Constipation in Adults

Constipation refers to a decrease in the frequency of bowel movements. For some people, it may mean difficulty in passing stools. A constipated stool is hard because it contains less water than normal. Constipation is a symptom, not a disease.

Generally, constipation is difficult to define clearly because as a symptom it varies from person to person.

• The frequency of bowel movements also varies greatly, ranging from 3 movements per day to 3 per week. Generally, if your bowel has not opened for 3 successive days, the intestinal contents harden, and you may have difficulty or even pain during defecation.

• A common misconception about constipation is that wastes stored in your body are absorbed, are dangerous to your health, and may shorten your lifespan. Some people have an underlying fear that they will be "poisoned" by their own intestinal wastes (feces) if they retain the waste in their bodies for more than a certain length of time. None of this is true.

• Older people are 5 times more likely than younger people to develop constipation. But experts believe that older people become too concerned with having a daily bowel movement and that constipation in this age group is overestimated.

Constipation may result from a poor diet, poor bowel habits, or problems in elimination of stool, whether physical, functional, or voluntary.

These are the most common causes of constipation:

• Poor diet: Eating foods rich in animal fats (dairy products, meats, and eggs) or refined sugar but low in fiber (whole grains, fruits, and vegetables) may cause constipation.

• Poor bowel habits: Ignoring the desire to have bowel movements may initiate a cycle of constipation.
  
  
  • After a period of time, you may stop feeling the desire for opening your bowel.
    
    
  • This leads to progressive constipation. For example, some people may avoid using public toilets or ignore going to the toilet because they are busy.

• Medications: Many medications can cause constipation.
  
  
  • Antacids - Those containing aluminum hydroxide and calcium carbonate
    
    
  • Antispasmodic drugs
    
    
  • Antidepressants
    
    
  • Iron tablets
    
    
  • Anticonvulsant drugs

• Painkillers: Narcotic-containing drugs, for instance, may interfere with bowel functions.

• Travel: Changes in lifestyle, low fluid intake, and eating fast food may cause constipation.

• Irritable bowel syndrome (spastic colon): This is one of the most common causes of constipation. Because of changes in bowel function, if you have this disorder, you may have crampy abdominal pain, excessive gas, bloating, and constipation.

• Laxative abuse: Habitually using laxatives gradually will produce dependency on them.
  
  • You may eventually require increasing amounts of laxatives to move your bowels.
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  • In some instances, the bowel will become insensitive to laxatives and fail to open.

• Pregnancy: Constipation during pregnancy may be due to several factors. Each of the following conditions produces severe pain on defecation, which may trigger a reflex spasm of the anal sphincter muscle. The spasm may delay bowel movement and decrease the desire for bowel opening as a means to avoid the anal pain.
  
  
  • Mechanical pressure on your bowel by the heavy womb
    
    
  • Hormonal changes during pregnancy
    
    
  • Changes in food and fluid intake
    
    
  • Anal fissure (cracks in the anus)
    
    
  • Hemorrhoids (piles)
    
    
  • Anal stenosis (narrow anus)

• Intestinal obstruction: Mechanical compression and interference with the normal functions of the bowel may occur in the following ways:
  
  
  • Inflammatory adhesions and joining of tissues
    
    
  • Intestinal tumors or foreign bodies
    
    
  • Gallstones that have become immovably wedged in the intestine
    
    
  • Twisting of the intestine upon itself (volvulus)
    
    
  • Intussusception – "Telescoping of the intestine" in which one part of your intestine slips or is drawn onto another part just below it (This occurs mainly in children.)
    
    
  • Abdominal hernia - Loops of the intestine become obstructed
    
    
  • Damage to nerves within your intestine - (Spinal cord tumors, multiple sclerosis, or spinal cord injuries may produce constipation by interfering with the function of the nerves supplying the intestine.)
    
    
  • Connective tissue diseases – Conditions such as scleroderma and lupus
    
    
  • Poor-functioning thyroid gland - A low production of thyroxin, a hormone produced by the thyroid gland, hypothyroidism, causing constipation
    
    
  • Lead poisoning and other metabolic disorders

• Age: Older adults are more likely to have constipation for these reasons:
  
  
  • Poor diet and insufficient intake of fluids
    
    
  • Lack of exercise
    
    
  • Side effects of prescription drugs used to treat other conditions
    
    
  • Poor bowel habits
    
    
  • Prolonged bed rest, for example after an accident or during an illness
    
    
  • Habitual use of enemas and laxatives

You may exhibit a broad range of symptoms of constipation depending on your normal bowel habits, diet, and age. These are common problems you may have if you are constipated:

• Difficulty in starting or completing a bowel movement
  
  
• Infrequent and difficult passage of stool
  
  
• Passing hard stool after prolonged straining in the toilet
  
  
• If you have irritable bowel syndrome, crampy abdominal pain, excessive gas, a sense of bloating, and a change in bowel habits
  
  
• If you have intestinal obstruction, nausea, vomiting, no defecation, and inability to pass gas
  
  
• Distended abdomen, headaches, and loss of appetite
  
  
• Coated (furred) tongue, offensive breath, and bad taste in your mouth

Call your health care provider if you have these concerns:

• Symptoms are severe and last longer than 3 weeks
  
  
• Recent and significant change in bowel habits, for instance, constipation alternates with diarrhea
  
  
• Severe pain in the anus during a bowel movement
  
  
• Symptoms of other diseases in addition to constipation (For example, tiredness, fatigue, poor tolerance to cold weather may suggest the need to assess your thyroid function for hypothyroidism, an underactive gland.)
  
