Constipation

Everyone has different bowel habits, so there isn't a 'normal' pattern; some people may go twice a week, others maybe three times a day. However, the longer that stools (feces) remain in the large intestine, the drier and harder they become, making evacuation more difficult and often painful.

Most people will suffer from brief (acute) episodes of constipation at some stage in their lives without any issues. Some people, though, may be constantly (chronically) constipated, with the condition affecting their quality of life.

Constipation is often due to a lack of exercise, delaying going to the toilet, too much caffeine, changes in routine or a diet low in dietary fiber/liquids. Medications such as antacids, antidepressants or even iron supplements can also cause constipation.

A doctor will diagnose you with constipation if you have had two of the following symptoms for a period of three months:

• Less than two bowel movements a week;
• Having to strain or push during a bowel movement more than 25% of the time;
• A non-complete bowel movement at least 25% of the time, and;
• Having pellet-like or hard stools more than 25% of the time.

Types

There are two types of constipation: acute (lasting between one and three weeks) and chronic (lasting more than three weeks).

Chronic constipation

This type of constipation is ongoing and can be caused by medications, lifestyle factors, poor diet choices, not drinking enough liquids or an underlying medical condition.

Complications of chronic constipation can include:

• Urinary incontinence - straining too much weakens pelvic muscles, which can cause a small amount of urine to leak out when laughing, sneezing or running;
• Hemorrhoids - these are swollen blood vessels in the rectum, causing itching, pain and sometimes bleeding;
• Rectal prolapse - too much straining can cause a part of the rectal lining to protrude from the anus;
• Fecal incontinence - if the bowel is too full, some fecal matter may leak out, and;
• Fecal impaction - fecal matter can build up in the colon.

Acute constipation

This type of constipation usually starts suddenly and is often caused by travel, taking new medications, or changes in routine. Tell your doctor if you have sudden constipation accompanied by pain, bleeding, nausea or lack of appetite, especially if you have:

• A family history of colon cancer;
• Irritable bowel syndrome (IBS), bloating, cramping and change in bowel habits, or;
• Intestinal obstruction, inability to pass wind, vomiting and nausea.

Signs and symptoms

As everyone has different bowel habits, the symptoms of constipation will vary between individuals, depending on their normal toilet routine. If you develop sudden constipation along with pain, fever, inability to pass wind/stools, bleeding, severe abdominal pain, unexplained weight loss, or thin, pencil-like stools, it is recommended you see a doctor immediately.

The most common symptoms of constipation are:

• Having to stay on the toilet for long periods of time;
• Having a distended abdomen, loss of appetite and headaches;
• Having bad breath (halitosis), a furred (coated) tongue and an unpleasant taste in the mouth;
• Excessive straining to pass hard stools, and;
• Difficult to pass, irregular bowel movements.

Constipation can cause excessive straining. 

Causes

Constipation is often caused by a combination of factors, such as a sedentary lifestyle coupled with a low-fiber diet. There may also be an underlying medical condition. Reasons for constipation can include:

• Old age - constipation is common in the elderly, especially if bedbound or less mobile;
• Taking certain medications, such as strong pain relievers, antidepressants, anticonvulsants or iron supplements;
• Dehydration - drinking lots of tea/coffee/alcohol, but not enough water;
• Taking antacids containing aluminum and calcium;
• Some neurological (brain) disorders, such as multiple sclerosis (MS), stroke or Parkinson's disease;
• Some hormone/endocrine disorders such as diabetes, underactive thyroid (hypothyroidism) or underactive pituitary gland (hypopituitarism);
• Stress;
• Depression;
• Overuse of some laxatives - this can weaken the bowel;
• Eating disorders, irritable bowel syndrome (IBS) or bowel cancer;
• Resisting the urge to defecate due to pain from conditions such as an anal fissure (tear), bowel obstruction or hemorrhoids;
• Surgery - any gynecological or abdominal surgery can result in temporary constipation due to pain, fear of splitting sutures and use of codeine-based pain-relief medication
• Disrupted routine due to travelling or being unable to eat at regular times;
• Eating large amounts of dairy products;
• Lack of muscle tone and healthy nerve supply to abdominal region, and;
• Rectocele - this can occur in a woman after difficult childbirth, in which the rectum bulges through the weakened rear wall of the vagina whenever the woman strains to pass a stool.

Methods for diagnosis

A doctor can quite easily diagnose constipation by asking questions and doing a simple examination, if necessary. Always tell your doctor if you experience any bleeding or pain during defecation (passing a bowel movement).

Physical examination

This routine examination involves the person lying on their side on a doctor's examination couch. Using a glove and lubrication, the doctor will insert a finger into the rectum to check for impacted/collected stools. Children's constipation is usually diagnosed by a doctor feeling their lower abdomen.

Pathological tests

To check for any underlying medical condition, your doctor may arrange further pathology tests, such as blood tests, stool and urine tests, or a thyroid function test.

