Chronic constipation

Chronic constipation is infrequent bowel movements or difficult passage of stools that persists for several weeks or longer.

Constipation is generally described as having fewer than three bowel movements a week.

Though occasional constipation is very common, some people experience chronic constipation that can interfere with their ability to go about their daily tasks. Chronic constipation may also cause excessive straining to have a bowel movement and other signs and symptoms.

Treatment for chronic constipation depends on the underlying cause. Though, in some cases, a cause for chronic constipation is never found.

Signs and symptoms of chronic constipation include:

• Passing fewer than three stools a week
• Having lumpy or hard stools
• Straining to have bowel movements
• Feeling as though there’s a blockage in your rectum that prevents bowel movements
• Feeling as though you can’t completely empty the stool from your rectum
• Needing help to empty your rectum, such as using your hands to press on your abdomen and using a finger to remove stool from your rectum

Constipation may be considered chronic if you’ve experienced two or more of these symptoms for the last three months.

When to see a doctor

Make an appointment with your doctor if you experience unexplained and persistent changes in your bowel habits.

Constipation most commonly occurs when waste or stool moves too slowly through the digestive tract, causing it to become hard and dry. Chronic constipation has many causes:

Blockages in the colon or rectum

Blockages in the colon or rectum may slow or stop stool movement. Causes include:

• Anal fissure
• Bowel obstruction
• Colon cancer
• Narrowing of the colon (bowel stricture)
• Other abdominal cancer that presses on the colon
• Rectal cancer
• Rectocele

Problems with the nerves around the colon and rectum

Neurological problems can affect the nerves that cause muscles in the colon and rectum to contract and move stool through the intestines. Causes include:

• Autonomic neuropathy
• Multiple sclerosis
• Parkinson’s disease
• Spinal cord injury
• Stroke

Difficulty with the muscles involved in elimination

Problems with the pelvic muscles involved in having a bowel movement may cause chronic constipation. These problems may include:

• Inability to relax the pelvic muscles to allow for a bowel movement (anismus)
• Pelvic muscles don’t coordinate relaxation and contraction correctly (dyssynergia)
• Weakened pelvic muscles

Conditions that affect hormones in the body

Hormones help balance fluids in your body. Diseases and conditions that upset the balance of hormones may lead to constipation, including:

• Diabetes
• Overactive parathyroid gland (hyperparathyroidism)
• Pregnancy
• Underactive thyroid (hypothyroidism)

Factors that may increase your risk of chronic constipation include:

• Being an older adult
• Being a woman
• Being dehydrated
• Eating a diet that’s low in fiber
• Getting little or no physical activity
• Taking certain medications, including sedatives, narcotics or certain medications to lower blood pressure

Complications of chronic constipation include:

• Swollen veins in your anus (hemorrhoids). Straining to have a bowel movement may cause swelling in the veins in and around your anus.
• Torn skin in your anus (anal fissure). A large or hard stool can cause tiny tears in the anus.
• Stool that can’t be expelled (fecal impaction). Chronic constipation may cause an accumulation of hardened stool that gets stuck in your intestines.
• Intestine that protrudes from the anus (rectal prolapse).Straining to have a bowel movement can cause a small amount of the rectum to stretch and protrude from the anus.

You’ll likely first seek medical care for constipation from your family doctor or general practitioner. You may be referred to a specialist in digestive disorders (gastroenterologist) if your doctor suspects a more advanced case of constipation.

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 or eating certain high-fiber foods to prepare for diagnostic testing.
• Write down any symptoms you’re experiencing, including any that may seem unrelated to constipation.
• Write down key personal information, including any major stresses or recent life changes, such as traveling or becoming 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 accompanies you may remember something that you missed or forgot.
• Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions ahead of time will help you make the most of your time together. List your questions from most important to least important, in case time runs out. For constipation, some basic questions to ask your doctor include:

• What is likely causing my symptoms or condition?
• Are there other possible causes for my symptoms or condition?
• What kinds of tests do I need?
• What treatment approach do you recommend?
• What other treatment options exist?
• How soon do you expect my symptoms to improve with treatment?
• I have these other health conditions. How can I best manage them together?
• Are there any restrictions that I need to follow?
• Should I see a gastroenterologist? What will that cost, and will my insurance cover it?
• Is there a generic alternative to the medicine you’re prescribing?
• Are there brochures or other printed material that I can take with me? What websites do you recommend?

