This information is intended only to provide general guidance. It does not provide definitive medical advice. It is important that you consult your doctor about your specific condition.
What is constipation?
Constipation is unsatisfactory bowel movements (defecation), which may be not frequent enough, difficult to evacuate, uncomfortably hard and small, or with the sensation of not completely emptying the bowels. It is not necessary to defecate every day, as long as you are not uncomfortable on the days without defecation. However, defecation less than 3 times per week is abnormal and should be corrected. It is not uncommon to have occasional, brief periods of constipation. Constipation lasting more than 2 weeks should cause you to see your doctor. Also, any change in bowel habits should be reported to your doctor. Gastroenterologists such as Dr. Albert Harary, M.D., whose office is in New York City, specialize in evaluating and treating problems with the intestine such as constipation.
What happens during a bowel movement?
The colon, or large intestine, is the lower part of the intestine. It is a hollow muscular tube. When partially digested liquid food passes from the small intestine into the colon, the material is slowly moved by the muscular activity (peristalsis) of the colon over several days. By absorbing water and any remaining nutrients from this material, the colon changes waste from liquid to a solid material called stool. The rectum is the lowermost part of the colon, and it stores the stool prior to a bowel movement. When the rectum becomes full enough with stool, there is an urge to defecate. The anus, which is the opening through which stool exits the body, is a muscular valve that needs to relax in order for the bowel movement to occur.
What causes constipation?
Constipation occurs when the stool (waste) moves too slowly throughout the colon, too much water is absorbed from the stool, and it becomes hard, dry, and difficult to evacuate. Slow transit of stools through the colon can be caused by dehydration, not enough fiber in the diet, not enough physical activity and exercise, certain medications (especially narcotics, some antidepressants, birth control pills, and iron pills), faulty function of the nerves and muscles of the colon, irritable bowel syndrome, depression, stress, hormonal conditions such as an underactive thyroid (hypothyroidism), pregnancy, blockage of the colon, and neurologic conditions such as stroke, Parkinson's disease, and multiple sclerosis.
In addition to slow transit, constipation can also result from repeatedly ignoring the urge to defecate, so the rectum no longer senses being filled with stool, or from a failure to relax the anus to allow the stool to exit.
What can you do to prevent to treat constipation?
- High fiber diet: Fruits, vegetables, and whole grains.
- Fruits, especially solid, round fruits such as apples, pears, peaches, plums, and prunes.
- Vegetables, especially beans, peas, carrots, peppers, broccoli, artichoke, kale, cauliflower, eggplant, and squash.
- Whole grains, including whole wheat bread, brown rice, and bran.
- Cereal containing at least 5 grams of fiber per serving (read the information on the box).
- Drink enough fluids: 6-8 glasses of water or other fluids (not counting caffeinated coffee or alcohol) every day (unless your doctor has restricted your fluid intake)
- Get enough exercise.
- Over-the-counter (nonprescription) stool softeners such as docusate (Colace, etc.) may be helpful for constipation.
- Fiber supplements, such as psyllium (Metamucil, Konsyl, etc.), FiberCon, or Benefiber, may be helpful if the dietary fiber intake is not enough to control the constipation.
- Herbal laxatives containing senna (teas, pills), should not be used regularly, but can be used occasionally.
- Milk of Magnesia (2-3 tablespoons) or Dulcolax (1-3 tablets) can be used on an as-needed basis, when there has been no bowel movement for 1-1/2 to 2 days or more, but should only be taken regularly under a doctor’s supervision.
- Enemas, such as Fleet enemas or tap water enemas, can be used occasionally but should not be taken every day.
- Suppositories, which are pills or capsules inserted into the rectum, may contain glycerin or bisacodyl (Dulcolax). They can quickly stimulate a bowel movement. They should not be used every day.
How does your doctor treat constipation?
Dr. Albert Harary, M.D., in his New York City office, will first make sure that you are following the good digestive habits listed above. If these are not sufficient to correct your constipation, he may prescribe one or more of the following medications:
- Linzess, or linaclotide, a pill that promotes the transfer of fluid from the bloodstream to the colon and therefore stimulates comfortable bowel movements and relieves constipation. It is a safe medication, but if it works too well, linaclotide (Linzess) can cause diarrhea. It should be taken about 1 hour before a meal once every day.
- Amitiza (lubiprostone), which also promotes the transfer of fluid into the colon, stimulating bowel movements and relieving constipation. It is taken with food and water twice a day.
- Polyethylene glycol (MiraLax) causes the medicated glass of liquid you drink to be retained in the intestine, therefore promoting bowel movements and relieving constipation. It is available without a prescription. It comes as a powder in a jar that is filled up to the mark in the cap and then dissolved in an 8-ounce glass of water. It produces a clear solution that is usually taken on a daily basis to maintain regular bowel movements.
- Naloxegol (Movantik) and methylnaltrexone (Relistor) are prescription medications used to treat constipation caused by narcotic (opiate) pain relievers.
- Lactulose (Cephulac) and sorbitol are osmotic laxatives, which are thick liquids that draw fluid into the colon and thereby relieve constipation. The dose can be adjusted from 1 to 6 tablespoons per day. Lactulose (Cephulac) and sorbitol are often effective but may cause excessive flatulence (gas), bloating, and abdominal distention.
If you are found to have a problem with the relaxation or coordination of the muscles of the rectum and anus, you may benefit from biofeedback therapy, in which a small probe is placed in the anus that allows you to observe on a video screen the contraction of the muscles of the anus and pelvis. By doing this repeatedly, you can learn to appropriately relax these muscles when you need to defecate. This treatment can also be used for fecal incontinence. Several months of training, with practice at home, may be necessary to succeed with biofeedback therapy. This treatment is usually provided by pelvic floor physical therapists or specialists in the office of a rectal surgeon.
What are the complications of constipation?
Hemorrhoids are inflamed or swollen veins in the anus that can bleed (on the toilet paper or toilet water or stool), itch, protrude, or hurt during or after a bowel movement. They can be treated by improving constipation, avoiding straining or spending too much time on the toilet, using special soothing creams or suppositories, avoiding alcohol and spicy foods, and taking warm baths. If these are not sufficient, you should see your doctor. If you have bleeding, you should see your doctor to make sure you do not have a more serious condition causing the bleeding.
Anal fissures are small cracks or tears in the lining of the anus that may cause bleeding or pain during defecation. They can be prevented by relieving constipation and avoiding hard stools that can injure the anus. They often require a prescription for a cream to place in the anus or even minor surgery.
Fecal impactions are large collections of stool in the rectum that overfill and stretch the rectum and cannot be easily evacuated. They cause either pain or pressure in the rectum. Sometimes diarrhea or incontinence can result from the increased pressure in the intestine above the impaction. These need to be treated by a vigorous program of laxatives and enemas as prescribed by a doctor and sometimes need to be mechanically dislodged by the doctor.
Rectal prolapse is protrusion of the wall of the rectum through the opening of the anus. It is caused by excessive straining or severe coughing. There may be weakness of the muscles of the pelvic floor around the rectum. It can cause a mucus or bloody discharge, pain, or irritation. Avoiding straining to defecate can help, but surgical treatment sometimes becomes necessary.