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CONSTIPATION

Constipation is a symptom that has different meanings to different individuals. Most commonly, it refers to infrequent bowel movements, but it may also refer to a decrease in the volume or weight of stool, the need to strain to have a movement, a sense of incomplete evacuation, or the need for enemas, suppositories or laxatives in order to maintain regularity.

What are the symptoms of constipation?

For most people, it is normal for bowel ¬movements to occur from three times a day to three times a week; other people may go a week or more without experiencing discomfort or harmful effects. Normal bowel habits are affected by diet. The average Scottish diet includes 12 to 15 grams of fibre per day, although 25 to 30 grams of fibre and about 1500 to 2000 mls of fluid daily are recommended for proper bowel function. Exercise is also beneficial to proper function of the colon.

About 80 percent of people suffer from ¬constipation at some time during their lives, and brief periods of constipation are normal. Constipation may be diagnosed if bowel movements occur fewer than three times ¬weekly on an ongoing basis. Widespread beliefs, such as the assumption that everyone should have a movement at least once each day, have led to overuse and abuse of laxatives.

Eating foods high in fibre, including bran, shredded wheat, whole grain breads and certain fruits and vegetables will help provide the 25 to 30 grams of fibre per day recommended for proper bowel function.

What causes constipation?

There may be several, possibly simultaneous, causes for constipation, including inadequate fibre and fluid intake, a sedentary lifestyle, and environmental changes. Constipation may be aggravated by travel, pregnancy or change in diet. In some people, it may result from repeatedly ignoring the urge to have a bowel movement.

More serious causes of constipation include growths or areas of narrowing in the colon, so it is wise to seek the advice of a colon and rectal surgeon when constipation persists. Individuals with spinal cord injuries frequently experience problems with constipation. Constipation may be a symptom of diabetes. Constipation may also be associated with scleroderma, or disorders of the nervous or endocrine systems, including thyroid disease, multiple sclerosis, or Parkinson's disease.

Can medication cause constipation?

Yes, many medications, including pain killers, antidepressants, tranquillizers, and other psychiatric medications, blood pressure medication, diuretics, iron ¬supplements, calcium supplements, and aluminium containing antacids can slow the movement of the colon and worsen constipation.

When should I see a doctor about constipation?

Any persistent change in bowel habit, increase or decrease in frequency or size of stool or an increased difficulty in evacuating warrants evaluation. Whenever constipation symptoms persist for more than three weeks, you should consult your physician. If blood appears in the stool, consult your physician right away.

How can the cause of constipation be determined?

Constipation may have many causes, and it is important to identify them so that treatment can be as simple and specific as possible. Your doctor will want to check for any anatomic causes, such as growths or areas of narrowing in the colon.

Digital examination of the anorectal area is usually the first step, since it is relatively simple and may provide clues to the underlying causes of the problem. Examination of the intestine with either a flexible lighted instrument or barium x-ray study may help pinpoint the problem and exclude serious conditions known to cause constipation, such as polyps, tumours, or diverticular disease. If an anatomic problem is identified, treatment can be directed toward correcting the abnormality.

Other tests may identify specific functional ¬causes to help direct treatment. For example, "marker studies," in which the patient swallows a capsule containing markers that show up on ¬x-rays taken repeatedly over several days, may ¬provide clues to disorders in muscle function within the intestine. Other physiologic tests ¬evaluate the function of the anus and rectum. These tests may involve evaluating the reflexes of anal muscles that control bowel movements using a small plastic catheter, or x-ray testing to evaluate function of the anus and rectum ¬during defecation. In many cases, no specific anatomic or functional causes are identified and the cause of constipation is said to be nonspecific.

How can I relieve the symptoms of constipation?

The vast majority of patients with constipation are successfully treated by adding high fibre foods like bran, shredded wheat, whole grain breads and certain fruits and vegetables to the diet, along with increased fluids. Your physician may also recommend lifestyle changes. Fibre supplements containing indigestible vegetable fibre, such as bran, are often recommended and may provide many benefits in addition to relief of ¬constipation. They may help to lower cholesterol levels, reduce the risk of developing colon polyps and cancer, and help prevent symptomatic haemorrhoids.

Fibre supplements may take several weeks, possibly months, to reach full effectiveness, but they are neither harmful nor habit forming, as some stimulant laxatives may become with overuse or abuse. Other types of laxatives, enemas or suppositories should be used only when recommended and monitored by your colon and rectal surgeon.

1. Lifestyle changes
It is important to try to make time for your bowels each day. Most bowels respond best to a regular habit. About 30 minutes after eating is the most likely time for the bowel to work. This is because of the “gastro-colic response” which means that eating sets waves of activity in motion in the bowel. Try not to rush going to the toilet. If you have a tendency to be constipated, set aside about 10 minutes in the toilet. Preferably this should be at a time when you are not rushing to do other things. Find a toilet that you feel comfortable to use and where you do not feel inhibited by lack of privacy or time. Sport and exercise improve bowel habits in some people. If you lead a very inactive lifestyle (driving to work at a desk job) even taking a regular walk at lunchtime can make a difference. You can also try your own toilet exercises if you want to avoid a formal retraining program supervised by a therapist.

