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Causes and Treatments of Constipation

Constipation is the name given to infrequency of bowel movements. Some people wrongly assume that in order to prevent constipation they must have a bowel movement every day. In fact a person can only be clinically defined as constipated if they have fewer than three bowel movements a week.
The full, clinical definition of constipation is having two out of the following five symptoms over a period of at least twelve weeks out of the year: fewer than three bowel movements per week; hard/lumpy stools; straining when passing stools; feeling that there is an anorectal obstruction or blockage; and a sensation that evacuation is not complete.

In medicine there are many different names for constipation such as costiveness, dyschezia, delayed transit, dyssynergic defecation, outlet obstruction and outlet delay.

Fast Facts about Constipation

  • Constipation is very common and it is often caused by lack of exercise and poor diet
  • Its other causes include drugs, certain diseases (e.g. irritable bowel syndrome) and even over-dependence on laxatives
  • Many people erroneously think they are constipated if they do not have a bowel movement each day
  • Simple lifestyle changes – such as eating more fiber, drinking enough liquids and taking regular exercise – will often be enough to cure constipation
  • Setting aside enough time to have a bowel movement will also help prevent constipation
  • Other treatment options include laxatives, biofeedback and surgery

Common Causes of Constipation

Constipation can be caused by a diet that is too low in fiber, by not drinking enough liquids, or by taking calcium/iron supplements or medications (e.g. codeine-based painkillers, antidepressants, diuretics and certain antacids). It can also result from stress, changes in daily routine, a lack of physical activity or even from ignoring the urge to defecate. Constipation in children is often caused by situations when children may withhold their stools because of embarrassment and stress over potty training or using a public bathroom, or simply because they do not want to stop playing.

Ironically, constipation can also occur as a result of abuse of/dependency on stimulant-type laxatives and it is believed to result from damage to the nerves and muscles in the colon.

Occasionally constipation can be a symptom of some underlying problems in intestinal function. Such problems include irritable bowel syndrome, diverticulosis, obstructions in the intestines, scarring, Hirschsprung disease, tumors and colorectal stricture – all of these serve to narrow or compress the intestine or rectum and thus make it harder to pass stools. Colonic inertia and delayed transit are two types of constipation that result from a decrease in colonic muscle activity while another type of the disease, pelvic floor dysfunction, arises from weakness in the muscles surrounding the anus and rectum.

Constipation can also be caused by other diseases such as neurological disorders (e.g. multiple sclerosis or Parkinson’s disease), metabolic and endocrine disorders (e.g. diabetes or hypothyroidism) or systemic disorders, including scleroderma, amyloidosis and lupus. High levels of estrogen and progesterone during menstruation and pregnancy may also cause constipation.

Risk Factors for Constipation

Constipation is a common gastrointestinal complaint in the Western world. It can happen at any age but the incidence increases as one gets older. Women – especially pregnant or menstruating women – are more likely to get it than men and it often occurs after surgery or childbirth. Constipation, along with bloating and pain when passing stools, is often experienced by patients with irritable bowel syndrome.

Symptoms of Constipation

The main symptom are very infrequent bowel movements (less than three times a week). In addition to this, the stools are usually small, hard, dry and difficult or even painful to pass. The sufferer may also be bloated and feel as though they have a full bowel.

Diagnosing Constipation

Although the actual symptoms of constipation are obvious to the sufferer, further diagnostic procedures may be necessary to determine the underlying cause. A rectal exam can be carried out by inserting a gloved and lubricated finger to find out the tone of the anal sphincter muscle and also whether there is any tenderness, obstruction or bleeding.

In order to find out whether there is any underlying metabolic or inflammatory disease, your doctor may perform a thyroid or blood test.

Patients with more severe or sudden-onset symptoms can also undergo a colorectal transit study. This is an X-ray based technique which shows how well food passes along the colon. Another X-ray technique is known as defecography involves X-raying the anorectal area to find out how completely stools are eliminated as well as how efficiently the rectal muscles contract/relax and if there are any anorectal abnormalities. To view a wider area – the colon and lower part of the small intestine as well as the rectum – a barium enema X-ray may be used.

Endoscopic techniques can be employed for visual examination of the bowel. These include sigmoidoscopy (used to view the lower colon and rectum) and colonoscopy, which is used to examine the entire colon (a colonoscope is longer than a sigmoidoscope). In both cases the visual examination can be supplemented by a biopsy. Barium enema X-rays and sigmoidoscopy/colonoscopy are also used to rule out colorectal cancer.

An alternative to X-ray and endoscopic techniques is the so-called anorectal function test, which aim is to find out whether the constipation is caused by abnormalities in the function of the rectum or anus. There are two types of anorectal function test – anorectal manometry and balloon expulsion. Anorectal manometry involves inserting an air-filled balloon or catheter in the anus and slowly pulling it back out to measure the contractions and muscle tone of the anal sphincter. In a balloon explusion test, a balloon is inserted into the rectum and then filled with water. The patient then tries to expel the balloon – a decrease in bowel function is indicated if the patient cannot expel a balloon containing less than 150 ml of water.

Treatment Options for Constipation

Over-the-counter laxatives are the most common way to treat constipation and can work e.g. by stimulating intestinal muscle contraction, making the stool softer, lubricating the stool or drawing water into the colon.

However, most people with mild symptoms do not need laxatives – they just need to adjust their lifestyle by increasing the amount of fiber in their diet, drinking more water and fruit or vegetable juice, engaging in enough exercise and even setting aside enough time to have a bowel movement.

Pelvic floor dysfunction can be treated with biofeedback training, where the muscles around the anus and rectum are re-educated to relax and work normally. Biofeedback involves using a sensor to detect activity in the muscle – the resulting computer-generated display is then shown to the patient to help them learn how to retrain their muscles.

Removing the colon by surgery may be necessary in severe cases of constipation associated with colonic inertia.

Prevention of Constipation

Most of the time constipation can be prevented by eating more fiber in the form of vegetables, fruits, grains and beans, e.g. kidney and lima beans. Since dehydration can cause constipation it is also important to drink enough water, fruit/vegetable juices and even clear soups. Twenty or thirty minutes a day of exercise will help your digestive system to remain active. Do not put off having bowel movements and make sure that you allow enough time for them. It can help to set aside a specific time of every day to try to have a bowel movement.

Coping with Constipation

Making improvements to your diet and lifestyle will help control the symptoms in most cases. Remember that most people with mild constipation do not need laxatives – you should only take them if you find that lifestyle improvements do not work for you. You should check with your doctor to find out whether any medication you are on might be the cause of the constipation.

If you experience acute constipation (i.e. the symptoms come on very suddenly), you should make an urgent appointment to see your doctor, since there might be a serious underlying condition such as a tumor which is causing a sudden blockage. You should also have your constipation checked with no delay if it is accompanied by rectal bleeding, abdominal cramp or pain, vomiting, nausea and/or sudden weight loss.

Where to Get More Information: American Society of Colon and Rectal Surgeons