  
• Constipation for 2 weeks or longer with returning abdominal pain, which might be a sign of lead poisoning

Seek emergency medical care: Although constipation may be extremely uncomfortable, it is usually not serious. It may signal a serious underlying disorder, however, such as cancer of the bowel. Because constipation may lead to complications, go to a hospital’s emergency department for any of the following reasons:

• Rectal bleeding
  
  
• Anal pain and hemorrhoids
  
  
• Anal fissures or cracks in the mucous lining (severe pain during defecation in the anal area)
  
  
• Fecal impaction (immovable intestinal contents) in very young children and in older adults
  
  
• Rectal prolapse or sagging (Occasionally, straining causes a small amount of the intestinal lining to push out from the rectal opening. This may lead to secretion of mucus that may stain underpants.)
  
  
• Recurrent vomiting with constipation and abdominal pain (This may suggest intestinal obstruction and needs urgent hospital treatment.)

Your health care provider may ask you several questions, conduct a physical exam, and perform certain lab tests to find out possible causes of your constipation.

• Your answers to these questions will help your doctor assess your condition and plan treatment options.
  • What are your normal bowel habits?

  • How long have you had difficulty in passing stool?

  • When was the last time you passed stool?

  • Are you able to pass gas?

  • Do you experience any abdominal or anal pain?

  • Could you indicate with your finger the site of your pain?

  • How would you describe your abdominal pain?

  • Have you noticed any changes in your body temperature?

  • Have you tried any medication? Did it help?

  • Do you usually take laxatives or an enema? If yes, what type of laxatives and how many tablets per day do you usually take?

  • Do you feel that you always need laxatives to pass stool?

  • Do you have any other symptoms?

  • Any changes in your appetite?

  • Any changes in your body weight?

  • Do you feel better after passing stools?

  • Do you feel sick? Have you thrown up?

  • Any hospital admission or investigations for similar illness?

  • Are you pregnant?

  • Do you smoke cigarettes? When did you start smoking? How many cigarettes do you smoke per day?

  • Do you drink alcohol? Coffee? Tea?

  • Do you use drugs? Any medications?

  • Have you ever had surgery? What surgery? When?

  • Any joint pain, eye problems, back or neck pain, or skin changes?

  • Do you usually prefer the warm weather?

  • Do you usually feel tired?

  • Do you have a family history of constipation or bowel cancer?

• Your health care provider will examine your abdomen, anus, and other body systems including the nervous system, the thyroid gland (for any goiter), and the musculoskeletal system. What the provider examines will depend on your answers to the questions and any history that may suggest certain disorders.

• Your provider will decide which tests you need based on your symptoms, history, and exam. These tests will help assess the actual cause of the problem. The most commonly used tests may include the following:
  • Lab tests
    • Examining a stool sample under a microscope

    • Full blood count and blood film

    • Thyroid function tests if hypothyroidism suspected
      

  • Imaging
    • Upright plain x-ray of your chest and abdomen - May show free air from intestinal perforation or signs of intestinal obstruction

    • Barium enema - May reveal a normal sized colon

    • Assessment of food movement - May demonstrate a prolonged and delayed transit time
      

  • Procedures
    • Sigmoidoscopy - May help to detect problems in your rectum and lower colon. Your doctor will insert a flexible lighted instrument through your anus to visualize the rectum and the lower intestine.

    • Colonoscopy - Using an internal examination, your doctor can confirm the diagnosis of irritable bowel syndrome by ruling out more serious disorders. The doctor also may take tissue biopsies for further studies to assess the cause underlying your symptoms.

If your bowel is not blocked, you and your health care provider must establish realistic goals of medical treatment.

• All cases will require dietary advice. Treatment may be difficult, particularly in those with chronic constipation. Your doctor may prescribe bulk-forming agents in addition to dietary changes.
  
  
• Increased activity in the elderly and regular exercise in younger people will help.

|Self-Care at Home|

• Get more fiber or bulk in your diet.
  
  
• Regular physical activity is an important component in bowel health.
  
  
• Drink plenty of fluids, especially water and fruit juices. Drink 6-8 glasses of water daily in addition to your beverages with meals.
  
  
• Go to the toilet at the same time every day—preferably after meals—and take enough time.
  
  
• Use nondigestible sugar (lactulose) or specially formulated solutions.
  
  
• Avoid using over-the-counter laxatives. Try to avoid laxatives containing senna (Senokot) or buckthorn (Rhamnus purshiana) because long-term intake may damage the lining of your bowel and injure nerve endings to the colon.
  
