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Constipation by Rosalyn Carson-DeWitt, MD

Definition

Constipation is infrequent and/or uncomfortable bowel movements. Stool is often hard and dry. This is a very common gastrointestinal complaint.

Causes

Constipation has many causes, including:

Not enough fluid intake
Overuse of laxative medicines
Too little exercise
Bed rest
Certain medicines, including:
- Pain relievers
- Narcotics
- Aluminum-containing antacids
- Antidepressant and antipsychotic medicines
- Medicines for epilepsy and Parkinson's disease
- Antispasmodic medicines
- Tranquilizers
- Iron supplements
- Calcium channel blockers
Frequently delaying the need to have a bowel movement
Pregnancy
Diabetes
Spasm of the anal sphincter; due to painful anal fissures or hemorrhoids
Underactive thyroid
Irritable bowel syndrome (periods of constipation may alternate with episodes of diarrhea)
Neurological diseases such as:
- Parkinson's disease
- Multiple sclerosis
- Stroke
- Spinal cord injuries or tumors
Scleroderma
Systemic lupus erythematosus
Intestinal disorders, including:
- Scarring
- Tumors
- Cancer
- Inflammation
Travel (due to schedule changes, stress, and poor diet)

Risk Factors

Risk factors include:

Advancing age
Sedentary lifestyle
Prolonged bed rest due to surgery or an accident
Diet that is high in fat and sugar and low in fiber

Symptoms

Symptoms include:

Abdominal pain
Sensation of abdominal fullness
Rectal pain and pressure
Difficulty passing stool, despite straining
Hard, dry, small stool
Black stool
"Rabbit pellet" appearance to stool
Sensation of retained stool after defecating

When Should I Call My Doctor?

Call your doctor if you:

Are constipated and never had this condition before
Have constipation that lasts longer than 2-3 weeks
Have a painful or swollen abdomen
Have nausea or vomiting
Have signs of an infection, such as fever or chills
Have pain or burning in anal area with or without bowel movement
Have blood in your stool or black stool
Think that your prescription medicine is causing constipation
Are losing weight

Diagnosis

Changes in bowel habits, such as constipation, may indicate a more serious condition. Your doctor may order tests to rule out other conditions. Tests may include:

Physical exam
Blood tests
Digital rectal exam—examination of the rectum with the doctor's gloved, lubricated finger inserted into your rectum
Abdominal x-ray—a test that uses radiation to take a picture of structures inside the abdomen
Barium enema—injection of fluid into the rectum that makes your colon light up on an x-ray
Flexible sigmoidoscopy—a thin, lighted tube with a camera inserted into the rectum to examine the rectum and the lower colon

Barium Enema

Treatment

Treatment may include:

Understanding Normal Bowel Movements

Talk to your doctor about what is a normal frequency of bowel movements for you. The range of normal is quite broad. Some people have several stools a day. Others have one stool every several days.

Making Lifestyle Changes

Eat a healthy, balanced diet that is high in fiber (such as unprocessed bran, whole-wheat grains, fresh fruit, and cereals). Eating prunes every day may also improve bowel movements.
Limit your intake of processed and fatty foods.
Exercise regularly.
Drink at least eight, 8-ounce glasses of water each day.

Taking Laxatives, Stool Softeners, or Glycerin Suppositories

Regularly using laxatives or enemas can be habit forming. Your bowels can become accustomed to these products and require them in order to produce a stool. Stool softeners, though, are not habit-forming. Ask your doctor about how often and for how long to use these products.

Examples of medicines include:

Polyethylene glycol 3350 (GlycoLax, MiraLax)—a type of laxative
Psyllium—a bulk laxative
Docusate—a stool softener
Lactulose—a type of laxative
Lubiprostone (Amitiza)—a medicine that increases fluid in stool
Botulism injections—may be used to treat certain types of constipation

Retraining Your Bowels

Set aside the same time each day to move your bowels. Typically, this works best after breakfast and coffee. Sit on the toilet for 15-20 minutes. Over time, your body will learn to have regular bowel movements at the same time each day.

Using Biofeedback

Biofeedback works by attaching sensors to the body. These sensors give you information about your muscles. By working with a therapist, you learn how to control certain muscles that can help you to move your bowels.

Treating Underlying Conditions

Work with your doctor to treat other conditions that may be causing your constipation.

