Constipation

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 or cannot be eliminated effectively from the rectum, which may cause the stool to become hard and dry. Chronic constipation has many possible causes.

Blockages in the colon or rectum

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

• Tiny tears in the skin around the anus (anal fissure)
• A blockage in the intestines (bowel obstruction)
• Colon cancer
• Narrowing of the colon (bowel stricture)
• Other abdominal cancer that presses on the colon
• Rectal cancer
• Rectum bulge through the back wall of the vagina (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:

• Damage to the nerves that control bodily functions (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:

• The inability to relax the pelvic muscles to allow for a bowel movement (anismus)
• Pelvic muscles that 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, opioid pain medications, some antidepressants or medications to lower blood pressure
• Having a mental health condition such as depression or an eating disorder

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.

The following can help you avoid developing chronic constipation.

• Include plenty of high-fiber foods in your diet, including beans, vegetables, fruits, whole grain cereals and bran.
• Eat fewer foods with low amounts of fiber such as processed foods, and dairy and meat products.
• Drink plenty of fluids.
• Stay as active as possible and try to get regular exercise.
• Try to manage stress.
• Don't ignore the urge to pass stool.
• Try to create a regular schedule for bowel movements, especially after a meal.
• Make sure children who begin to eat solid foods get plenty of fiber in their diets.

In addition to a general physical exam and a digital rectal exam, doctors use the following tests and procedures to diagnose chronic constipation and try to find the cause:

• Blood tests. Your doctor will look for a systemic condition such as low thyroid (hypothyroidism) or high calcium levels.
• An X-ray. An X-ray can help your doctor determine whether our intestines are blocked and whether there is stool present throughout the colon.
• 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 anal sphincter muscle speed (balloon expulsion test). Often used along with anorectal manometry, this test measures the amount of time it takes for you to push out a balloon that has been filled with water and placed in your rectum.

• Evaluation of how well food moves through the colon (colonic transit study). In this procedure, you may swallow a capsule that contains either a radiopaque marker or a wireless recording device. The progress of the capsule through your colon will be recorded over 24 to 48 hours and will be visible on X-rays.

  In some cases, you may eat radiocarbon-activated food and a special camera will record its progress (scintigraphy). 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.
• MRI defecography. During this procedure, as in barium defecography, a doctor will insert contrast gel into your rectum. You then pass the gel. The MRI scanner can visualize and assess the function of the defecation muscles. This test also can diagnose problems that can cause constipation, such as rectocele or rectal prolapse.

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. If you do not already exercise, talk to your doctor about whether you are healthy enough to start an exercise program.
• 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. The following are available over-the-counter:

• Fiber supplements. Fiber supplements add bulk to your stool. Bulky stools are softer and easier to pass. Fiber supplements include psyllium (Metamucil, Konsyl, others), calcium polycarbophil (FiberCon, Equalactin, others) and methylcellulose (Citrucel).
• Stimulants. Stimulants including bisacodyl (Correctol, Dulcolax, others) and sennosides (Senokot, Ex-Lax, Perdiem) cause your intestines to contract.
• Osmotics. Osmotic laxatives help stool move through the colon by increasing secretion of fluid from the intestines and helping to stimulate bowel movements. Examples include oral magnesium hydroxide (Phillips' Milk of Magnesia, Dulcolax Milk of Magnesia, others), magnesium citrate, lactulose (Cholac, Constilac, others), polyethylene glycol (Miralax, Glycolax).
• Lubricants. Lubricants such as mineral oil enable stool to move through your colon more easily.
• Stool softeners. Stool softeners such as docusate sodium (Colace) and docusate calcium (Surfak) moisten the stool by drawing water from the intestines.
• Enemas and suppositories. Tap water enemas with or without soapsuds can be useful to soften stool and produce a bowel movement. Glycerin or bisacodyl suppositories also aid in moving stool out of the body by providing lubrication and stimulation.

Other medications

If over-the-counter medications don't help your chronic constipation, your doctor may recommend a prescription medication, especially if you have irritable bowel syndrome.

• Medications that draw water into your intestines. A number of prescription medications are available to treat chronic constipation. Lubiprostone (Amitiza), linaclotide (Linzess) and plecanatide (Trulance) work by drawing water into your intestines and speeding up the movement of stool.
• Serotonin 5-hydroxytryptamine 4 receptors. Prucalopride (Motegrity) helps move stool through the colon.
• Peripherally acting mu-opioid receptor antagonists (PAMORAs). If constipation is caused by opioid pain medications, PAMORAs such as naloxegol (Movantik) and methylnaltrexone (Relistor) reverse the effect of opioids on the intestine to keep the bowel moving.

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 treatments and your chronic constipation is caused by a blockage, rectocele 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 entire colon is rarely necessary.

Many people use alternative and complementary medicine to treat constipation, but these approaches have not been well-studied. Researchers currently are evaluating the usefulness of acupuncture.

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.
• 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.

For constipation, some questions you might want to ask your doctor include:

• What's the most likely cause of my symptoms?
• What kinds of tests do I need, and how do I need to prepare for them?
• Am I at risk of complications related to this condition?
• What treatment do you recommend?
• If the initial treatment doesn't work, what will you recommend next?
• Are there any dietary restrictions that I need to follow?
• I have other medical problems. How can I manage these along with constipation?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask other questions 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 a day?
• How much liquid, including water, do you drink a 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?