Constipation is difficult or infrequent bowel movements, hard stool, or a feeling that the rectum is not totally empty after a bowel movement (incomplete evacuation). (See also Constipation in Children Constipation in Children Constipation refers to delay or difficulty in passing stool for a period of at least 1 month in infants and toddlers and a period of 2 months in older children (see also Constipation in adults)... read more .)
Constipation may be acute or chronic. Acute constipation begins suddenly and noticeably. Chronic constipation may begin gradually and persists for months or years.
Many people believe they are constipated if they do not have a bowel movement every day. However, daily bowel movements are not normal for everyone. It is normal to have anywhere from 1 to 3 bowel movements per day to 2 to 3 bowel movements per week. Having infrequent bowel movements does not necessarily indicate a problem unless there has been a substantial change from previous patterns. The same is true of the color, size, and consistency of stool. People often blame constipation for many symptoms (such as abdominal discomfort, nausea, fatigue, and poor appetite) that are actually the result of other disorders (such as irritable bowel syndrome [IBS] and depression). People should not expect all symptoms to be relieved by a daily bowel movement, and measures to aid bowel habits, such as laxatives and enemas, should not be overused. However, people may harmlessly help relieve their symptoms by eating more fruits, vegetables, fiber, and cereals. Foods that can affect the frequency of bowel movements are listed in table Foods That Often Affect Gastrointestinal Function Foods That Often Affect Gastrointestinal Function .
The complications of constipation include
Excessive straining during bowel movements increases pressure on the veins around the anus and can lead to hemorrhoids Hemorrhoids Hemorrhoids are dilated, twisted blood vessels located in the wall of the lower rectum and anus. The swollen vessels are caused by an increase in pressure. Lumps form inside or outside of the... read more and, rarely, protrusion of the rectum through the anus (rectal prolapse Rectal Prolapse Rectal prolapse is a painless protrusion of the rectum through the anus. A rectal prolapse is often triggered while straining, such as during a bowel movement. The diagnosis is based on an examination... read more ). Passing hard stool can cause a split in the skin of the anus (anal fissure Anal Fissure An anal fissure is a tear or ulcer in the lining of the anus (the opening at the end of the digestive tract where stool leaves the body). Anal fissures may occur after passage of hard or large... read more ). Each of these complications can make having a bowel movement uncomfortable and make people reluctant to move their bowels. Putting off bowel movements can cause a vicious circle of worsening constipation and complications.
Diverticular disease Definition of Diverticular Disease Diverticular disease is characterized by small, balloon-like sacs (diverticula) protruding through the layers of particular structures in the gastrointestinal tract (digestive tract). A single... read more can develop if the walls of the large intestine are damaged by the increased pressure required to move small, hard stools. Damage to the walls of the large intestine leads to the formation of balloon-like sacs or outpocketings (diverticula), which can become inflamed (diverticulitis Diverticulitis Diverticulitis is inflammation of one or more balloon-like sacs (diverticula). Infection may or may not develop. Diverticulitis usually affects the large intestine (colon). Left lower abdominal... read more ). Diverticula sometimes bleed and rarely rupture (causing peritonitis Peritonitis Abdominal pain is common and often minor. Severe abdominal pain that comes on quickly, however, almost always indicates a significant problem. The pain may be the only sign of the need for surgery... read more ).
Fecal impaction, in which stool in the rectum and last part of the large intestine hardens and completely blocks the passage of other stool, sometimes develops in people with constipation. Fecal impaction leads to cramps, rectal pain, and strong but futile efforts to defecate. Sometimes, watery mucus or liquid stool oozes around the blockage, which gives the false impression of diarrhea (overflow diarrhea). Fecal impaction is especially common among older people, particularly those who are bedridden or have decreased physical activity, pregnant women, and people who have been given barium by mouth or as an enema for certain types of x-ray tests.