Changing Medications

If you are taking medicine that causes constipation, talk to your doctor to find out if you can take another drug.

If you are taking opioids to relieve pain, you may have constipation. A medicine called methylnaltrexone (Relistor) may help to reduce this side effect.

Having Surgery

If you have severe, chronic constipation, your doctor may recommend surgery.

If you are diagnosed with constipation, follow your doctor's instructions.

Prevention

To reduce your chance of getting constipation:

Eat a healthy, balanced diet that is high in fiber.
Exercise regularly.
Drink at least eight, 8-ounce glasses of water a day.
In an effort to train your bowels, schedule a time daily to sit on the toilet just after a meal.
Do not rush yourself when using the bathroom.
If you feel the urge to move your bowels, do not ignore this feeling. Go to the bathroom right away.

RESOURCES:

American Gastroenterological Association http://www.gastro.org
National Institute of Diabetes and Digestive and Kidney Diseases http://www.niddk.nih.gov

CANADIAN RESOURCES:

Health Canada http://www.hc-sc.gc.ca
Healthy U http://www.healthyalberta.com

References:

Botox, not just for wrinkles. Johns Hopkins Health Alerts website. Available at: http://www.johnshopkinshealthalerts.com/alerts/digestive_health/JohnsHopkinsHealthAlertsDigestiveDisorders_2898-1.html. Published January 2009. Accessed July 9, 2009.
Camilleri M, Kerstens R, Rykx A, Vandeplassche L. A placebo-controlled trial of prucalopride for severe chronic constipation. N Engl J Med. 2008;358(22):2344-2354.
Cephulac. Drugs.com website. Available at: http://www.drugs.com/mtm/cephulac.html. Updated March 2008. Accessed July 9, 2009.
Cisapride. Mayo Clinic website. Available at: http://www.mayoclinic.com/health/drug-information/DR600429. Updated June 2009. Accessed July 9, 2009.
Constipation. AGA Patient Center, American Gastroenterological Association website. Available at: http://www.gastro.org/wmspage.cfm?parm1=687. Updated April 2008. Accessed July 9, 2009.
Constipation. Family Doctor.org website. Available at: http://familydoctor.org/familydoctor/en/diseases-conditions/constipation.printerview.all.html. Updated July 2010. Accessed January 12, 2012.
Constipation. National Digestive Diseases Information Clearinghouse website. Available at: http://digestive.niddk.nih.gov/ddiseases/pubs/constipation/. Updated July 2007. Accessed January 31, 2012.
Constipation. National Institute of Diabetes and Digestive and Kidney Diseases website. Available at: http://digestive.niddk.nih.gov/ddiseases/pubs/constipation/. Published July 2007. Accessed July 9, 2009.
Goroll AH, Mulley AG. Primary Care Medicine. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2000.
Professional Guide to Diseases. 9th ed. Ambler, PA: Lippincott Williams & Wilkins; 2009.
Treatment of constipation. International Foundation for Functional Gastrointestinal Disorders website. Available at: http://www.aboutconstipation.org/site/about-constipation/treatment. Updated May 2009. Accessed July 9, 2009.
What I need to know about constipation. National Institute of Diabetes and Digestive and Kidney Diseases website. Available at: http://digestive.niddk.nih.gov/ddiseases/pubs/constipation_ez. Published December 2008. Accessed July 9, 2009.
6/25/2008 DynaMed Systematic Literature Surveillance https://dynamed.ebscohost.com/about/about-us: Thomas J, Karver S, Cooney GA, et al. Methylnaltrexone for opioid-induced constipation in advanced illness. N Engl J Med. 2008;358:2332-2343.
11/30/2010 DynaMed's Systematic Literature Surveillance https://dynamed.ebscohost.com/about/about-us: Arebi N, Kalli T, Howson W, Clark S, Norton C. Systematic review of abdominal surgery for chronic idiopathic constipation. Colorectal Dis. 2010 Oct 22. [Epub ahead of print]
6/20/2011 DynaMed's Systematic Literature Surveillance https://dynamed.ebscohost.com/about/about-us: Attaluri A, Donahoe R, Valestin J, Brown K, Rao SS. Randomised clinical trial: dried plums (prunes) vs. psyllium for constipation. Aliment Pharmacol Ther. 2011;33(7):822-828.

Last reviewed October 2012 by Daus Mahnke, MD

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