Suffering From Constipation
Constipation is passage of small amounts of hard, dry bowel movements,
usually fewer than three times a week. People who are constipated may find it
difficult and painful to have a bowel movement. Other symptoms of constipation
include feeling bloated, uncomfortable, and sluggish.
Many people think they are constipated when, in fact, their bowel movements
are regular. For example, some people believe they are constipated, or
irregular, if they do not have a bowel movement every day. However, there is no
right number of daily or weekly bowel movements. Normal may be three times a day
or three times a week depending on the person. Also, some people naturally have
firmer stools than others.
At one time or another, almost everyone gets constipated. Poor diet and lack
of exercise are usually the causes. In most cases, constipation is temporary and
not serious. Understanding its causes, prevention, and treatment will help most
people find relief.
Who gets constipated?
According to the 1996 National Health Interview Survey, about 3 million
people in the United States have frequent constipation. Those reporting
constipation most often are women and adults age 65 and over. Pregnant women may
have constipation, and it is a common problem following childbirth or
Constipation is one of the most common gastrointestinal complaints in the
United States, resulting in about 2 million doctor visits annually. However,
most people treat themselves without seeking medical help, as is evident from
the millions of dollars Americans spend on laxatives each year.
What causes constipation?
To understand constipation, it helps to know how the colon (large intestine)
works. As food moves through the colon, it absorbs water while forming waste
products, or stool. Muscle contractions in the colon push the stool toward the
rectum. By the time stool reaches the rectum, it is solid because most of the
water has been absorbed.
The hard and dry stools of constipation occur when the colon absorbs too much
water or if the colon’s muscle contractions are slow or sluggish, causing the
stool to move through the colon too slowly. Common causes of constipation
- not enough fiber in the diet
- not enough liquids
- lack of exercise
- irritable bowel syndrome
- changes in life or routine such as pregnancy, older age, and travel
- abuse of laxatives
- ignoring the urge to have a bowel movement
- specific diseases such as stroke (by far the most common)
- problems with the colon and rectum
- problems with intestinal function (chronic idiopathic constipation)
Not Enough Fiber in the Diet
The most common cause of constipation is a diet low in fiber found in
vegetables, fruits, and whole grains and high in fats found in cheese, eggs, and
meats. People who eat plenty of high-fiber foods are less likely to become
Fiber—both soluble and insoluble—is the part of fruits, vegetables, and
grains that the body cannot digest. Soluble fiber dissolves easily in water and
takes on a soft, gel-like texture in the intestines. Insoluble fiber passes
through the intestines almost unchanged. The bulk and soft texture of fiber help
prevent hard, dry stools that are difficult to pass.
According to the National Center for Health Statistics, Americans eat an
average of 5 to 14 grams of fiber daily,* short of the 20 to 35 grams
recommended by the American Dietetic Association. Both children and adults eat
too many refined and processed foods from which the natural fiber has been
A low-fiber diet also plays a key role in constipation among older adults,
who may lose interest in eating and choose convenience foods low in fiber. In
addition, difficulties with chewing or swallowing may force older people to eat
soft foods that are processed and low in fiber.
*National Center for Health Statistics. Dietary Intake of
Macronutrients, Micronutrients, and Other Dietary Constituents: United States,
1988–94. Vital and Health Statistics, Series 11, number 245. July 2002.
Not Enough Liquids
Liquids like water and juice add fluid to the colon and bulk to stools,
making bowel movements softer and easier to pass. People who have problems with
constipation should drink enough of these liquids every day, about eight 8-ounce
glasses. Liquids that contain caffeine, like coffee and cola drinks, and alcohol
have a dehydrating effect.
Lack of Exercise
Lack of exercise can lead to constipation, although doctors do not know
precisely why. For example, constipation often occurs after an accident or
during an illness when one must stay in bed and cannot exercise.