Overconcern with regular bowel movements causes many people to abuse their bowels with laxatives, suppositories, and enemas. Overusing these treatments can actually inhibit the bowel’s normal contractions and worsen constipation. People with obsessive-compulsive disorder (OCD) Obsessive-Compulsive Disorder (OCD) Obsessive-compulsive disorder is characterized by obsessions, compulsions, or both. Obsessions are recurring, persistent, unwanted, anxiety-provoking, intrusive ideas, images, or urges. Compulsions... read more often feel the need to rid their body daily of “unclean” wastes or "toxins." Such people often spend excessive time on the toilet or become chronic users of laxatives.
Causes of Constipation
The most common causes of constipation include
Changes in diet (such as decreased fluid intake, low-fiber diet, and/or constipating foods)
Drugs that slow the bowels
Constipation-predominant irritable bowel syndrome (IBS)
Dietary causes are very common. Dehydration causes constipation because the body tries to conserve water in the blood by removing additional water from the stool. Stool that contains less water is harder to pass. Fruits, vegetables, cereals, and other fiber-containing foods are the natural laxatives of the digestive tract. People who do not eat enough of these foods can become constipated. Lack of fiber (the indigestible part of food) in the diet can lead to constipation because fiber helps hold water in the stool and increases its bulk, making it easier to pass.
The most common drugs that can slow the bowels include opioids, iron salts, and drugs with anticholinergic effects (such as many antihistamines and tricyclic antidepressants—see sidebar Anticholinergic: What Does It Mean? Anticholinergic: What Does It Mean? ). Other drugs include aluminum hydroxide (common in over-the-counter antacids), bismuth subsalicylate, certain drugs that lower blood pressure (antihypertensives), and many sedatives.
Disordered defecation (dyschezia) refers to a problem with the bowels generating enough force to propel stool from the rectum and/or difficulty relaxing the muscle fibers around the rectum and the external anal sphincter during defecation. People with dyschezia sense the need to have a bowel movement but cannot. Even stool that is not hard may be difficult to pass. People with IBS Irritable Bowel Syndrome (IBS) Irritable bowel syndrome is a disorder of the digestive tract that causes recurring abdominal pain and constipation or diarrhea. Symptoms vary but often include lower abdominal pain, bloating... read more may have IBS-disordered defecation.
People with IBS may have loose stools, disordered defecation, or constipation. If IBS is usually accompanied by constipation, it is called constipation-predominant IBS.
People who frequently use laxatives and/or enemas often lose the ability to move their bowels without such aids. A vicious circle can result with constipation leading to more laxative use and thus more constipation.
Less common causes of constipation include specific medical disorders ( see Table: Some Causes and Features of Constipation Some Causes and Features of Constipation ), such as intestinal obstruction Intestinal Obstruction An obstruction of the intestine is a blockage that completely stops or seriously impairs the passage of food, fluid, digestive secretions, and gas through the intestines. The most common causes... read more , and certain metabolic disorders and neurologic disorders. Constipation also can occur during any major illness that requires prolonged bed rest (because physical activity helps the intestines move stool along), with decreased food intake, with use of drugs that can cause constipation, and after a head or spinal cord injury. In many cases, however, the cause of constipation is unknown.
Constipation is sometimes caused by obstruction of the large intestine. Obstruction can be caused by a cancer, especially in the last portion of the large intestine, that blocks the movement of stool. People who previously had abdominal surgery may develop obstruction, usually of the small intestine, because bands of fibrous tissues (adhesions) can form around the intestines and impede the flow of stool.
