Constipation

Constipation is a common condition which affects people of all ages. It can mean that patients are not passing stools (poo) regularly, or that they are unable to completely empty their bowels. Constipation may also cause their stools to be hard, lumpy, large or small.

The severity of constipation varies from person to person. Many people only experience constipation for a short time, but for others, constipation can be a chronic (long-term) condition which causes significant pain and discomfort and affects their quality of life.

What causes constipation?

It is often difficult to identify the cause. However, there are a number of things which increase the risk of constipation, including:

• not eating enough fibre, (e.g. fruit, vegetables and cereals).
• not drinking enough water/ fluids.
• a change in the routine or lifestyle (e.g. a change in the eating habits).
• ignoring the urge to pass stools.
• side effects of certain medications.
• Certain medical conditions (e.g. hypothyroidism - underactive thyroid).  
• anxiety or depression

In children, poor diet, fear about using the toilet, and poor toilet training may all be responsible.

Should I see my doctor?

People may be able to help treat constipation themselves by making simple changes to their diet and lifestyle. If these changes do not help, then they see their doctor/ physician. Parents should also speak to their doctor if they suspect their child might be constipated.

Treating constipation

An oral laxative (medication to help people empty their bowels) is usually prescribed, in order to treat constipation. Treatment for constipation is effective, although in some cases it may take several months before a regular bowel pattern is re-established.

Preventing constipation

Making diet and lifestyle changes (e.g. eating high-fibre foods, drinking plenty of fluids and regularly exercising) will help people to prevent or ease their constipation. It may also help to give themselves enough time and privacy to pass stools comfortably, and they should never ignore the urge to go to the toilet.

Complications

For most people, constipation rarely causes any complications, but people with long-term constipation may develop:

• haemorrhoids (piles).
• faecal impaction (where dry, hard stools collect in the rectum).
• faecal incontinence (the leakage of liquid stools).

Who is affected?

Constipation can occur in babies, children and adults, and affects twice as many women as men. Older people are five times more likely than younger adults to experience constipation, usually because of diet, lack of exercise, use of medication and poor bowel habits. Approximately 40% of pregnant women experience constipation during their pregnancy.

Causes of constipation 

Most cases of constipation are not caused by a specific condition, and it may be difficult to identify the exact cause. However, several factors can increase someone's chances of having constipation, and these include:

• not eating enough fibre (e.g. fruit, vegetables and cereals).
• anxiety or depression.
• immobility or lack of exercise.
• a change in the routine or lifestyle (e.g. a change in the eating habits).
• having limited privacy when using the toilet.
• ignoring the urge to pass stools.
• not drinking enough fluids.
• being underweight or overweight.
• psychiatric problems (e.g. like those brought on by sexual abuse, violence or trauma).

Medication

Sometimes, constipation may be a side effect of a medicine which people are taking. Common types of medication which can cause constipation include:

• antidepressants.
• aluminium antacids (medicine to treat indigestion).
• calcium supplements.
• antiepileptics (medicine to treat epilepsy).
• antipsychotics (medicine to treat schizophrenia and other mental health disorders).
• codeine, found in some types of painkiller (e.g. codeine phosphate, co-dydramol, co-codamol).
• diuretics (water tablets).
• iron supplements. 

If the constipation is caused by medication, the condition usually eases once the patient stops taking the medicine. However, under no circumstances patients should stop taking their medication unless their doctor/ physician advises them to do so. People must speak to their doctor if they experience constipation due to a medicine. Their doctor may be able to prescribe an alternative.

Pregnancy

About 40% of women experience some form of constipation during their pregnancy, mostly during the early stages of their pregnancy. Constipation occurs during pregnancy because their body produces more of the female hormone progesterone, which acts as a muscle relaxant. The bowel normally moves stools and waste products along to the anus by a process known as peristalsis. This is when the muscles which line the bowel contract and relax in a rippling, wave-like motion. An increase in progesterone makes it more difficult for the bowel muscles to contract, making it harder to move waste products along. If a woman is pregnant, there are ways that she can safely treat constipation without harming themselves or their baby.

