemorrhoids to prevent straining.
Side effects can include –vitamins and medicines may not be absorbed as well in the intestine due to the increased rate of movement of the stool, pruritus ani
These work by increasing the amount of fluid that is retained in the stool as it passes through the digestive system. The stool is easier to pass but it is a slower method to treat the constipation, it can take up to four days to be effective.
Side effects can include – nausea, abdominal bloating and flatulence skin rashes
This kind of laxative is effective by stimulating the muscles that line your bowel. These are the harshest of the laxatives and should not be considered prior to improving your diet for your constipation. Stimulant laxatives should not be taken for over a week if you feel you need a stimulant laxative after this time you will need to discuss this with your doctor.
Side effects can include – malabsorption of medication/contraceptive pill, gastric irritation or vomiting, abdominal cramps
How long should I take laxatives for?
Laxatives are a short term relief for constipation and should not be taken for longer than seven days without medical consultation. Once you have corrected your constipation and are passing stools which are soft and comfortable to evacuate, you can stop the laxatives however you will need to as a long term solution alter your diet and lifestyle. If the constipation returns it may be due to medication you are taking or an underlying disease you will need to consult with your doctor. Long term use of laxatives should not be stopped but reduced over a period of time. The aim is to return full motility function to the bowel.
If your chronic condition requires laxatives on a regular basis you will be monitored by a continence team and have a bowel management plan.
Be aware that herbal “natural” remedies for constipation often contain a stimulant which may not necessarily be the right laxative for you.
An enema is a liquid preparation that is introduced into the body via the rectum to produce a bowel movement. Enemas are not the first choice of laxative as there are many oral alternatives however some people like to be able to administer these in the comfort of their own homes. When administered by professionals they will ask for your informed consent to the procedure. They will explain the procedure for the administration of the enema as well as possible side effects.
There are two types of enema
Evacuant – this is used to promote a bowel movement phosphate and sodium citrate is the most commonly used
Retention-this is used to soften the compact faecal matter to allow a bowel movement. These oils often include nut oils therefore it is important prior to use to establish if there is an existing allergy.
Instruction on the packaging for the use of over the counter (O.T.C.) enemas should be followed explicitly to ensure a positive bowel movement. Care needs to be taken when administering an enema as the vagal nerve in the rectum can be stimulated which may result in a slowing of the heart rate and a feeling of lightheadedness.
These can be used as a stimulant laxative when you have constipation. They are made in the shape of a bullet for easy insertion into the anus. It is important that they are not swallowed orally and that they are inserted far enough into the anal passage to not be expelled immediately. The suppository will melt in the rectum having a stimulant affect which will lubricate the bowel allowing the compacted faeces to be expelled. You should always follow the instructions on the packaging to allow for a good bowel movement. Suppositories once inserted usually take between 15-30 minutes to have an effect. If your constipation continues after you have been using suppositories for three days you should consult your doctor.