Disorders and diseases that often cause constipation include an underactive thyroid gland (hypothyroidism Hypothyroidism Hypothyroidism is underactivity of the thyroid gland that leads to inadequate production of thyroid hormones and a slowing of vital body functions. Facial expressions become dull, the voice... read more ), high blood calcium levels (hypercalcemia Hypercalcemia (High Level of Calcium in the Blood) In hypercalcemia, the level of calcium in blood is too high. A high calcium level may result from a problem with the parathyroid glands, as well as from diet, cancer, or disorders affecting... read more ), and Parkinson disease Parkinson Disease (PD) Parkinson disease is a slowly progressive degenerative disorder of specific areas of the brain. It is characterized by tremor when muscles are at rest (resting tremor), increased muscle tone... read more . People with diabetes Diabetes Mellitus (DM) Diabetes mellitus is a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high. Urination and thirst are... read more often develop nerve damage (neuropathy). If the neuropathy affects nerves to the digestive tract, the intestines may slow down, resulting in constipation. Spinal cord injury Injuries of the Spinal Cord and Vertebrae Most spinal cord injuries result from motor vehicle crashes, falls, assaults, and sports injuries. Symptoms, such as loss of sensation, loss of muscle strength, and loss of bowel, bladder, and... read more can also interfere with the nerves to the intestines and cause constipation.
Evaluation of Constipation
Not every episode of constipation requires immediate evaluation by a doctor. The following information can help people decide whether a doctor’s evaluation is needed and help them know what to expect during the evaluation.
In people with constipation, certain symptoms and characteristics are cause for concern. They include
Distended, swollen abdomen
Blood in stool
New/worsening severe constipation in older people
When to see a doctor
People who have warning signs should see a doctor right away, unless the only warning signs are weight loss and/or new constipation in older people. In such cases, a delay of a few days to a week is not harmful.
People who have constipation but no warning signs should call their doctor, who can help decide how quickly they need to be seen. Depending on the person's other symptoms and known disorders, doctors may wish to see the person within a few days or may simply recommend trying changes in diet and/or a mild laxative.
What the doctor does
Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the constipation and the tests that may need to be done ( see Table: Some Causes and Features of Constipation Some Causes and Features of Constipation ).
During the history, doctors ask about the following:
Stool frequency, consistency, and the need to strain or use maneuvers (such as pushing on the area between the scrotum or vagina and the anus [perineum] during defecation)
Feeling of incomplete evacuation
Satisfaction after defecation, including how often and how long people have used laxatives or enemas
Diet and physical activity level, particularly any change in these factors
Prescription and nonprescription drug use (particularly those known to cause constipation)
Doctors also ask about symptoms of metabolic (such as hypothyroidism and diabetes) and neurologic (such as spinal cord injury) disorders.
During the physical examination, doctors look at the following:
Signs of bodywide (systemic) disease, including weight loss, fever, and severe wasting away of muscle and fat tissue (cachexia)
The abdomen for distention and masses
The rectum for fissures, hemorrhoids, blood, or masses (including fecal impaction) and also anal muscle tone and sensation
The need for tests depends on what doctors find during the history and physical examination, particularly whether warning signs are present. When the cause of the constipation is clear (such as due to drugs, injury, or bed rest), doctors often treat the person’s symptoms and do no testing.
People with symptoms of intestinal obstruction undergo abdominal x-rays and possibly a computed tomography (CT) scan Computed Tomography (CT) In computed tomography (CT), which used to be called computed axial tomography (CAT), an x-ray source and x-ray detector rotate around a person. In modern scanners, the x-ray detector usually... read more . Most people with no clear cause or whose symptoms have not been relieved with treatment should have tests. Typically, doctors do a colonoscopy Endoscopy Endoscopy is an examination of internal structures using a flexible viewing tube (endoscope). Endoscopy can also be used to treat many disorders because doctors are able to pass instruments... read more (to detect cancer) and blood tests to check for an underactive thyroid gland (hypothyroidism) or high calcium levels in the blood (hypercalcemia).
People whose initial test results are normal but whose symptoms are not relieved with treatment usually require further testing. If the main symptom is difficulty with defecation, doctors measure the pressure inside the anus and rectum (called anorectal manometry). If the main symptom is infrequent defecation, doctors measure how long it takes stool to leave the intestines by having people swallow small, slightly radioactive objects that can be tracked using a scanner (a type of radionuclide scanning Radionuclide Scanning In radionuclide scanning, radionuclides are used to produce images. A radionuclide is a radioactive form of an element, which means it is an unstable atom that becomes more stable by releasing... read more ) or swallow a wireless motility capsule that is tracked over a 4-day period.
