Constipation

Many people think the day isn't complete without a bowel movement, a notion that leads to a lot of unnecessary worrying. Elderly people, who are more prone to constipation, are especially likely to fret if a day or two passes without a little "quality time" in the bathroom, according to the National Institutes of Health.

No matter what your age, though, bowel movements don't have to be an everyday event. While some perfectly healthy people move their bowels three times each day, others go three times each week. If you feel comfortable with your own bowel habits and there haven't been any significant changes, it's unlikely that you're constipated.

If you frequently find yourself straining to have a bowel movement, however, you may be constipated. Other symptoms include a feeling that the bowels haven't been completely emptied, having bowel movements fewer than three times a week, or producing dry, hard stools that are difficult or painful to pass. You may also feel bloated or sluggish.

Surveys show that more than 4 million Americans suffer from frequent constipation. For some people, the misery goes beyond feeling backed up. Repeated straining can cause hemorrhoids or small tears (fissures) in the skin around the anus. In rare cases, constipation can be a signal of a more serious ailment, such as cancer, so it's good to let your doctor know if your bowel habits change.

Fortunately, most people can prevent and control constipation with a few easy steps. Here's what you need to know to get back on schedule.

The causes of constipation

The number-one cause of constipation is a shortage of fiber in the diet. Fiber is like a lubricant that helps stools move through the intestines. Unfortunately, many staples of the American diet -- including white bread and processed foods -- have little or no fiber. If you aren't getting enough roughage, your stools will travel through your system much more slowly. This gives your intestines more time to absorb water, potentially turning soft stools into something more akin to small bricks.

Shortfalls of fiber are especially common in senior citizens. Some older people simply aren't eating enough, while others stick to soft, low-fiber foods that are easy to chew.

Not getting enough fluids is another common cause of constipation. Simply put, if there isn't enough water in your system, there won't be enough in your stools. Other causes include pregnancy, irritable bowel syndrome, lack of exercise, ignoring the urge to have a bowel movement, and medications such as narcotic pain relievers, antacids containing aluminum, antidepressants, iron supplements, and -- believe it or not -- laxative abuse.

You may be surprised to see laxatives on the list. But if you take these drugs too often for too long, your intestines can "forget" how to work on their own. Stimulant laxatives such as Correctol and Senokot are especially likely to cause constipation if overused and then withdrawn.

Getting regular

Despite the risks, many people start taking laxatives at the first sign of constipation. But drugs should really be a last resort. Before you try artificial relief, see if you can get your body back on track. Here's how:

  • First, make sure you get enough fiber. The American Dietetic Association recommends 25 to 38 grams each day. You can reach this goal by eating plenty of whole grain breads, bran cereals, beans, and high-fiber fruits and vegetables such as apples, peaches, carrots, squash, broccoli, and cabbage. Just changing your breakfast cereal can have a big impact: One third of a cup of some all-bran cereals, for example, contains up to 33 percent of the fiber you'll need in a day. (If you don't like bran cereal by itself, try mixing it with another cereal.)
  • Eating bran cereal at breakfast, a salad at lunch, and a salad and two one-cup servings of cooked vegetables at dinner would not only help you reach your fiber goal but give you a diet rich in antioxidants and other vitamins. As you fill up on fiber, you may want to cut back on cheeses, ice cream, and other low-fiber foods that can back you up, according to the National Digestive Diseases Information Clearinghouse. And if you normally don't each much fiber, start slow. Too much at once can cause bloating and flatulence.
  • Consider a fiber supplement such as Metamucil (which contains psyllium), if your physician recommends it. These vegetable fiber supplements absorb water and so make your stools softer and easier to pass. It's important to drink an 8-ounce glass of water (and preferably two) with each dose of flaxseed or a fiber supplement, including psyllium. Ironically, both can cause constipation if they're not taken with enough liquid.
  • Drink plenty of liquids such as water or other non-alcoholic, non-caffeinated beverages. Many physicians recommend you drink six to eight 8-ounce glasses of liquid a day.
  • Work out a routine time to have a bowel movement, if possible, where you can relax and take your time.
  • Whether you're at work or at home, don't ignore the urge to have a bowel movement.
  • Exercise regularly: This may help stimulate intestinal activity and helps relax you as well. Gary Gitnick, MD, co-chief of the division of digestive diseases at the University of California at Los Angeles, recommends that all his patients exercise at least 30 minutes every day. If the patient is just beginning an exercise program, he suggests exercising 10 minutes a day and adding 10 minutes every other day or so, until the person is on the move for a half hour a day. Because running or aerobics can aggravate symptoms of heartburn, Gitnick recommends brisk walking, swimming, or cycling for most of his patients. "I consider walking to be one of the best forms of exercise, especially for people who aren't used to working out," he writes in his book Freedom from Digestive Distress.
  • Always check with your doctor if you have a major or consistent change in bowel habits.