Diagnostic tests

Further testing is usually only performed on people with severe symptoms, or elderly people presenting with sudden onset constipation. For most of these tests, you will need to clear out your bowels before your procedure. Depending on the symptoms that need investigating, the following diagnostic options are available:

X-ray of the anorectal region (defecography)

A paste-like substance is inserted into the colon, which is then excreted into a special commode (toilet). An X-ray is taken during the process, to see if the rectum and sphincter (the ring-like muscle of the anus) are working properly.

Colonoscopy

A colonoscopy allows examination of the entire length of the colon. A thin and flexible tube with an attached camera and light at the end is inserted into the rectum and colon. This allows your doctor to take photos, tissue samples or video.

A colonoscopy procedure. 

Sigmoidoscopy

A similar procedure to a colonoscopy, a sigmoidoscopy is limited to the rectum and sigmoid colon. A flexible tube with a camera attached is inserted into the lower part of the colon (sigmoid colon), via the rectum, allowing the doctor to investigate blockages, take photos or video, or tissue samples. A sigmoidoscopy can be done with a limited bowel preparation and no sedation.

Barium enema

A barium enema has become an uncommon test since colonoscopy is now readily available. It uses a contrasting barium dye and an X-ray scan to detect possible bowel cancer.

Marker or colorectal studies

These involve swallowing a pill containing radioactive compounds. The pill can then be monitored in the following few days by X-rays. These will help your doctor assess if the bowel is functioning properly, and show how long it takes for the capsule to travel through your system.

Anorectal manometry

This procedure tests whether the anal sphincter (muscle) is working properly. A small balloon is inserted into the anus via a flexible, narrow tube. The balloon is then inflated and gently pulled backwards, to observe the sphincter muscle in action.

Types of treatment

Constipation can often be resolved by making simple lifestyle changes, such as adopting a healthy diet with more fruit and vegetables, exercising more and drinking more water. If these measures do not help, many people turn to laxatives to temporarily ease their constipation. However, laxatives may interfere with the absorption of some medications, so always check with your doctor or pharmacist before taking them.

Laxatives

These over-the-counter medications help to move the bowels. However, care must be taken with them, as some can become habit-forming. Laxatives fall under several categories depending on how they work:

• Saline laxatives (e.g. Epsom salts) - these act like a sponge, drawing water out of the colon to moisten stools;
• Osmotic (e.g. lactulose, glycerol, macrogol) - these help fluids move through the colon, helping the passage of stools;
• Fiber supplements (e.g. psyllium) - these bulk out stools, making them easier to pass;
• Lubricants (e.g. liquid paraffin) - these help the stools move through the colon more easily;
• Stool softeners - these moisten stools, making them easier to pass, and;
• Stimulants (e.g. bisacodyl, senna) - these increase the movement of the intestines (peristalsis), helping to expel stools.

Suppositories or enemas can be helpful if you have impacted stools.

Outpatient procedures

For chronic constipation that has not responded to lifestyle changes or laxative medications, sometimes other procedures are recommended.

Manual procedures

If laxatives have not worked to shift impacted stools, your doctor may manually help to remove them. First, the doctor will insert a gloved finger into the anal passage to break up impacted feces (disimpaction), then an enema will be used to clear the remainder of the impacted stools and help clear the bowels.

Prevention

In most cases, simple lifestyle changes can make a huge difference to constipation symptoms. If there are any underlying causes for constipation, such as weak pelvic floor muscles, special exercises could be suggested. If diet is the issue, a visit to a dietitian may be recommended. In general, getting as much exercise as possible, alongside increasing fluid and fiber intake, are good ways to help bowel function.

Diet and lifestyle changes.

Making simple changes in lifestyle may help reduce the occurrence of constipation.

Drink more liquids

Liquid is absorbed from our stools as they move through the bowels. The longer the stool remains in the system, the less liquid it contains. This can lead to dry, hard-to-pass stools. Aim to drink six to eight glasses of water each day to avoid this.

Eat a high-fiber diet

Adding more fruit, vegetables and whole grain foods to your diet will help ease constipation. Try brown rice instead of white, wholemeal bread instead of white, and snacks such as raisins or prunes. Limit low-fiber foods such as cheese, cakes and processed foods.

Exercise regularly

Try to get some exercise each day. A daily walk or outdoor activity can be fun, and will help improve a sluggish bowel system. Getting up and moving around will let gravity help to move the contents of the bowel along naturally. Special exercises called pelvic floor exercises have been designed to help improve muscle tone in the pelvic region. Better muscle tone will help the colon to push fecal matter along, lessening the need to push or strain.

Allow time for bowel movements

Constantly ignoring the urge to open the bowels can lead to constipation, as the body will eventually learn to ignore the signals.

Avoid taking too many laxatives

Taking too many laxatives, particularly stimulant laxatives, can weaken the bowel's ability to work properly. Osmotic laxatives are not associated with this side effect. However, it can be easy to become dependent on laxatives, relying on them to cause a bowel movement instead of making lifestyle changes. Children should not be given laxatives unless advised by a doctor or pharmacist.

Constipation can be reduced by following a healthy diet rich in fiber, and making other lifestyle changes.