Constipation means infrequent or difficult bowel movements. It often occurs when digested food moves too slowly through the digestive tract. As a result, the body removes (absorbs) too much water from the stools, causing them to become hard, dry and difficult to pass.

Constipation is very common: one in 4 Canadians has symptoms of constipation. It can affect the young and elderly and everyone in between. For some people, constipation develops suddenly and lasts for a short time. For others, particularly older people, it may begin gradually and last for an extended period of time.

Constipation is common but it is not normal. While making good choices about diet and exercise can usually relieve occasional constipation, those who suffer from chronic constipation know these don’t work and may need to speak to a pharmacist or doctor to find a solution.

What causes constipation?

Constipation arises if you have a problem that affects your colon in one or more of three key areas:

• Intake: what you eat (e.g., food, water, fibre)
• Transit: how quickly stool moves through your colon
• Outlet: how stool exits your body.

How can I prevent constipation?

1. Food and drink: Start by aiming for about 18 grams of fibre per day, which you can gradually increase to 20-30 grams. (Look for fibre content on food labels or online.) Similarly, if you’re like most adults and don’t drink enough fluids, gradually increase your intake of fluids such as water and broth, while cutting back on caffeine, alcohol, sugary drinks.
2. Exercise: For many, regular exercise may improve your constipation symptoms, along with your mood, energy and general fitness. Aim for at least 30 minutes of walking or physical activity five times a week.
3. Toilet habits: Practice good “toilet hygiene” by setting aside a time – ideally in the morning or about 30 minutes after a meal – to pass stool. When you feel the urge to defecate, ignoring it can significantly increase your chances of having constipation. Familiarity with local facilities can help ensure you can get to a bathroom quickly when you feel the urge. When you use the toilet, make sure you have enough time and privacy to pass stools comfortably.
4. Regular daily routine: Strive to maintain a regular lifestyle. As a general rule, the more consistent your eating and sleeping patterns, the better your bowel function.

Constipation in Children

Constipation in children doesn’t necessarily signal the same problems as it does in adults: children often develop constipation when they deliberately or subconsciously prevent themselves from passing stool. They may be reluctant to interrupt playtime, embarrassed to use a public washroom, or afraid to have an unpleasant bowel movement (a particular concern for kids at the potty-training stage).

Of course, some of the causes of adult constipation also apply to kids, such as:

• A low-fibre diet
• Certain medications, such as antacids, opioids or antidepressants
• Certain diseases, such as diabetes or Down syndrome
• Anatomic abnormalities such as Hirschsprung’s disease Experts recommend having your child see a doctor if constipation symptoms last more than two weeks, and sooner than that if the constipation is accompanied by fever, vomiting, weight loss, blood in the stool, cracks in the skin around the anus, or rectal prolapse (intestine protruding from the anus)
• Treatment, which depends on the child’s age and severity of the problem, may include changing diet, adopting a regular schedule for clearing bowels, and (in some cases, such as stool stuck in the bowel) taking laxatives

Watch this educational video to learn how to get things moving and get on with enjoying your life!

When you are constipated, you have to strain to defecate and you typically pass small, hard stools. You may also have a feeling that your rectum has not been completely emptied. Other signs and symptoms of constipation may include:

• Abdominal discomfort or pain
• A sense that something is blocked in your rectum
• Excessive straining during bowel movements
• Lower frequency of bowel movements (compared to your normal)
• Change in type of stool

Most people don’t need extensive testing to identify constipation: you know it when you have it. Still, understanding what’s normal can help you identify constipation earlier and explain it to your doctor.

Understanding Constipation with Dr. Armstrong

At the 2012 CDHF Digestive Health Public Education Forum, Dr. David Armstrong gave an interesting and educational presentation on Constipation to a capacity crowd.

The Bristol Stool Chart

The Bristol Stool Chart classifies human feces into 7 categories based on shape and consistency.

• Types 1 and 2 occur with constipation
• Types 3 and 4 are considered normal
• Types 5 to 7 occur with diarrhea

Constipated

Type 1

Separate hard lumps, like nuts (hard to pass)

Type 2

Sausage-shaped but lumpy

Normal

Type 3

Like sausage but with cracks on its surface

Type 4

Like a sausage or snake, smooth and soft

Diarrhea

Type 5

Soft blobs with clearcut edges (passes easily)

Type 6

Fluffy pieces with ragged edges, a mushy stool

Type 7

Water, no solid pieces. Entirely liquid.

