Constipation, the most common digestive complaint in the U.S. population, can make life miserable. Not only does constipation make you feel bloated, headachy, and irritable, but relieving constipation -- especially long-term or chronic constipation -- is time consuming and expensive. Each year in the U.S., chronic constipation leads to around 2.5 million doctor visits -- and medication costs of many hundreds of millions of dollars.
Chronic Constipation: What Is It?
The definition of chronic constipation varies among different people. For some people, chronic constipation means infrequent bowel movements for weeks at a time. To others, chronic constipation means straining or having difficulty passing stools. For instance, many describe chronic constipation as feeling like you need to have a bowel movement, but no matter how long you sit, it just won't happen. With chronic constipation, you may have hard or formed stools, small stools, or a combination of infrequent hard, formed or small stools.
Generally, the definition of chronic constipation is a stool frequency of less than three per week that lasts several months. Still, experts believe that many who think they suffer from chronic constipation may actually underestimate the frequency of their bowel habits, so this definition may not be accurate.
Chronic Constipation: What's Normal? What's Not?
If you or a loved one has chronic constipation, much of the anxiety and distress may result from a lack of knowledge about this problem. Not only are there magnified fears about what might be causing the problem, the discomfort of chronic constipation itself can be debilitating. Constipation may slow your performance at work and even cause you to miss recreational activities. That's why it's important to know the facts about chronic constipation and talk to your doctor about your personal situation.
Let's look at some chronic constipation myths and then identify the truths:
Chronic Constipation Myth: If you don't have one bowel movement a day, it's abnormal.
The Truth: Less than 50% of people have one bowel movement a day.
Chronic Constipation Myth: Fewer than five or six bowel movements a week is considered to be chronic constipation.
The Truth: 95% of adults have bowel movements between three and 21 times per week. The entire range -- even just three bowel movements a week -- is normal.
Chronic Constipation Myth: Toxins accumulate in the intestine when bowel movements are infrequent.
The Truth: Contrary to popular belief, there is no evidence that "toxins" accumulate when bowel movements are infrequent or that constipation leads to disease such as cancer. However, if you are still constipated after trying fiber, laxatives, or milk of magnesia, it is time to consult a doctor for an evaluation.
Chronic Constipation Myth: The number of bowel movements increases with age.
The Truth: Actually, the number of bowel movements decreases with age.
Chronic Constipation Myth: Chronic constipation does not affect that many people.
The Truth: Chronic constipation is a serious issue, affecting 15% to 20% of the U.S. population.
Chronic Constipation Myth: If you eat right, exercise, and drink plenty of fluids, you should never suffer from chronic constipation.
The Truth: Sometimes psychological issues trigger chronic constipation. For instance, childhood sexual or physical abuse -- or the loss of a parent through divorce, separation, or death -- may contribute to adult chronic constipation. Constipation often coexists with depression. Chronic constipation can also be caused by an underlying medical condition such as low thyroid hormone levels.
Chronic Constipation: What Causes It?
After you eat, food moves through your digestive tract. The intestines take water and nutrients from the food. Normally, the process continues until a stool is formed. Squeezing contractions in the intestine then pass the stool out of the body.
Because constipation is often linked with hard stools, one theory is that too much water is absorbed from the stool, leaving it dry and hard. Another theory is that abnormal hormonal responses to the ingested water may trigger chronic constipation. More research is necessary to better understand how constipation happens and to unravel the mysterious link between the gut, hormones, and the brain.
6 Keys to Relieving Chronic Constipation
Relieving chronic constipation takes a multifaceted, lifestyle approach:
1. Get Regular
Go to the bathroom at the same time each morning. Make this your morning "habit," as colonic motor activity is highest at this time.
2. Listen to Your Body
Don't ignore the urge to go. Peristalsis of the bowel -- the movements that trigger a bowel movement -- come and go. If you ignore this urge, you may lose the opportunity. The longer stool stays in the bowel, the harder it gets as more water is reabsorbed, and the more difficult it is to expel. The urge to defecate also increases after mealtime, so take advantage of your body's signals.