Other conditions

In rare cases, constipation may be a sign of an underlying condition, such as:

• Colon or rectal cancer.
• Hypothyroidism (underactive thyroid).
• Diabetes mellitus (DM).
• Hypercalcaemia, when there is too much calcium in the bloodstream.
• Spinal cord injury.
• Muscular dystrophy, a genetic condition which causes muscle wasting.
• Multiple sclerosis, a condition which affects the nervous system.
• Parkinson's disease, a brain condition which affects the co-ordination of body movements.
• Anal fissure, a small tear of the skin just inside the anus.
• Inflammatory bowel disease, a condition which causes the intestines to become inflamed (irritated and swollen) (e.g. Crohn's disease, Ulcerative colitis).
• Irritable bowel syndrome (IBS).

Babies and children

Constipation in babies and children is quite common. About one in three parents in Western countries (e.g. USA / UK) report constipation at some time in their child's life. Poor diet, fear about using the toilet and poor toilet training can all be responsible.

Poor diet

Children who are over-fed are more likely to have constipation, as are those who do not get enough fluids. Babies who have too much milk are also more likely to get constipation. As with adults, it is very important that the child has enough fibre in their diet.

Toilet training

Parents must make sure that they do not make their child feel stressed or pressured about using the toilet. It is also important to let their children try things by themselves (when appropriate). Constantly intervening when they are using the toilet may make them feel anxious.

Toilet habits

Some children may feel stressed or anxious about using the toilet. They may have a phobia about using the toilet, or feel that they are unable to use the toilets at school. This fear or phobia may be the result of the child experiencing pain when passing stools. This can lead to poor bowel habits, where children ignore the urge to pass stools and instead withhold them for fear of experiencing pain and discomfort. However, this will mean that their condition only worsens.

Other conditions

In rare cases, constipation in babies and children can be a sign of an underlying condition such as:

• Hirschsprung's disease, which affects the bowel, making it difficult to pass stools.
• Anorectal malformation, where the baby's anus and rectum do not develop properly.
• Spinal cord abnormalities, including rare conditions such as spina bifida and cerebral palsy.
• Cystic fibrosis, a genetic condition which causes the body to produce thick and sticky mucus, that can lead to constipation.

Symptoms of constipation 

When people are constipated, passing stools becomes more difficult than it used to be. Normal bowel habits vary from person to person. For example, some adults normally go to the toilet more than once a day, whereas it is normal for others to go only every three or four days. Some infants pass stools several times a day, while others pass stools only a few times a week.

Difficulty passing stools

Passing stools may feel more difficult for several reasons. For example, people may be going significantly less frequently or much less effectively (they feel that they are unable to completely empty their bowel). Passing stools may also seem more difficult because the stools are:

• Abnormally small.
• Dry, hard and lumpy.
• Abnormally large.

As well as causing a change in the normal bowel habits, constipation may also cause the following symptoms:

• Feeling nauseous.
• Stomach ache and cramps.
• Feeling bloated.
• Loss of appetite.

Constipation in children

As well as infrequent or irregular bowel movements, a child with constipation may also have the following signs and symptoms:

• Lack of energy.
• Loss of appetite.
• Soiling their clothes.
• Being irritable, angry or unhappy.
• Foul-smelling wind and stools.
• Abdominal pain and discomfort.
• Generally feeling unwell.

If the child has these symptoms or has spoken to his/ her parents about having difficulty passing stools, they the parents should speak to their doctor.

Diagnosing constipation 

Constipation is a very common condition. The doctor/ physician will not usually need to carry out any tests or procedures, but will confirm a diagnosis of constipation based on the patient's medical history and his symptoms.