Some medications can cause constipation. They include
- pain medications (especially narcotics)
- antacids that contain aluminum and calcium
- blood pressure medications (calcium channel blockers)
- antiparkinson drugs
- iron supplements
Irritable Bowel Syndrome (IBS)
Some people with IBS, also known as spastic colon, have spasms in the colon
that affect bowel movements. Constipation and diarrhea often alternate, and
abdominal cramping, gassiness, and bloating are other common complaints.
Although IBS can produce lifelong symptoms, it is not a life-threatening
condition. It often worsens with stress, but there is no specific cause or
anything unusual that the doctor can see in the colon.
Changes in Life or Routine
During pregnancy, women may be constipated because of hormonal changes or
because the heavy uterus compresses the intestine. Aging may also affect bowel
regularity because a slower metabolism results in less intestinal activity and
muscle tone. In addition, people often become constipated when traveling because
their normal diet and daily routines are disrupted.
Abuse of Laxatives
Myths about constipation have led to a serious abuse of laxatives. This is
common among people who are preoccupied with having a daily bowel movement.
Laxatives usually are not necessary and can be habit-forming. The colon
begins to rely on laxatives to bring on bowel movements. Over time, laxatives
can damage nerve cells in the colon and interfere with the colon’s natural
ability to contract. For the same reason, regular use of enemas can also lead to
a loss of normal bowel function.
Ignoring the Urge to Have a Bowel Movement
People who ignore the urge to have a bowel movement may eventually stop
feeling the urge, which can lead to constipation. Some people delay having a
bowel movement because they do not want to use toilets outside the home. Others
ignore the urge because of emotional stress or because they are too busy.
Children may postpone having a bowel movement because of stressful toilet
training or because they do not want to interrupt their play.
Diseases that cause constipation include neurological disorders, meta
Functional disorders are those in which the bowel looks normal but doesn’t work properly. They are the most common problems affecting the colon and rectum, and include constipation and irritable bowel syndrome (IBS). The primary causes for functional disorders include:
- Eating a diet low in fiber
- Not drinking enough water or other fluids
- Not getting enough exercise
- Traveling or other changes in routine
- Eating large amounts of dairy products
- Being stressed
- Resisting the urge to have a bowel movement
- Resisting the urge to have bowel movements due to pain from hemorrhoids
- Overusing laxatives (stool softeners) that, over time, weaken the bowel muscles
- Taking antacid medicines containing calcium or aluminum
- Taking certain medicines (especially antidepressants, iron pills, and strong pain medicines such as narcotics)
- Being pregnant
Constipation is the difficult passage of stools (bowel movements) or the infrequent (less than three times a week) or incomplete passage of stools. Constipation is usually caused by inadequate “roughage” or fiber in the diet, or a disruption of the regular routine or diet. Constipation causes a person to strain during a bowel movement. It might include small, hard stools, and sometimes causes anal problems such as fissures and hemorrhoids. Constipation is rarely the sign of a more serious medical condition.
Treatment of constipation includes increasing the amount of fiber you eat, drinking more fluids, exercising regularly, and moving your bowels when you have the urge (resisting the urge causes constipation). If these treatment methods don’t work, laxatives are a temporary solution. Note that the overuse of laxatives can actually aggravate symptoms of constipation. Always follow the package instructions on the laxative medicine, as well as the advice of your doctor.
Irritable bowel syndrome (IBS)
Irritable bowel syndrome (also called spastic colon, irritable colon, or nervous stomach) is a condition in which the colon muscle contracts more readily than in people without IBS. A number of factors can trigger IBS including certain foods, medicines, and emotional stress. Symptoms of IBS include abdominal pain and cramps, excess gas, bloating, and a change in bowel habits such as harder, looser, or more urgent stools than normal. Often people with IBS have alternating constipation and diarrhea.
Treatment includes avoiding caffeine, increasing fiber in the diet, drinking more fluids, monitoring which foods trigger IBS (and avoiding these foods), quitting smoking, minimizing stress or learning different ways to cope with stress, and sometimes taking medicines as prescribed by your health care provider.
