Constipation is difficult or infrequent bowel movements, hard stool, or a feeling that the rectum is not totally empty after a bowel movement (incomplete evacuation). (See also Constipation in Children.)
Constipation may be acute or chronic. Acute constipation begins suddenly and noticeably. Chronic constipation may begin gradually and persists for months or years.
Many people believe they are constipated if they do not have a bowel movement every day. However, daily bowel movements are not normal for everyone. It is normal to have anywhere from 1 to 3 bowel movements per day to 2 to 3 bowel movements per week. Having infrequent bowel movements does not necessarily indicate a problem unless there has been a substantial change from previous patterns. The same is true of the color, size, and consistency of stool. People often blame constipation for many symptoms (such as abdominal discomfort, nausea, fatigue, and poor appetite) that are actually the result of other disorders (such as irritable bowel syndrome [IBS] and depression). People should not expect all symptoms to be relieved by a daily bowel movement, and measures to aid bowel habits, such as laxatives and enemas, should not be overused. However, people may harmlessly help relieve their symptoms by eating more fruits, vegetables, fiber, and cereals. Foods that can affect the frequency of bowel movements are listed in table Foods That Often Affect Gastrointestinal Function.
Complications
The complications of constipation include
Fecal impaction
Excessive straining during bowel movements increases pressure on the veins around the anus and can lead to hemorrhoids and, rarely, protrusion of the rectum through the anus (rectal prolapse). Passing hard stool can cause a split in the skin of the anus (anal fissure). Each of these complications can make having a bowel movement uncomfortable and make people reluctant to move their bowels. Putting off bowel movements can cause a vicious circle of worsening constipation and complications.
Diverticular disease can develop if the walls of the large intestine are damaged by the increased pressure required to move small, hard stools. Damage to the walls of the large intestine leads to the formation of balloon-like sacs or outpocketings (diverticula), which can become inflamed (diverticulitis). Diverticula sometimes bleed and rarely rupture (causing peritonitis).
Fecal impaction, in which stool in the rectum and last part of the large intestine hardens and completely blocks the passage of other stool, sometimes develops in people with constipation. Fecal impaction leads to cramps, rectal pain, and strong but futile efforts to defecate. Sometimes, watery mucus or liquid stool oozes around the blockage, which gives the false impression of diarrhea (overflow diarrhea). Fecal impaction is especially common among older people, particularly those who are bedridden or have decreased physical activity, pregnant women, and people who have been given barium by mouth or as an enema for certain types of x-ray tests.
Overconcern with regular bowel movements causes many people to abuse their bowels with laxatives, suppositories, and enemas. Overusing these treatments can actually inhibit the bowel’s normal contractions and worsen constipation. People with obsessive-compulsive disorder (OCD) often feel the need to rid their body daily of “unclean” wastes or "toxins." Such people often spend excessive time on the toilet or become chronic users of laxatives.
Causes of Constipation
The most common causes of constipation include
Changes in diet (such as decreased fluid intake, low-fiber diet, and/or constipating foods)
Drugs that slow the bowels
Disordered defecation
Constipation-predominant irritable bowel syndrome (IBS)
Laxative overuse
Dietary causes are very common. Dehydration causes constipation because the body tries to conserve water in the blood by removing additional water from the stool. Stool that contains less water is harder to pass. Fruits, vegetables, cereals, and other fiber-containing foods are the natural laxatives of the digestive tract. People who do not eat enough of these foods can become constipated. Lack of fiber (the indigestible part of food) in the diet can lead to constipation because fiber helps hold water in the stool and increases its bulk, making it easier to pass.
The most common drugs that can slow the bowels include opioids, iron salts, and drugs with anticholinergic effects (such as many antihistamines and tricyclic antidepressants—see sidebar Anticholinergic: What Does It Mean?
Disordered defecation (dyschezia) refers to a problem with the bowels generating enough force to propel stool from the rectum and/or difficulty relaxing the muscle fibers around the rectum and the external anal sphincter during defecation. People with dyschezia sense the need to have a bowel movement but cannot. Even stool that is not hard may be difficult to pass. People with IBS may have IBS-disordered defecation.
People with IBS may have loose stools, disordered defecation, or constipation. If IBS is usually accompanied by constipation, it is called constipation-predominant IBS.