The doctor will ask the patient some questions about their bowel habits. Patients should not feel embarrassed about describing their bowel pattern and stools to their doctor. It is important that the doctor is aware of all of the patient's symptoms, so he can make the correct diagnosis. The doctor may also ask questions about diet, level of exercise and whether there have been any recent changes in the patient's routines. Doctors define constipation in a number of ways:

• Opening the bowels less than three times a week.
• Needing to strain to open the bowels on more than a quarter of occasions.
• Passing a hard or pellet-like stool on more than a quarter of occasions.

Physical examination

If the doctor suspects that a patient may have faecal impaction (when dry, hard stools collect in the rectum), they may carry out a physical examination. A typical examination will begin with the patient lying on their back while the doctor feels their abdomen. The patient will then lie on their side, while the doctor performs a digital rectal examination (DRE) using a lubricated, gloved finger. The doctor can feel for any stools which may have collected in the rectum. The doctor will rarely have to conduct an internal physical examination on a child. Instead, the diagnosis can normally be made by feeling their abdomen (tummy).

Further tests

If patients are experiencing severe symptoms, their doctor may request further tests, such as blood tests or thyroid tests, in order to diagnose or rule out other conditions. As there is an increased risk of colorectal cancer in older adults, doctors may also request tests to rule out a diagnosis of cancer, including a barium enema or colonoscopy.

Preventing constipation 

Although constipation is common, people may take several steps to prevent it, including making diet and lifestyle changes.

Fibre

People must ensure that they have enough fibre in their diet. Most adults do not eat enough fibre. They should have approximately 18g of fibre a day. They can increase their fibre intake by eating more:

• fruit.
• vegetables.
• nuts.
• wholegrain rice.
• oats.
• wholewheat pasta.
• seeds.
• wholemeal bread.

Eating more fibre will keep the bowel movements regular, because it helps food pass through the digestive system more easily. Foods high in fibre also make people feel fuller for longer. If patients are increasing their fibre intake, it is important to increase it gradually. A sudden increase may make them feel bloated. They may also produce more flatulence (wind) and have stomach cramps.

Fluids

People must make sure that they drink plenty of fluids in order to avoid dehydration and steadily increase their intake when they are exercising or when it is hot. they need to try to cut back on the amount of caffeine, alcohol and fizzy drinks which they consume.

Toilet habits

People should never ignore the urge to go to the toilet. Ignoring the urge may significantly increase their chances of having constipation. The best time for them to pass stools is first thing in the morning, or about 30 minutes after a meal. When they use the toilet, they must make sure that they have enough time and privacy to pass stools comfortably.

Exercise

Keeping mobile and active will greatly reduce someone's risk of getting constipation. Ideally, people should do at least 150 minutes of physical activity every week. Not only will regular exercise reduce their risk of becoming constipated, but it will also leave them feeling healthier and improve their mood, energy levels and general fitness.

Treating constipation 

Treatment for constipation depends on the cause, how long someone has had the condition, and how severe their symptoms are. In many cases, it is possible to relieve symptoms through dietary and lifestyle changes. Treatment methods include:

• Lifestyle advice.
• Laxatives.
• Treatment of faecal impaction.

Lifestyle advice

The doctor will first advise patients about how they can change their diet and lifestyle, which may mean that their constipation passes without the use of any medications. Some ways that people can help treat their constipation include:

• Increase their daily intake of fibre. They should eat at least 18-30g of fibre a day. High-fibre foods include fruit, vegetables and cereals.
• Avoid dehydration by drinking plenty of water.
• Add some bulking agents (e.g. wheat bran), to their diet. These will help make their stools softer and easier to pass.
• Get more exercise by going for a daily walk or run.
• If their constipation is causing pain or discomfort, they may want to take a painkiller (e.g. paracetamol). They must make sure that they always follow the dosage instructions carefully. Children under 16 years of age must not take aspirin.
• Identify a routine of a place and a time of day when they are comfortably able to spend time in the toilet. Respond to their bowel's natural pattern: when they feel the urge, they should not delay. 