The medical approach

If these changes don't ease your constipation, talk to your doctor. Getting regular again may be as easy as changing one of your prescriptions, adding a fiber supplement, or changing your diet. If you haven't been getting enough exercise, your doctor may also help you find a routine that's right for you.

If you suffer from chronic constipation, your doctor might also recommend fiber supplements and -- if more treatment is needed -- a brief course of laxatives. The first line of defense should be an inexpensive saline laxative (such as Milk of Magnesia), according to the American Gastroenterological Association, which advises physicians to only use stimulant laxatives such as Dulcolax later, if truly necessary. Whatever your doctor recommends, follow the directions carefully. Let your doctor know if you develop diarrhea or abdominal discomfort, or if your constipation doesn't go away.

Be aware that stimulant laxatives can cause the bowel to empty all at once. As a result, you may not have another bowel movement for a day or two. Some people think this means they're still constipated and so take more laxatives, to their detriment.

Also, be cautious with "natural" laxatives and laxative teas, such as those containing senna. Natural or not, they can be dangerous, especially if used for more than a few days at a time.

If you've already slipped into a laxative habit, your doctor can help you cut back. By slowly reducing your doses, you can retrain your system to work naturally.

Some cases call for a little detective work before treatment can begin. If your constipation is severe, if you're over 50, or if you have other symptoms such as bloody stools, abdominal pain, or unexplained weight loss, your doctor will want to take a close look at your digestive system.

New thinking about constipation

Besides the usual definitions of constipation, researchers have pinpointed two types of "evacuatory failure." The first is "slow-transit constipation," in which stool moves through the colon much slower than usual, sometimes for reasons of diet. This condition may also stem from an abnormally sluggish colon, which emits fewer powerful contractions to push the digested food along; this disruption in normal movement means that fecal matter may sit an uncomfortably long time in the right colon. In addition, an increase in uncoordinated motor activity in the distal colon makes it harder to move the stool along.

The second main type of evacuation problem is known as a "pelvic floor dysfunction," in which the contents of the colon take the normal length of time to reach the rectum, where they lodge themselves like guests determined to overstay their welcome -- that is, for a prolonged period of time. People with this condition find it hard to adequately expel stool from the rectum, a problem known as "outlet obstruction" or "obstructed defecation," among others.

If doctors suspect you suffer from one of these conditions, you may be referred to a specialist in digestive diseases, known as a gastroenterologist, who will do a variety of screening and exams. Treatment for the first condition may include a course of laxatives. If you have a disorder of the pelvic floor, you may benefit from special exercises and biofeedback, according to the AGA.

Ruling out other diseases

If a doctor suspects a more serious disorder, such as colon cancer, he or she may do a digital rectal exam and/or test the stool for hidden blood. Other possible tests include a double-contrast barium enema (an x-ray of the entire colon), or a colonoscopy (exploration of the colon with a kind of periscope -- a long, flexible tube with a tiny camera on the end). Researchers have also developed "virtual colonoscopy" -- a scanner that takes hundreds of x-rays of different parts of your colon, allowing software to combine the "slices" and present a 3-D image of the colon, allowing software to combine the "slices" and present a 3-D image of the colon. Virtual scans are less expensive than they were years ago and are increasingly covered by insurance. For most people, the news is nothing but good. Constipation can be overcome, and it doesn't take any radical lifestyle changes or a huge supply of drugs. With a little effort, your life can get back to regular.

References

American College of Radiology, Patient and Physician Groups Call on Medicare to Cover Virtual Colonoscopy, August 15, 2016, https://www.acr.org/About-Us/Media-Center/Press-Releases/2016-Press-Releases/20160815-Patient-and-Physician-Groups-Call-on-Medicare-to-Cover-Virtual-Colonoscopy

AGA Technical Review on Constipation. American Gastroenterological Association. www.gastrojournal.org

Digestive Health Resource Center. American Gastroenterological Association. www.gastro.org

Freedom from Digestive Distress: Medicine-Free Relief From Heartburn, Gas, Bloating, and Irritable Bowel Syndrome. Gary Gitnick, MD. Three Rivers Press, New York.

National Digestive Diseases Information Clearinghouse. Constipation. www.niddk.nih.gov

National Institute on Aging. Age page: Constipation. www.nih.gov/nia

The University of Chicago. Diseases we treat. Constipation.

American Dietetic Association. Dietary Fiber: An Important Link in the Fight Against Heart Disease.

American Dietetic Association: Position of the American Dietetic Association: Health Implications of Dietary Fiber. Journal of the American Dietetic Association. 2008; 108: 1716-1731.

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