In addition to the questions that you’ve prepared to ask your doctor, don’t hesitate to ask additional questions as they occur to you during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may allow more time to go over additional questions you may have. Your doctor may ask:

• When did you begin experiencing symptoms of constipation?
• Have your symptoms been continuous or occasional?
• 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 abdominal pain?
• Do your symptoms include vomiting?
• Have you recently lost weight without trying?
• How many meals do you eat per day?
• How much water and other fluids do you drink per day?
• Do you see blood with your bowel movements mixed in with the stool, in the toilet water or on the toilet paper?
• Do you strain with your bowel movements?
• 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 medications or recently changed the dosage of your current medications?

Tests and procedures used to diagnose chronic constipation include:

• Examination of the rectum and lower, or sigmoid, colon (sigmoidoscopy). In this procedure, your doctor inserts a lighted, flexible tube into your anus to examine your rectum and the lower portion of your colon.
• Examination of the rectum and entire colon (colonoscopy). This diagnostic procedure allows your doctor to examine the entire colon with a flexible, camera-equipped tube.
• Evaluation of anal sphincter muscle function (anorectal manometry). In this procedure, your doctor inserts a narrow, flexible tube into your anus and rectum and then inflates a small balloon at the tip of the tube. The device is then pulled back through the sphincter muscle. This procedure allows your doctor to measure the coordination of the muscles you use to move your bowels.
• Evaluation of how well food moves through the colon (colonic transit study). In this procedure, you’ll swallow a capsule containing markers that show up on X-rays taken over several days. Your doctor will look for signs of intestinal muscle dysfunction and how well food moves through your colon.
• An X-ray of the rectum during defecation (defecography).During this procedure, your doctor inserts a soft paste made of barium into your rectum. You then pass the barium paste as you would stool. The barium shows up on X-rays and may reveal a prolapse or problems with muscle function and muscle coordination.

Treatment for chronic constipation usually begins with diet and lifestyle changes meant to increase the speed at which stool moves through your intestines. If those changes don’t help, your doctor may recommend medications or surgery.

Diet and lifestyle changes

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

• Increase your fiber intake. Adding fiber to your diet increases the weight of your stool and speeds its passage through your intestines. Slowly begin to eat more fresh fruits and vegetables each day. Choose whole-grain breads and cereals.

  Your doctor may recommend a specific number of grams of fiber to consume each day. In general, aim for 14 grams of fiber for every 1,000 calories in your daily diet.

  A sudden increase in the amount of fiber you eat can cause bloating and gas, so start slowly and work your way up to your goal over a few weeks.

• Exercise most days of the week. Physical activity increases muscle activity in your intestines. Try to fit in exercise most days of the week.
• Don’t ignore the urge to have a bowel movement. Take your time in the bathroom, allowing yourself enough time to have a bowel movement without distractions and without feeling rushed.

Laxatives

Several types of laxatives exist. Each works somewhat differently to make it easier to have a bowel movement.

Examples of laxatives include:

• Fiber supplements. Fiber supplements add bulk to your stool. Common ingredients include methylcellulose, psyllium, calcium polycarbophil and guar gum. Brand names include FiberCon, Metamucil, Konsyl and Citrucel.
• Stimulants.
• Osmotics. Osmotic laxatives help fluids move through the colon. Examples include milk of magnesia, magnesium citrate, lactulose, polyethylene glycol (MiraLax) and sodium phosphate enema (Fleet Enema).
• Lubricants. Lubricants enable stool to move through your colon more easily. One example of a lubricant is mineral oil.
• Stool softeners. Stool softeners moisten the stool by drawing water from the intestines. Examples include Colace and Surfak.

Other medications

Prescription medications used to treat chronic constipation include:

• Medications that draw water into your intestines. The prescription medications lubiprostone (Amitiza) and linaclotide (Linzess) work in different ways to draw water into your intestines and speed up the movement of stool. Your doctor may recommend these medications if over-the-counter laxatives haven’t helped you.
• Medications in clinical trials. Several new medications for treating chronic constipation are being studied in clinical trials. Talk with your doctor about whether any of these drugs may benefit you.

Training your pelvic muscles

Biofeedback training involves working with a therapist who uses devices to help you learn to relax and tighten the muscles in your pelvis. Relaxing your pelvic floor muscles at the right time during defecation can help you pass stool more easily.

During a biofeedback session, a special tube (catheter) to measure muscle tension is inserted into your rectum. The therapist guides you through exercises to alternately relax and tighten your pelvic muscles. A machine will gauge your muscle tension and use sounds or lights to help you understand when you’ve relaxed your muscles.

Surgery

Surgery may be an option if you have tried other treatment and your chronic constipation is caused by rectocele, anal fissure or stricture.

For people who have tried other treatments without success and who have abnormally slow movement of stool through the colon, surgical removal of part of the colon may be an option. Surgery to remove the colon is rarely necessary.

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