Because stress can interfere with relaxation of the whole body, including the bowels, it's important to use some type of relaxation technique daily. Satish Rao, MD, PhD, FRCP, professor of medicine and director of neurogastroenterology and GI motility at the University of Iowa, finds that many patients cannot push properly because they are too rushed and stressed. "They have too little time to take care of their bodies," says Rao.
4. Increase Fluids
Drink plenty of liquids. It's recommended that you drink at least eight glasses of liquid (preferably water) each day. Drink more on hot days and when you are exercising.
5. Bulk Up Your Diet
Dietary fiber and bulk fiber laxatives such as psyllium or methylcelluose -- taken with plenty of fluids -- work well for relieving chronic constipation. Harris H. McIlwain, a Tampa-based rheumatologist and author of the new book A Diet for a Pain-Free Life, believes that wheat bran is the most effective fiber in relieving chronic constipation. "Wheat bran adds bulk to the stool and increases the rate of movement of the stool through the bowel," says McIlwain.
6. Talk to Your Doctor About Medications
Medications and laxatives can help relieve constipation, but they must be taken carefully and for short periods of time. Consult with your doctor before taking any medication.
Chronic Constipation: More Prevalent Today?
Are Americans becoming increasingly constipated? Rao says there's simply more awareness of constipation today.
"In the past, people who suffered with chronic constipation, diarrhea, irritable bowel syndrome, or even incontinence, kept it to themselves. They stayed at home much of the time and tolerated the uncomfortable symptoms," Rao tells WebMD. "Today's baby boomers are unwilling to accept problems like chronic constipation. They know that medical advances are excellent and these health issues can be successfully treated and resolved."
Rao says that constipation is not about frequency (or infrequency) of bowel movements, but rather chronic constipation is a "symptom complex." Rao explains the symptoms of chronic constipation as follows:
- Excessive straining
- Hard stools
- Feeling of incomplete evacuation
- Use of digital evacuation such as support of the pelvic floor
- A sensation that you cannot go or will not be able to go (because of obstruction)
- A decrease in frequency
Chronic constipation may be associated with normal or slow stool transit time, functional defecation disorder (dyssynergic defecation) or a combination of both. With slow-transit constipation, there is a prolonged delay in the transit of stool through the colon. Dyssynergic or outlet obstruction (also called pelvic floor dyssynergia) is characterized by either difficulty or inability to expel the stool. With pelvic floor dysfunction (dyssynergic defecation), the muscles of the lower pelvis that surround the rectum (the pelvic floor muscles) do not work normally. A third type of constipation occurs with irritable bowel syndrome (IBS) where constipation alternates with bouts of diarrhea.
Chronic Constipation: Why Are Baby Boomers at Risk?
If you're a baby boomer born between 1946 and 1964, you may wonder if chronic constipation tends to increase with age. McIlwain tells WebMD that there are several different causes that trigger constipation in aging adults.
"As adults age, we tend to become more sedentary, eat and drink less, and take in much less fiber in our daily diet," says McIlwain, "all of which are habits that aggravate chronic constipation."
Then, according to McIlwain, more problems occur when you are constipated and start depending on laxatives. "Within days, this laxative habit can aggravate the cycle of chronic constipation and the need to take another laxative and then another."
Not only do lifestyle habits put boomers at risk for chronic constipation, but McIlwain says that many over-the-counter and prescription medications commonly taken to treat arthritis, back pain, hypertension, allergies, and even depression can result in chronic constipation.
"When older adults are treated with multiple medications for health problems, chronic constipation can be the result," says McIlwain. "The most common medications that aggravate constipation are narcotic analgesics like codeine and Tylenol (Tylenol #3), oxycodone (Oxycontin), proposyphene and acetaminophen (Darvocet), and hydromophone (Dilaudid), which are sometimes used for severe pain of osteoarthritis, inflammatory arthritis, disc disease, and other problems. Because these stronger pain medications are known to cause chronic constipation, many physicians go ahead and treat the constipation at the same time the pain medications are prescribed -- before chronic constipation develops and becomes severe and unmanageable."