If these diet and lifestyle changes do not help, the doctor may prescribe them an oral laxative.

Laxatives

Laxatives are a type of medicine which help people pass stools. There are several different types of laxatives, and each one has a different effect on a patient's digestive system.

Bulk-forming laxatives

The doctor will normally start patients on a bulk-forming laxative. These laxatives work by helping the stools to retain fluid. This means they are less likely to dry out, which can lead to faecal impaction. Bulk-forming laxatives also make the stools denser and softer, which means they should be easier to pass.

Commonly prescribed bulk-forming laxatives include ispaghula husk, methylcellulose and sterculia. When taking this type of laxative, people must drink plenty of fluids. Also, they should not take them before going to bed. It will usually be two to three days before they feel the effects of a bulk-forming laxative.

Osmotic laxatives

If their stools remain hard after they have taken a bulk-forming laxative, the doctor may prescribe an osmotic laxative instead. Osmotic laxatives increase the amount of fluid in the bowels. This helps to stimulate the body to pass stools and also softens stools.

Commonly prescribed osmotic laxatives include lactulose and macrogols. As with bulk-forming laxatives, patients must make sure that they drink plenty of fluids. It will usually be two to three days before patients feel the effect of the laxative.

Stimulant laxatives

If the stools are soft but the patient still has difficulty passing them, the doctor may prescribe a stimulant laxative. This laxative stimulates the muscles which line the digestive tract, helping them to move stools and waste products along the large intestine to the anus. The most commonly prescribed stimulant laxatives are senna, bisacodyl and sodium picosulphate. These laxatives are usually only used on a short-term basis, and they will usually start to work within 6 to 12 hours.

According to an individual's preference and the speed with which he/ she requires relief, the doctor may decide to combine different laxatives.

How long will I take laxatives for?

If someone has only experienced constipation for a short period of time, their physician will normally advise them to stop taking the laxative once their stools are soft and easily passed. However, if they have constipation due to a medicine or an underlying medical condition, they may have to take laxatives for much longer, possibly many months or even years.

If a patient has been taking laxatives for some time, they may have to gradually reduce their dose rather than coming off them straight away. If they have been prescribed a combination of laxatives, they will normally have to reduce the dosage of each laxative, one at a time, before they can stop taking them. This can take several months. Their doctor will advise them when it is best to stop taking them. 

Treating faecal impaction

Faecal impaction occurs when stools become hard and dry and collect in the rectum. This obstructs the rectum, making it more difficult for stools to pass along. If a patient has faecal impaction, they will initially be treated with a high dose of the osmotic laxative macrogol. After a few days of using this laxative, patients may also have to start taking a stimulant laxative. If they do not respond to these laxatives, they may need one of the medications described below:

• Suppository: this type of medicine is inserted into the anus. The suppository gradually dissolves at body temperature, and it is then absorbed into the bloodstream. Bisacodyl and glycerol are two medicines which can be given in suppository form.
• Mini enema: this is when a medicine in fluid form is injected through the anus and into the large bowel. Docusate and sodium citrate may be given in this way.

Pregnancy or breastfeeding

If a patient is pregnant, there are ways for them to safely treat constipation without harming themselves or their baby. The doctor will first advise them to change their diet by increasing fibre and fluid intake. They will also be advised to do some gentle exercise.

If dietary and lifestyle changes do not work, women may be prescribed a laxative to help them pass stools more regularly. Lots of laxatives are safe for pregnant women to use because most are not absorbed by the digestive system. This means that their baby will not feel the effects of the laxative.

Laxatives which are safe to use during pregnancy include the osmotic laxatives lactulose and macrogols. If these do not work, the doctor may advise a small dose of bisacodyl or senna (stimulant laxatives). However, senna may not be suitable if a women is in her third trimester of pregnancy (27 weeks to birth), because this medicine is partially absorbed by the digestive system.