Treatment of Constipation
Any underlying disorder causing constipation must be treated. When possible, drugs that cause constipation are stopped or changed.
Constipation is best prevented with a combination of exercise, a high-fiber diet, and an adequate intake of fluids. When a potentially constipating drug is prescribed and/or people are placed on bed rest, doctors often give a laxative and recommend increased intake of dietary fiber and fluids rather than waiting for constipation to develop.
There are three approaches to treating people with constipation:
Diet and behavior
Doctors are cautious with use of laxatives, suppositories, and enemas because they can cause diarrhea, dehydration, cramps, and/or dependence on laxatives. People with sudden abdominal pain of unknown cause, inflammatory bowel disorders, intestinal obstruction, gastrointestinal bleeding, or fecal impaction should not use laxatives or enemas.
Diet and behavior
People need to ingest enough fiber in their diet (typically 15 to 20 grams per day) to ensure adequate stool bulk. Vegetables, fruits, and bran are excellent sources of fiber. Many people find it convenient to sprinkle 2 or 3 teaspoons of unrefined miller’s bran on high-fiber cereal or fruit 2 or 3 times a day. To work well, fiber must be consumed with plenty of fluids.
People should try to make changes to their behavior. For example, people should try to move their bowels at the same time every day, preferably 15 to 45 minutes after breakfast, because eating food stimulates movement in the colon. Glycerin suppositories may also help people have regular, unhurried bowel movements.
Doctors explain to people why diet and behavior modification are important in treating constipation. Doctors also explain that daily bowel movements are not necessary, that the bowel must be given a chance to function, and that frequent use of laxatives or enemas (more than once every 3 days) denies the bowel that chance. People who have obsessive-compulsive disorder (OCD) Treatment Obsessive-compulsive disorder is characterized by obsessions, compulsions, or both. Obsessions are recurring, persistent, unwanted, anxiety-provoking, intrusive ideas, images, or urges. Compulsions... read more are treated for that disorder.
People who have dyssynergic defecation may need to see specialized therapists for biofeedback training.
Some laxatives are safe for long-term use. Other laxatives should be used only occasionally. Some laxatives are good for preventing constipation, others for treating it. There are several classes of laxatives, including the following:
Bulking agents, such as bran and psyllium (also available in the fiber of many vegetables), add bulk to the stool and absorb water. The increased bulk stimulates the natural contractions of the intestine, and bulkier stools that contain more water are softer and easier to pass. Bulking agents act slowly and gently and are among the safest ways to promote regular bowel movements. These agents generally are taken in small amounts at first. The dose is increased gradually until regularity is achieved. People who use bulking agents should always drink plenty of fluids. These agents may cause problems with increased gas (flatulence) and bloating.
Stool softeners, such as docusate or mineral oil, act slowly to soften stools, making them easier to pass. In addition, the slightly increased bulk that results from these drugs stimulates the natural contractions of the large intestine and thus promotes easier elimination. Some people, however, find the softened nature of the stool unpleasant. Stool softeners are best reserved for people who must avoid straining, such as people who have hemorrhoids or have recently had abdominal surgery.
Osmotic agents pull large amounts of water into the large intestine, making the stool soft and loose. The excess fluid also stretches the walls of the large intestine, stimulating contractions. These laxatives consist of salts or sugars that are poorly absorbed. They may cause fluid retention in people who have kidney disease or heart failure, especially when given in large or frequent doses. In general, osmotic laxatives are reasonably safe even when used regularly. However, osmotic agents that contain magnesium and phosphate are partially absorbed into the bloodstream and can be harmful to older people, people who have kidney failure or kidney disease, and people who take drugs that affect kidney function (such as diuretics, angiotensin-converting enzyme [ACE] inhibitors, and angiotensin II receptor blockers). Although a rare occurrence, some people have developed kidney failure from taking sodium phosphate laxatives by mouth to clear stool from the intestine before x-rays of the digestive tract are taken or before a colonoscopy is done.