Structural disorders are those in which the bowel looks abnormal and doesn’t work properly. Sometimes, the structural abnormality needs to be removed surgically. The most common structural disorders are those affecting the anus, as well as diverticular disease and cancer.
Hemorrhoids are swollen blood vessels that line the anal opening caused by excess pressure from straining during a bowel movement, persistent diarrhea, or pregnancy. There are two types of hemorrhoids: internal and external.
- Internal hemorrhoids — Internal hemorrhoids are normal structures cushioning the lower rectum and protecting it from damage by stool. When they fall down into the anus as a result of straining, they become irritated and start to bleed. Ultimately, internal hemorrhoids can fall down enough to prolapse (sink or protrude) out of the anus.Treatment includes improving bowel habits (such as avoiding constipation, not straining during bowel movements, and moving your bowels when you have the urge), using elastic bands to pull the internal hemorrhoids back into the rectum, or removing them surgically. Surgery is needed only for a small number patients with very large, painful, and persistent hemorrhoids.
- External hemorrhoids — External hemorrhoids are veins that lie just under the skin on the outside of the anus. Sometimes, after straining, the external hemorrhoidal veins burst and a blood clot forms under the skin. This very painful condition is called a pile.Treatment includes removing the clot and vein under local anesthesia in the doctor’s office.
Anal fissures are splits or cracks in the lining of the anal opening. The most common cause of an anal fissure is the passage of very hard or watery stools. The crack in the anal lining exposes the underlying muscles that control the passage of stool through the anus and out of the body. An anal fissure is one of the most painful problems because the exposed muscles become irritated from exposure to stool or air, and leads to intense burning pain, bleeding, or spasm after bowel movements.
Initial treatment for anal fissures includes pain medicine, dietary fiber to reduce the occurrence of large, bulky stools, and sitz baths (sitting in a few inches of warm water). If these treatments don’t relieve pain, surgery might be needed to decrease spasm in the sphincter muscle.
Perianal abscesses can occur when the tiny anal glands that open on the inside of the anus become blocked, and the bacteria always present in these glands cause an infection. When pus develops, an abscess forms. Treatment includes draining the abscess, usually under local anesthesia in the doctor’s office.
An anal fistula often follows drainage of an abscess and is an abnormal tube-like passageway from the anal canal to a hole in the skin near the opening of the anus. Body wastes traveling through the anal canal are diverted through this tiny channel and out through the skin, causing itching and irritation. Fistulas also cause drainage, pain, and bleeding. They rarely heal by themselves and usually need surgery to drain the abscess and “close off” the fistula.
Other perianal infections
Sometimes the skin glands near the anus become infected and need to be drained. Just behind the anus, abscesses can form that contain a small tuft of hair at the back of the pelvis (called a pilonidal cyst).
Sexually transmitted diseases that can affect the anus include anal warts, herpes, AIDS, chlamydia, and gonorrhea.
Diverticulosis is the presence of small outpouchings (diverticula) in the muscular wall of the large intestine that form in weakened areas of the bowel. They usually occur in the sigmoid colon, the high-pressure area of the lower large intestine.
Diverticular disease is very common and occurs in 10 percent of people over age 40 and in 50 percent of people over age 60 in Western cultures. It is often caused by too little roughage (fiber) in the diet. Diverticulosis rarely causes symptoms but when the occur, they might include tenderness over the affected area or muscle spasms in the abdomen.
Complications of diverticular disease happen in about 10 percent of people with outpouchings. They include infection or inflammation (diverticulitis), bleeding, and obstruction. Treatment includes antibiotics, increased fluids, and a special diet. Surgery is needed in about half the patients who have complications to remove the involved segment of the colon.
Colon polyps and cancer
Each year 130,000 Americans are diagnosed with colorectal cance