People who frequently use laxatives and/or enemas often lose the ability to move their bowels without such aids. A vicious circle can result with constipation leading to more laxative use and thus more constipation.
Less common causes of constipation include specific medical disorders ( see Table: Some Causes and Features of Constipation), such as intestinal obstruction, and certain metabolic disorders and neurologic disorders. Constipation also can occur during any major illness that requires prolonged bed rest (because physical activity helps the intestines move stool along), with decreased food intake, with use of drugs that can cause constipation, and after a head or spinal cord injury. In many cases, however, the cause of constipation is unknown.
Constipation is sometimes caused by obstruction of the large intestine. Obstruction can be caused by a cancer, especially in the last portion of the large intestine, that blocks the movement of stool. People who previously had abdominal surgery may develop obstruction, usually of the small intestine, because bands of fibrous tissues (adhesions) can form around the intestines and impede the flow of stool.
Disorders and diseases that often cause constipation include an underactive thyroid gland (hypothyroidism), high blood calcium levels (hypercalcemia), and Parkinson disease. People with diabetes often develop nerve damage (neuropathy). If the neuropathy affects nerves to the digestive tract, the intestines may slow down, resulting in constipation. Spinal cord injury can also interfere with the nerves to the intestines and cause constipation.
Evaluation of Constipation
Not every episode of constipation requires immediate evaluation by a doctor. The following information can help people decide whether a doctor’s evaluation is needed and help them know what to expect during the evaluation.
Warning signs
In people with constipation, certain symptoms and characteristics are cause for concern. They include
Distended, swollen abdomen
Vomiting
Blood in stool
Weight loss
New/worsening severe constipation in older people
When to see a doctor
People who have warning signs should see a doctor right away, unless the only warning signs are weight loss and/or new constipation in older people. In such cases, a delay of a few days to a week is not harmful.
People who have constipation but no warning signs should call their doctor, who can help decide how quickly they need to be seen. Depending on the person's other symptoms and known disorders, doctors may wish to see the person within a few days or may simply recommend trying changes in diet and/or a mild laxative.
What the doctor does
Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the constipation and the tests that may need to be done ( see Table: Some Causes and Features of Constipation).
During the history, doctors ask about the following:
Stool frequency, consistency, and the need to strain or use maneuvers (such as pushing on the area between the scrotum or vagina and the anus [perineum] during defecation)
Feeling of incomplete evacuation
Satisfaction after defecation, including how often and how long people have used laxatives or enemas
Diet and physical activity level, particularly any change in these factors
Prescription and nonprescription drug use (particularly those known to cause constipation)
Doctors also ask about symptoms of metabolic (such as hypothyroidism and diabetes) and neurologic (such as spinal cord injury) disorders.
During the physical examination, doctors look at the following:
Signs of bodywide (systemic) disease, including weight loss, fever, and severe wasting away of muscle and fat tissue (cachexia)
The abdomen for distention and masses
The rectum for fissures, hemorrhoids, blood, or masses (including fecal impaction) and also anal muscle tone and sensation
Testing
The need for tests depends on what doctors find during the history and physical examination, particularly whether warning signs are present. When the cause of the constipation is clear (such as due to drugs, injury, or bed rest), doctors often treat the person’s symptoms and do no testing.
People with symptoms of intestinal obstruction undergo abdominal x-rays and possibly a computed tomography (CT) scan. Most people with no clear cause or whose symptoms have not been relieved with treatment should have tests. Typically, doctors do a colonoscopy (to detect cancer) and blood tests to check for an underactive thyroid gland (hypothyroidism) or high calcium levels in the blood (hypercalcemia).
People whose initial test results are normal but whose symptoms are not relieved with treatment usually require further testing. If the main symptom is difficulty with defecation, doctors measure the pressure inside the anus and rectum (called anorectal manometry). If the main symptom is infrequent defecation, doctors measure how long it takes stool to leave the intestines by having people swallow small, slightly radioactive objects that can be tracked using a scanner (a type of radionuclide scanning) or swallow a wireless motility capsule that is tracked over a 4-day period.
Treatment of Constipation
Any underlying disorder causing constipation must be treated. When possible, drugs that cause constipation are stopped or changed.