Stimulant laxatives (such as phenolphthalein, bisacodyl, and anthraquinones) contain irritating substances, such as senna and cascara. These substances stimulate the walls of the large intestine, causing them to contract and move the stool. They are useful for preventing constipation in people who are taking drugs that will almost certainly cause constipation, such as opioids. Stimulant laxatives are also often used to empty the large intestine before diagnostic tests are done.
Taken by mouth, stimulant laxatives usually cause a semisolid bowel movement in 6 to 8 hours, but they often cause cramping as well. As suppositories, stimulant laxatives often work in 15 to 60 minutes. Prolonged use of stimulant laxatives can create abnormal deposits of a dark pigment in the lining of the large intestine (a condition called melanosis coli). Other side effects include allergic reactions and loss of electrolytes from the blood. Also, the large intestine can become dependent on stimulant laxatives, leading to lazy bowel syndrome. Therefore, stimulant laxatives should be used only for brief periods.
Bisacodyl is an effective drug for chronic constipation. Anthraquinones are found in senna, cascara sagrada, aloe, and rhubarb and are common components of herbal and over-the-counter laxatives. Lubiprostone works by making the large intestine secrete extra fluid, which makes stool easier to pass. Unlike other stimulant laxatives, lubiprostone is safe for prolonged use.
Mu-opioid receptor antagonists (such as methylnaltrexone, naloxegol, naldemedine, and alvimopan) are drugs that are used to treat opioid-induced constipation that is not relieved by other measures. These drugs are designed to block the effects of opioids on the bowel without interfering with the pain relief opioids deliver. The most common side effects include stomach pain, diarrhea, nausea, vomiting, and headache.
Enemas mechanically flush stool from the rectum and lower part of the large intestine. Small-volume enemas can be purchased in squeeze bottles at a pharmacy. They can also be given with a reusable squeeze-ball device. However, small-volume enemas are often inadequate, especially for older people, whose rectal capacity increases with age, thus making the rectum more easily stretched. Larger-volume enemas are given with an enema bag.
Plain water is often the best fluid to be used as an enema. The water should be room temperature to slightly warm, not hot or cold. About 5 to 10 fluid ounces (150 to 300 milliliters) is gently directed into the rectum. (CAUTION: Too much force is dangerous.) People then expel the water, washing stool out with it.
Various ingredients are sometimes added to enemas. Prepackaged enemas often contain small amounts of salts, often phosphates. Other enemas contain small amounts of soap (soapsuds enema), which has a stimulant laxative effect, or mineral oil. These enemas offer little advantage, however, to plain water.
Very large-volume enemas, called colonic enemas, are rarely used in medical practice. Doctors use colonic enemas in people with very severe constipation (obstipation). Some practitioners of alternative medicine use colonic enemas in the belief that cleansing the large intestine is beneficial. Tea, coffee, and other substances are often added to colonic enemas but have no proven health value and may be dangerous.
Fecal impaction cannot be treated by modifying the diet or taking laxatives. Fecal impaction is first treated with enemas of tap water followed by small enemas of commercially prepared solutions. If these enemas do not work, the hard stool must be removed by a doctor or nurse using a gloved finger. This procedure is painful, so an anesthetic (such as lidocaine 5% ointment) is often applied. Some people need to be sedated. Typically, an enema is given after the hard stool is removed.
Essentials for Older People
The rectum enlarges as people age, and increased storage of stool in the rectum means that older people often need to have larger volumes of stool in their rectum in order to feel the urge to defecate. The increased rectal volume also allows hard stool to become impacted.
Other common factors in older people that lead to constipation include increased use of constipating drugs, a low-fiber diet, coexisting medical conditions (such as diabetes and an underactive thyroid), and reduced physical activity. Many older people also have misconceptions about normal bowel habits and use laxatives too often.
Drug causes (such as use of anticholinergic or opioid drugs) are common.
Doctors look for intestinal obstruction when constipation is sudden and severe.
Symptoms may be treated if no warning signs are found and doctors find no evidence of disordered defecation.