When it comes to frequency of bowel movements, it’s a little harder to draw the line between what’s healthy and what’s not because every individual has a different pattern of bowel movements: some people have bowel movements three or more times a day, while others only defecate a few times per week. Both patterns can still be normal.

Alarm symptoms of constipation

Alarm symptoms are not typical constipation symptoms and may signal other, possibly more serious health issues. Consult your doctor if you experience any of the following:

• Rectal bleeding with or without dark red blood mixed in with the stool
• Unintended weight loss
• Fever (check your temperature to see if it is over 36.5°C)
• Nausea
• Vomiting
• Persistent diarrhea
• Anemia, especially iron-deficiency anemia
• Abdominal pain that is not relieved by a bowel movement or that wakes you up at night.

As a rough guideline, you probably have a chronic (long-term) constipation problem if you’ve experienced 2 or more of the following symptoms for at least 3 months:

• Straining during more than 1 out of 4 bowel movements
• Hard stools more than 25% of the time
• Incomplete evacuation more than 25% of the time
• Fewer than 3 bowel movements in a week

If you have constipation for more than 2 weeks, be sure to see a doctor to find out why you have developed this problem and how you can treat it.

At the start, your doctor will generally ask you about your eating and drinking habits, your stress levels, your medications and any symptoms that may suggest that your constipation has a specific, treatable cause. Depending on your symptoms, your doctor may also perform a blood test to find out if you have anemia.

Colon cancer is an important but uncommon cause of constipation. If you are over 50 years of age, have a first-degree relative (parent, sibling, or child) who has had colon cancer or if you’ve had a positive stool test in a provincial colorectal cancer screening program, you will be offered a colonoscopy.

Constipation can usually be prevented or treated successfully. It is best to start with simple strategies and move on to stronger measures when necessary.

Although most of us will suffer from constipation at some point in our lives, chronic constipation is not normal. If you continue to be constipated after unsuccessfully trying the lifestyle changes suggested below it is important to speak with your doctor about treatment options.

Managing Constipation

Even if you can’t prevent all constipation, you may be able to reduce its frequency or severity by eating enough fibre, drinking enough fluids, exercising, and maintaining good toilet habits. The following small changes in your daily habits may help relieve constipation:

Increasing the amount of fibre in your diet:

For best general health and colon function, aim to consume about 20 to 30 grams of fibre every day. Derived from plants, fibre is the indigestible portion of food. Fibre may cause bloating and discomfort, especially if you’re not used to it, so be sure to “fibre up” over several days or weeks by gradually increasing your intake of:

• Vegetables and fruits (ideally with the skin)
• Whole-grain breads, cereals and pastas
• Legumes such as beans and peas
• Nuts and seeds

Note: If you have narrowings (strictures) or scar tissue in your digestive tract, significantly increasing your fibre intake can cause a bowel obstruction; if you have had any previous surgeries or blockages (e.g. due to adhesions), discuss this with your doctor before making any big changes in your diet.

There are two types of fibre:

• Soluble fibre: this type dissolves in water and keeps water in the digestive system. Sources include oatmeal, lentils, apples, oranges, nuts, beans, celery, and carrots. Pectin (found in apples, strawberries, lychees, and pears) is a form of soluble fibre.
• Insoluble fibre: this type does not dissolve in water and adds bulk or “roughage” that helps move stool through the digestive system. Sources include whole grains, bran, seeds, nuts, celery, broccoli, dark leafy vegetables, fruit, and root vegetable skins.

You can also eat foods with probiotics and prebiotics

Such as yogurt, kefir, bananas, whole-grain breads and honey, which help soften stool and ease its passage through the colon.

Avoiding or limiting fat

Foods that are greasy, fried, or high in animal fat or contain refined sugar, such as candy and rich desserts can contribute to constipation.

Increasing consumption of healthy liquids

Aim for 8-10 glasses a day of liquid which can include water, juices, milk, soup or other beverages. Avoid liquids with caffeine, alcohol or are rich with lots of sugar or artificial sweeteners.

