Constipation

Overview

Constipation is a problem with passing stool. Constipation generally means passing fewer than three stools a week or having a difficult time passing stool.

Constipation is fairly common. A lack of dietary fiber, fluids and exercise can cause constipation. But other medical conditions or certain medicines may be the cause.

Constipation is usually treated with changes in diet and exercise or with nonprescription medicines. Constipation may require medicines, changes in medicines or other treatments prescribed by a health care professional.

Long-term constipation, also called chronic constipation, may require treating another disease or condition that can cause or worsen constipation.

Symptoms

Symptoms of constipation include:

• Fewer than three stools a week.
• Hard, dry or lumpy stools.
• Straining or pain when passing stools.
• A feeling that not all stool has passed.
• A feeling that the rectum is blocked.
• The need to use a finger to pass stool.

Chronic constipation is having two or more of these symptoms for three months or longer.

When to see a doctor

Make an appointment with your health care professional if you have constipation with any of the following conditions:

• Symptoms that last longer than three weeks.
• Symptoms that make it difficult to do everyday activities.
• Bleeding from your rectum or blood on toilet tissue.
• Blood in your stools or black stools.
• Other unusual changes in the shape or color of stools.
• Stomach pain that doesn't stop.
• Weight loss without trying.

Causes

Patterns of bowel movements vary from one person to another. The typical range is three times a day to three times a week. So it's important to know what is typical for you.

In general, constipation occurs when stool moves too slowly through the large intestine, also called the colon. If the stool moves slowly, the body absorbs too much water from the stool. The stool can become hard, dry and difficult to pass.

Lifestyle causes

Slow stool movement may happen when a person does not:

• Drink enough fluids.
• Eat enough dietary fiber.
• Exercise regularly.
• Use the toilet when there's an urge to pass stool.

Medicines

Constipation may be a side effect of some medicines, particularly opioid pain relievers. Other medicines that may cause constipation include some that treat the following conditions:

• Pain.
• High blood pressure.
• Seizures.
• Depression.
• Disorders of the nervous system.
• Allergies.

Problems with pelvic floor muscles

The muscles that hold up organs at the bottom of the torso are called the pelvic floor muscles. The ability both to relax these muscles and to bear down are necessary to pass stool from the rectum. Problems with weakness or coordination of these muscles can cause chronic constipation.

Blockages in the colon or rectum

Damage or changes to tissues in the colon or rectum can block the passage of stool. Also, tumors in the colon, rectum or nearby tissues can cause a blockage.

Other factors

A number of conditions can affect the work of muscles, nerves or hormones involved in passing stool. Chronic constipation may be linked to any number of things, including:

• Irritable bowel syndrome.
• Diabetes.
• Multiple sclerosis.
• Nerve dysfunction or damage.
• Overactive thyroid, also called hyperthyroidism.
• Parkinson's disease.
• Pregnancy.

Sometimes, the cause of chronic constipation can't be found.

Risk factors

Factors that may increase your risk of chronic constipation include:

• Being an older adult
• Being a woman
• Getting little or no physical activity
• Having a mental health condition such as depression or an eating disorder

Complications

Complications of chronic constipation include:

• Swollen tissues around the anus, also called hemorrhoids.
• Torn tissues of the anus, also called anal fissures.
• Hard stools backed up into the colon, also called fecal impaction.
• Exposed tissues of the rectum that have slipped out of the anal opening, also called rectal prolapse.

Prevention

The following tips can help you avoid developing constipation.

• Eat lots of high-fiber foods, including vegetables, fruits, beans and whole-grain foods.
• Eat fewer foods with low amounts of fiber such as processed foods, dairy and meats.
• Drink plenty of fluids.
• Stay active and exercise regularly.
• Don't ignore the urge to pass stool.
• Create a regular schedule for passing stool, especially after a meal.

Diagnosis

In addition to giving you a general physical exam, your health care professional will likely do the following during your appointment:

• Gently press on your abdomen to check for pain, tenderness or irregular lumps.
• Look at the tissue of the anus and the surrounding skin.
• Use a gloved finger to check the condition of the rectum and the muscles of the anus.