For people of all ages, certain medications do result in chronic constipation, including some analgesics for pain, antidepressants, and medications to treat hypertension, among others. Iron supplements that many women of childbearing age take in their daily multivitamin increases the chance of chronic constipation, as can pregnancy.
What does McIlwain recommend to boomers for relieving chronic constipation? "Stay active and exercise daily," says Mcllwain. "Also, watch your fluids and drink even when you don't feel thirsty, as older adults sometimes lose this thirst mechanism that alerts us to drink fluids. Add more fiber to your diet and maybe consider a stool softener, if necessary."
McIlwain also recommends low-dose magnesium hydroxide (Phillips® Milk of Magnesia or Ducolax® Milk of Magnesia) to his patients for relieving chronic constipation.
Chronic Constipation: When to See Your Doctor
If you have chronic constipation or if constipation is new or is a change in your normal bowel habits, give your doctor a call. Because chronic constipation may be an early symptom of serious problems such as colon cancer, your doctor will ask about your medical history, perform a physical examination, and then do laboratory testing for screening purposes. Some medical conditions such as hypothyroidism, irritable bowel syndrome, Parkinson's disease, and diabetes can also cause chronic constipation. Treating the disease itself may help in relieving chronic constipation.
Your doctor will perform a rectal examination to look for hemorrhoids or tears caused by straining and will check the function of the anal sphincter muscles. If your medical history, physical exam, and lab results give no clues as to the cause of chronic constipation, your doctor may order an imaging study of the colon and rectum to rule out more serious problems such as an obstruction.
Once your doctor determines your diagnosis, relieving chronic constipation may involve a multidisciplinary approach with diet and lifestyle changes and over-the-counter or prescription medications. If your doctor finds that your chronic constipation needs regular medical management, you might consider going to a gastroenterologist with special interest and expertise in the field of constipation. Assistance from such a health care provider can go a long way towards relieving chronic constipation long term and improving your quality of life
When you meet with your doctor, have a list of questions ready to ask him or her, and be assertive when describing the signs and symptoms of chronic constipation. According to Rao, there's a major problem in how doctors today perceive constipation.
"Physicians are too dismissive of symptoms when patients tell of having chronic constipation," says Rao, "and patients must be more forceful in describing their problem with constipation. Physicians must ask more questions to find out what's really going on."
To gain an understanding of the mechanism that's causing chronic constipation, Rao uses specific tests, including a colonic transit study, a balloon expulsion, and anal rectometry
After testing, Rao says that an estimated one-third of those individuals with chronic constipation might have normal results. The colon and rectum are normal, but there's still hypersensitivity, pain, and discomfort when having a bowel movement.
"But nearly one-third of those with chronic constipation have dyssynergic defecation," Rao says. "People with dyssynergic defecation cannot sense stool in their bowel or have difficulty using bodily mechanisms to expel the stool. Many with dyssynergic defecation are unaware that this is the cause of their constipation and often they don't seek help beyond using over-the-counter laxatives."
For those chronic constipation sufferers with dyssynergic defecation, Rao recommends biofeedback. "This is a simple, noninvasive therapy that can correct improper contraction of the pelvic floor muscles and external anal sphincter during defecation," says Rao. "This nondrug therapy has been shown categorically to be the only effective method to correct the behavior as these patients learn what is wrong and then learn how to correct it."
Traditional over-the-counter laxatives may work in relieving chronic constipation. Rao recommends senna products, magnesium, and fiber supplements. The prescription medication, Amitiza® (lubiprostone), a chloride channel activator that enhances intestinal fluid secretion, may also help in relieving chronic constipation.
When Chronic Constipation Is a Warning Sign
Changes in your bowel habits may be a warning sign of a viral or bacterial infection, obstruction, inflammatory bowel disease (IBD), or colon cancer. If you have one or more of the following symptoms, call your health care provider:
- Constipation that lasts for more than two weeks
- Severe diarrhea lasting more than two days
- Mild diarrhea lasting a week
- Unexplained urges to have a bowel movement
- Bloody diarrhea
- Black or tarry-colored stools