Constipation is best prevented with a combination of exercise, a high-fiber diet, and an adequate intake of fluids. When a potentially constipating drug is prescribed and/or people are placed on bed rest, doctors often give a laxative and recommend increased intake of dietary fiber and fluids rather than waiting for constipation to develop.
There are three approaches to treating people with constipation:
Diet and behavior
Laxatives
Enemas
Doctors are cautious with use of laxatives, suppositories, and enemas because they can cause diarrhea, dehydration, cramps, and/or dependence on laxatives. People with sudden abdominal pain of unknown cause, inflammatory bowel disorders, intestinal obstruction, gastrointestinal bleeding, or fecal impaction should not use laxatives or enemas.
Diet and behavior
People need to ingest enough fiber in their diet (typically 15 to 20 grams per day) to ensure adequate stool bulk. Vegetables, fruits, and bran are excellent sources of fiber. Many people find it convenient to sprinkle 2 or 3 teaspoons of unrefined miller’s bran on high-fiber cereal or fruit 2 or 3 times a day. To work well, fiber must be consumed with plenty of fluids.
Doctors explain to people why diet and behavior modification are important in treating constipation. Doctors also explain that daily bowel movements are not necessary, that the bowel must be given a chance to function, and that frequent use of laxatives or enemas (more than once every 3 days) denies the bowel that chance. People who have obsessive-compulsive disorder (OCD) are treated for that disorder.
People who have dyssynergic defecation may need to see specialized therapists for biofeedback training.
Laxatives
Some laxatives are safe for long-term use. Other laxatives should be used only occasionally. Some laxatives are good for preventing constipation, others for treating it. There are several classes of laxatives, including the following:
Bulking agents
Stool softeners
Osmotic agents
Stimulants
Mu-opioid receptors
Bulking agents,
Stool softeners,
Osmotic agents
Stimulant laxatives
Taken by mouth, stimulant laxatives usually cause a semisolid bowel movement in 6 to 8 hours, but they often cause cramping as well. As suppositories, stimulant laxatives often work in 15 to 60 minutes. Prolonged use of stimulant laxatives can create abnormal deposits of a dark pigment in the lining of the large intestine (a condition called melanosis coli). Other side effects include allergic reactions and loss of electrolytes from the blood. Also, the large intestine can become dependent on stimulant laxatives, leading to lazy bowel syndrome. Therefore, stimulant laxatives should be used only for brief periods.
Mu-opioid receptor antagonists
Enemas
Enemas mechanically flush stool from the rectum and lower part of the large intestine. Small-volume enemas can be purchased in squeeze bottles at a pharmacy. They can also be given with a reusable squeeze-ball device. However, small-volume enemas are often inadequate, especially for older people, whose rectal capacity increases with age, thus making the rectum more easily stretched. Larger-volume enemas are given with an enema bag.
Plain water is often the best fluid to be used as an enema. The water should be room temperature to slightly warm, not hot or cold. About 5 to 10 fluid ounces (150 to 300 milliliters) is gently directed into the rectum. (CAUTION: Too much force is dangerous.) People then expel the water, washing stool out with it.
Very large-volume enemas, called colonic enemas, are rarely used in medical practice. Doctors use colonic enemas in people with very severe constipation (obstipation). Some practitioners of alternative medicine use colonic enemas in the belief that cleansing the large intestine is beneficial. Tea, coffee, and other substances are often added to colonic enemas but have no proven health value and may be dangerous.
Fecal impaction
Essentials for Older People
The rectum enlarges as people age, and increased storage of stool in the rectum means that older people often need to have larger volumes of stool in their rectum in order to feel the urge to defecate. The increased rectal volume also allows hard stool to become impacted.
Other common factors in older people that lead to constipation include increased use of constipating drugs, a low-fiber diet, coexisting medical conditions (such as diabetes and an underactive thyroid), and reduced physical activity. Many older people also have misconceptions about normal bowel habits and use laxatives too often.
Key Points
Drug causes (such as use of anticholinergic or opioid drugs) are common.
Doctors look for intestinal obstruction when constipation is sudden and severe.
Symptoms may be treated if no warning signs are found and doctors find no evidence of disordered defecation.