2. Diet and fluids
Eating regularly is the best stimulant for your bowels. Skipping meals, especially breakfast, can lead to a sluggish or irregular bowel habit. Contrary to popular belief a high fibre diet is not always the best diet for the constipation sufferer. Regular meals and an adequate fluid intake are the main aims. Too much fibre can lead to an increase in bloating and discomfort, especially for people with slow gut transit. If you do feel your diet is short on fibre try to use fruit and vegetables (soluble fibre) rather than cereals (insoluble fibre) as they are less bloating. Some foods can act as natural laxatives in some people . Try to drink at least eight to 10 mugs of fluid a day. However, excessive fluid intake may make you feel more bloated and is unlikely to improve your bowel function further. Too much caffeine (coffee, tea and cola) can be dehydrating, as can too much alcohol.

3. Medications and remedies
If you are taking any medicines (prescribed or bought from the chemist) ask your doctor or chemist if they could be adding to your constipation. If possible, try to remove constipating medications. If really necessary, try using a fibre supplement such as fybogel and possibly suppositories or mini-enemas to help regularise the bowels. It is best only to use these as an aid to getting into a regular routine, rather than relying on them long term.
Laxatives
The use of laxatives should usually be confined to people:

  • Who have only very occasional episodes of constipation.
  • Who need laxatives to counteract a short-term constipating medication.
  • Who need to avoid straining (e.g. angina sufferers)
  • Who are in hospital.
  • With an anal condition which needs soft stools for the healing period.
  • Undergoing a radiological or surgical procedure.
  • Who are severely or terminally ill.

It is common for patients to come to clinic and say: “I tried this laxative and it worked well to start with but then it stopped working so well.” They try another and another and another and it’s the same story every time. The nature of long-term laxative use is that the bowel becomes progressively less responsive to all these agents, meaning that increasing doses are required.

There is no convincing evidence that the colon is permanently damaged by long term laxative use, and in particular there is no increased risk of bowel cancer caused by laxatives. Nevertheless, these are not drugs that should be considered harmless. Some laxatives such as Senna stain the insides of the bowel and this can be seen at colonoscopy (examination of the lining of the colon). The fact that a product is “natural” does not mean that it is necessarily “good for you”. Laxatives can cause significant loss of minerals from the bowel, and uncontrolled long-term use can result in changes in the body’s chemistry, especially in older people and those who are unwell. The more you take laxatives, the less likely it is that the bowel will work on its own. This does not mean that you cannot stop taking laxatives once you have started, but it can take a while for the bowel to start working on its own again.
Suppositories or mini-enemas
Whilst the idea of inserting a suppository or enema may not appeal to all, it is important to bear in mind a number of advantages.

  • Their action is more predictable than that of laxatives, without the tendency to cause diarrhoea.
  • They can encourage a more regular bowel action especially if taken at the same time of day, every day, every other day or once every three days.
  • There are generally well-tolerated - they are acting locally just like a nasal spray taken for hay fever or inhalers for asthma. Since there is minimal absorption into the body, there is low potential for side-effects.
  • They must be inserted into the rectum for maximum effect. You can get a supply of gloves from your chemist. Suppositories and enemas work by causing contraction of the rectum, softening the stool in the rectum and by causing the bowel higher up to contract.

4. Biofeedback
This is a bowel retraining programme run by therapists who are usually nurses or physiotherapists. Advice on diet, toileting habits and access to acceptable facilities is reviewed. Patients are shown how the muscles and nerves can be retrained to co-ordinate and produce a satisfactory effort to empty the bowel. The therapy may involve four to five one-to-one sessions between the patient and therapist.

5. Surgery
This is needed in only a very small minority of people. There are women who benefit from a repair of a rectocoele. Rectal prolapse may also require an operation.

The results of removal of all or part of the colon to improve bowel function are often poor. About a tenth of patients return quickly to their previous levels of constipation, and a third have incapacitating diarrhoea, some with a degree of incontinence. Approximately one in ten who have part of the colon removed will end up with a stoma (bowel brought out to the skin to discharge bowel contents into bag) either because of severe symptoms that cannot be controlled, or as a result of the failure of previous surgery.

What can I do myself to try and help my constipation?

     
  • Try to go to the toilet at a regular time or times every day. This may follow breakfast or a coffee.
  • Take your time. Try to ensure that you will have about 10 minutes without interruption.
  • Firstly make sure you are comfortable on the toilet. It is most natural for humans to squat to pass a stool. You may find that having your feet on a footstool about 20-30 cm (8-10 inches) high helps by improving the angle of the rectum within the pelvis, making it easier to pass stools. Keep your feet about 1.5 - 2 feet apart.
  • Relax and breathe normally. Do not hold your breath as this will encourage you to strain.
  • Using your abdominal muscles effectively is best done with one hand on your lower abdomen, and one on your waist. As your abdominal muscles tighten you should feel your hands being pushed out forwards and sideways. This is called ‘brace’ or ‘brace and bulge’.
  • Concentrate on relaxing the anus to allow the stool to pass. Do not push from above without relaxing the anus below.
  • Do not adopt any “weird and wonderful” positions - this will not help you in the long-term.
  • Do not spend endless time on the toilet straining. If the bowels do not open - do not panic - try again at the same time the next day. It may not be normal for you to pass a stool every day.

What are the best foods to take to help constipation?

Examples of foods which can act as natural laxatives for some people:

     
  • Prunes / prune juice
  • Figs / fig juice
  • Molasses
  • Liquorice
  • Chocolate
  • Coffee
  • Alcohol (within recommended limits!)
  • Spicy food / curry