  
• Try a daily exercise such as the knee-to-chest position. Such positions may activate bowel movements. Spend about 10-15 minutes in this position. Breathe in and out deeply.

|Medications|

If these initial measures fail, your doctor may try a number of laxatives on a short-term basis. You must consult with your doctor before using any of these agents, particularly on long-term basis.

• Mineral oils
  
  
• Sodium docusate or calcium docusate are useful when you must avoid straining, such as after a heart attack, during pregnancy, or after gastrointestinal surgery.
  
  
• Saline laxatives such as magnesium hydroxide (Phillips Milk of Magnesia) or sodium phosphate (Phospho-Soda, Fleet enema) are not recommended if you have renal insufficiency (an inability or reduced capacity of the kidney to remove waste). These laxatives may produce severe side effects if used on long-term basis.
  
  
• Polyethylene glycol 3350 (Miralax) is an osmotic laxative that is not absorbed by your stomach. It holds water in the bowel, resulting in looser stools and a laxative effect. It may be taken occasionally for constipation (up to 2 wk). Miralax is a drink prepared by mixing a powder with 240 mL (8 oz) of water.
  
  
• Nonabsorbable sugars such as lactulose and sorbitol may be useful. Furthermore, they are usually acceptable for long-term use. However, they usually produce crampy abdominal pain, diarrhea, and electrolyte imbalance.
  
  
• Cisapride (Propulsid) may work if you have constipation caused by slow fecal movement. However, it has been withdrawn from US markets because it may cause lethal irregular heartbeats.

Your doctor will treat any underlying diseases (intestinal obstruction, anal fissure, hemorrhoids, and bowel cancer).

• If you have irritable bowel syndrome, you should stop smoking and avoid coffee and milk-containing foods. A food diary may help to identify foods that seem to worsen symptoms.
  
  
• Thyroxin will be prescribed if the doctor determines through clinical and laboratory tests that you have an underactive thyroid gland (hypothyroidism).

|Other Therapy|

Aloe juice or aloe latex have been used as a laxative, but should not be confused with aloe vera gel used for wound healing or sunburn. The FDA rules that aloe is not safe as a stimulant laxative. Rhubarb or any tonics containing it are also not proven safe as a laxative.

NOTE: If you choose to use remedies involving homeopathy, herbs, dietary and nutritional supplements, acupressure, aromatherapy, and other alternative or complementary healing methods, be advised that these products and techniques have usually not been scientifically proven to diagnose, treat, prevent, or cure any disease. Serious interactions with prescription and nonprescription medications are always a possibility. Keep your doctor informed about every medication or medicine-like substance you use and seek medical advice for your health concerns before taking any medication or remedy.

|Follow-up|

• If you have specific disorders such as hypothyroidism, scleroderma, and lupus, you may require regular follow-ups with your health care provider.
  
  
• Elderly people with a history of fecal impaction and fecal incontinence should be followed regularly to ensure that they do not develop further attacks.
  
  
• Young people with anorexia nervosa need a team of specialists to assess and follow the underlying illness, as well as to provide support and education.

|Prevention|

• Develop regular bowel habits. Set aside time after breakfast to visit the toilet.
  
  
• Do not ignore the desire to defecate. Answer nature’s call to empty your bowel as soon as possible.
  
  
• Eat a well-balanced diet that includes wheat grains, fresh fruits, and vegetables. Recent evidence suggests that increasing dietary fiber intake may help some people with hard stools but is not necessarily of benefit to every person with constipation.
  
  
• Drink plenty of water and fruit juice.
  
  
• Exercise regularly. Walking is especially important.
  
  
• Avoid intake of medications that may cause constipation. Your doctor will help you in this regard.
  
  
• The use of laxatives can actively make a constipation problem worse in the long run and should be avoided.

|Outlook|

Most people with constipation have no physical disease of the digestive system nor any widespread disease associated with constipation. Most of the time, constipation is related to poor dietary habits, low fluid intake, and lack of exercise.

• For people with constipation caused by illness, recovery will be determined by how sick you are.
  
  
• You will usually recover well if your constipation is caused by hemorrhoids or anal fissures.

|Web Links|

National Digestive Diseases Information Clearinghouse, Why Am I Constipated?

National Institute on Aging, AgePage, Constipation

University of Iowa, Virtual Hospital, Constipation: A Guide for Patients

constipation, hard stools, straining with defecation, infrequent bowel opening, impaction, laxative, bowel movement, BM, bowel, elimination of stool, poor bowel habits, fiber, diarrhea, colonoscopy, sigmoidoscopy, acute constipation, chronic constipation, abdominal pain, constipation in adults

Author: Samy A Azer, MD, PhD, Associate Chair, Senior Lecturer, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia.

Editors: Steven C Gabaeff, MD, FAAEM, Attending Physician, Emergency Medicine, Sutter Amador Hospital, Jackson, CA; Expert Consultant, Medical Board of California, Sacramento, CA; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Steven L Bernstein, MD, Vice-Chair, Academic Affairs, Department of Emergency Medicine, Newark Beth Israel Medical Center; Assistant Professor, Department of Emergency Medicine, Mt Sinai School of Medicine.