You'll also be asked questions about your medical history, diet, exercise habits and stools. For some people, the information from this appointment may be enough for a diagnosis and treatment plan.

For other people, one or more additional tests may be needed to help the health care team understand the nature or cause of constipation.

Laboratory tests

Your health care professional may send samples of your blood to a lab to test for diseases or conditions that can cause constipation.

Endoscopy

Your health care professional may order a procedure called an endoscopy. A small tube with a camera is guided into the colon. This can reveal the condition of the colon or the presence of irregular tissues. Before this procedure, you may have a limited diet, use an enema or drink solutions that clean out your colon. There are generally two types of tests:

• A colonoscopy is an exam of the rectum and entire colon.
• A sigmoidoscopy is an exam of the rectum and the lower part of the colon, also called the sigmoid or descending colon.

Imaging tests

Depending on your symptoms, your health care professional may order X-ray imaging. An X-ray can show where stool is present in the colon and if the colon is blocked. Imaging tests, such as a CT scan or MRI, may be needed to diagnose conditions that may be causing constipation.

Tests of stool movement

Your health care professional may order a test that tracks the movement of stool through the colon. This is called a colorectal transit study. Such studies include:

• Radiopaque marker study. This X-ray procedure shows how far tiny pellets from a pill have moved through the colon over a period of time.
• Scintigraphy. This study involves eating a meal with tiny radioactive substances that are tracked with special technology as they move through the colon.

Tests of the rectum and anus

Other tests may be used to measure how well the rectum and anus work and how well a person can pass stool.

• Anorectal manometry. A narrow, flexible tube is inserted into the anus and rectum. After a small balloonlike device is inflated, it is pulled back out the anus. The procedure measures the coordination of the muscles used to pass stool.
• Balloon expulsion test. This test measures the amount of time it takes to push out a small, water-filled balloon in the rectum. This provides information on how well muscles work or are controlled.
• Defecography. This test is designed to mimic passing stool. A thick substance that can be tracked with imaging technology is placed in the rectum. X-ray or MRI images can reveal information about how well the rectum and anus work when the substance is passed like stool.

Treatment

Treatment for constipation usually begins with diet and lifestyle changes meant to increase the speed at which stool moves through the colon. Also, your health care professional may change the medicines you take if they may be causing or worsening constipation. If those changes don't help, other treatments may be necessary.

Diet and lifestyle changes

Your doctor may recommend the following changes to relieve your constipation:

• Eat a high-fiber diet. Fiber adds bulk to stool and helps the stool hold fluids. These factors give stool the right shape and weight to move through the colon. Fiber-rich foods include fruits, vegetables, beans, and whole-grain bread, cereal and rice. Increase dietary fiber slowly to prevent bloating and gas. The Dietary Guidelines for Americans recommend 25 to 34 grams of fiber a day depending on recommended daily calories.
• Drink plenty of water. Drink water and beverages without caffeine. This keeps stools soft and prevents bloating and gas that can happen with increased dietary fiber.
• Exercise most days of the week. Regular physical activity helps improve the movement of stool through the colon. Try to exercise most days of the week. If you do not already exercise, talk with your health care professional about safe ways to start.
• Use good bowel habits. Don't avoid the urge to pass stool. Keep a schedule for passing stool. For example, try to pass stool 15 to 45 minutes after a meal because digestion helps move stool through the colon.

Prunes, also called dried plums, have long been used to treat or prevent constipation. Prunes are a good source of fiber, but they also have naturally present agents that draw fluids into the colon.