Babies who have not yet been weaned 

If a baby is constipated but has not yet started to eat solid foods, the first way to treat them is to give them extra water between their normal feeds. If a mother is using formula milk, then she must make the formula as directed by the manufacturer and do not dilute the mixture. She may want to try gently moving her baby's legs in a bicycling motion or carefully massaging their abdomen (tummy) to help stimulate their bowels.

Babies who are eating solids 

If a baby is eating solid foods, their mother should give them plenty of water or diluted fruit juice. They should try to encourage them to eat fruit, which can be pureed or chopped, depending on their ability to chew. The best fruits for babies to eat to treat constipation are:

• apples.
• grapes.
• prunes.
• pears.
• apricots.
• peaches.
• plums.
• raspberries.
• strawberries.

Mothers must never force their baby to eat food if they do not want to. If they do, it can turn mealtimes into a battle, and their child may start to think of eating as a negative and stressful experience. If the baby is still constipated after a change in diet, they may have to be prescribed a laxative. Bulk-forming laxatives are not suitable for babies, so they will usually be given an osmotic laxative. However, if this does not work, they can be prescribed a stimulant laxative.

Children

As with babies and adults, children with constipation will first be advised to change their diet. If this does not work, laxatives can be prescribed, usually an osmotic laxative followed, if necessary, by a stimulant laxative. As well as eating fruit, older children should have a well-balanced diet, that also contains vegetables and wholegrain foods such as wholemeal bread and pasta.

Try to minimise stress or conflict associated with using the toilet or meal times. It is important to be positive and encouraging when it comes to establishing a toilet routine. The child should be allowed at least 10 minutes on the toilet to make sure they have passed as many stools as possible. To encourage a positive toilet routine, mothers should try making a diary of their child's bowel movements linked to a reward system. This can help them focus on using the toilet successfully.

Top tips for parents

• A diet rich in fibre and with plenty of fluids will help, even if the child is being treated with laxatives.
• Children with chronic (long-term) constipation do not normally have anything physically wrong with them. However, it can take time to correct the problem, so be patient.
• Encourage the child to have a regular toilet habit and allow them plenty of time.
• A reward chart for passing a stool can be useful if the child tends to ‘hold on’.

Complications with constipation 

Constipation rarely causes any complications or long-term health problems. Treatment is usually effective, particularly if it is started promptly. However, if a patient has chronic (long-term) constipation, they may be more at risk of experiencing complications.

Haemorrhoids

If patients continually strain to pass stools, it can cause pain, discomfort and bleeding. Excessive straining can also lead to haemorrhoids (piles). Haemorrhoids are swollen blood vessels which form in the lower rectum and anus. Haemorrhoids can cause:

• Pain.
• Itching around the anus.
• Swelling of the anus.
• Bleeding from the anus.

Faecal impaction

Chronic constipation may increase the risk of faecal impaction (where dried, hard stools collect in the rectum and anus). Once a patients has faecal impaction, it is very unlikely that they will be able to get rid of the stools naturally.

Faecal impaction worsens constipation because it makes it harder for stools and waste products to pass out of your anus as the path is obstructed. If you experience faecal impaction, it can lead to a number of other complications. These include:

1) swelling of the rectum

2) losing sensation in and around your anus

3) faecal incontinence, when you uncontrollably leak soft or liquid stools

4) bleeding from your anus

5) rectal prolapse, when part of your lower intestine falls out of place and protrudes from your anus.

Psychological effects

If your child experiences faecal incontinence, it may affect them psychologically. Faecal incontinence can be very upsetting and embarrassing for children. If they are at school, they may find themselves teased or socially excluded. This may make a child feel withdrawn, alone and unable to talk about what they are experiencing.

If a parent notices a change in their child's behaviour, they must talk openly and honestly with them and encourage them to tell them how they are feeling. Also parents should try to speak to their child's teacher, to make sure they understand the situation. The teacher can help ensure the child is not upset or left feeling excluded by other children.

Source: NHS Choices.

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