Laxatives

Laxatives are medicines that help move stool through the colon. Each laxative works somewhat differently. The following are available without prescriptions:

• Fiber supplements. Fiber supplements help stool retain fluids. The stool is then softer and easier to pass. Fiber supplements include psyllium (Metamucil, Konsyl, others), calcium polycarbophil (FiberCon, Equalactin, others) and methylcellulose (Citrucel).
• Osmotics. Osmotic laxatives help stool move through the colon by increasing the amount of fluids released into the intestine. Examples include oral magnesium hydroxide (Phillips' Milk of Magnesia, Dulcolax Liquid, others), magnesium citrate, lactulose (Generlac) and polyethylene glycol (Miralax).
• Stimulants. Stimulants cause the walls of the intestine to tighten, forcing the movement of stool. These include bisacodyl (Correctol, Dulcolax Laxative, others) and sennosides (Senokot, Ex-Lax, Perdiem).
• Lubricants. Lubricants such as mineral oil enable stool to move through the colon more easily.
• Stool softeners. Stool softeners such as docusate sodium (Colace) and docusate calcium allow more fluids to be drawn into the stool.

Enemas and suppositories

An enema is a fluid gently pumped into the rectum to help pass stool. An enema may be used when other treatments don't work. Your health care professional may use one of these if the rectum is blocked with stool. Some are also available without prescription. The fluid may be:

• Tap water.
• Tap water with mild soap.
• Mineral oil.

A suppository is a small tube-shaped object placed in the rectum to deliver a medicine. The suppository melts at body temperature and releases the medicine. Suppositories for constipation may have one of the following:

• Osmotic laxative.
• Stimulant laxative.
• Lubricant laxative.

Prescription medicines

Your health care professional may prescribe other medicines if other treatments don't work. These include:

• Lubiprostone (Amitiza).
• Linaclotide (Linzess).
• Plecanatide (Trulance).
• Prucalopride (Motegrity).

If constipation is caused by opioid pain medicine, you may take a prescription medicine that blocks the effect of opioids on stool movement through the colon. These include:

• Methylnaltrexone (Relistor).
• Naldemedine (Symproic).
• Naloxegol (Movantik).

Pelvic muscle training

Biofeedback training involves working with a therapist who uses devices to help you learn to relax muscles and coordinate the use of muscles in your pelvis, rectum and anus. These exercises may correct problems with chronic constipation.

Sensors in the rectum and on the skin provide feedback as sound or light on a device as the therapist helps you go through various exercises. These cues help train you to control the muscles needed to pass stool.

Surgery

Surgery may be necessary to correct damage or irregularities in the tissues or nerves of the colon or rectum. Surgery is usually done only when other treatments for chronic constipation haven't worked.

Alternative medicine

Researcher are studying the use of probiotics and acupuncture to treat constipation. Further research is needed to understand these options.

Preparing for an appointment

You'll likely first see your doctor or other general health care professional. You may be referred to a specialist in digestive disorders, called a gastroenterologist.

Because appointments can be brief, and because there's often a lot of information to cover, it's a good idea to be well prepared. Here's some information to help you get ready, and what to expect from your doctor.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restricting your diet.
• Write down any symptoms you're experiencing.
• Write down key personal information, including any major stresses or recent life changes, such as traveling or be coming pregnant.
• Make a list of all medications, vitamins, supplements or herbal medications you're taking.
• Take a family member or friend along. Sometimes it can be difficult to remember all the information provided to you during an appointment. Someone who comes with you may remember something that you missed or forgot.
• Write down questions to ask your doctor.

For constipation, some questions you might want to ask your doctor include:

• What's the most likely cause of my symptoms?
• What kinds of tests do I need, and how do I need to prepare for them?
• Am I at risk of complications related to this condition?
• What treatment do you recommend?
• If the first treatment doesn't work, what will we try next?
• Are there any dietary restrictions that I need to follow?
• I have other medical problems. How can I manage these along with constipation?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask other questions during your appointment.

What to expect from your doctor

Your doctor is likely to ask you several questions. Your doctor may ask:

• When did you did you first have symptoms of constipation?
• Have your symptoms been constant or off-and-on?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Do your symptoms include stomach pain?
• Do your symptoms include vomiting?
• Have you recently lost weight without trying?
• How many meals do you eat a day?
• How much liquid, including water, do you drink a day?
• Do you see blood mixed in with the stool, in the toilet water or on the toilet paper?
• Do you strain when passing stool?
• Do you have any family history of digestive problems or colon cancer?
• Have you been diagnosed with any other medical conditions?
• Have you started any new medicines or recently changed the dosage of your current medicine?