Increasing your activity level

A sedentary lifestyle can lead to sluggish bowels. Regular exercise – even walking – can help boost bowel activity.

Developing “regularity” in your lifestyle

Try to find a consistent time every day to relax and have a bowel movement, your body will become accustomed to this pattern over time. Remember to avoid straining.

• Try to eat at regular and consistent times
• Establish regular sleeping patterns

Avoiding overuse of certain laxatives

Regular use of certain stimulant laxatives may decrease your “bowel tone,” resulting in poor bowel function. Watch for herbal laxatives, which may contain stimulants. Other laxatives that help you retain more water and are safe for regular use. Always check with your doctor before using any laxatives on a regular basis.

Taking care of your general well-being

Don’t smoke, limit alcohol, and adopt strategies to manage time and cope with stress.

How should I prepare for a doctor appointment about constipation?

Good communication with your doctor is an important part of managing your digestive health, regardless of your diagnosis. To ensure that all doctors have the most accurate information about you, it’s a good idea to keep a journal in which you:

• Write down the symptoms that are bothering you, and for how long you have had them.
• Write down key personal and medical information, including any recent changes or stressful events in your life.
• Jot down triggers (such as food, stress, activity, or menstrual cycle) that seem to make your symptoms worse.
• Make a list of medications are you taking, including the conditions you take them for; this should include any non-prescription medications, probiotics or herbal preparations you may use. Also note if any of your medications seem to affect your symptoms.
• Create a list of the health-related questions you would like your doctor to answer during your appointment.

Depending on your specific symptoms and diagnosis, here are some questions you may want to ask your doctor:

• What do you think is causing my symptoms?
• Are there other possible causes for my condition?
• What diagnostic tests do I need?
• Do these tests require any special preparation?
• What treatment approach do you recommend trying first?
• If the first treatment doesn’t work, what will we try next?
• Are there any side effects associated with these treatments?

Pharmacy products for constipation

If dietary and other lifestyle changes do not relieve constipation, you have several options for over-the-counter and prescription products.

Constipation – Selecting your Laxative

Constipation can happen when your stool moves too slowly through your colon, causing it to become dry and hard. When you have constipation, you want relief. Laxatives generally relieve constipation by increasing the frequency of bowel movements. In this animation you will learn about the mode of actions for three different types of laxatives Osmotic, Stimulant and Bulk-Forming.

Bulking agents

Products such as psyllium or methylcellulose help hold water in the stool and add bulk to it, which stimulates normal bowel contractions.

Emollient laxatives

Also known as stool softeners, these products contain a wetting agent that helps water penetrate and mix with the stool, so it becomes softer and easier to pass. It may take a week or longer for stool softeners to take effect. Examples include docusate sodium and docusate calcium.

Lubricant laxatives

This type of laxative may contain mineral oil, which coats the particles of stool to prevent water from escaping. Because fat-soluble vitamins (A, D, E and K) dissolve in the oil, they will not be absorbed as well by the intestine. For this reason, lubricant laxatives should only be used short-term.

Osmotic laxatives

These medications help retain the water in the stool, making it softer. Products in this class contain polyethylene glycol, undigestible sugars (lactulose, sorbitol) or ions such as magnesium, sulfate, phosphate or citrate; some require a prescription but many are available, ‘over-the-counter’, without a prescription. Osmotic laxatives are not absorbed or are poorly absorbed by the bowel, have few side effects, and are generally safe for long-term use with your health care provider’s recommendation.

As a general rule, try gentler products such as those listed above first. If they fail to provide relief move on to those that follow below.

Stimulant laxatives

This group of laxatives causes the bowel muscles to propel their contents more rapidly and also increases the amount of water in the stool. While very effective, using them can lead to diarrhea, dehydration and intestinal cramping.

Although there is no proof that chronic use damages the colon or worsens constipation, most experts agree that these products should be used sparingly. Common stimulant laxatives contain cascara, senna, bisacodyl, or aloe.

Enemas and suppositories

Enemas expand or irritate the rectum, which stimulates the colon to contract and eliminate stool. Especially useful when the stool is hardened and blocked (impacted) in the rectum, they are meant for occasional use and can disrupt the balance of fluids and electrolytes in the body if used regularly or in access. Suppositories also trigger bowel movements by stimulating or “irritating” the rectum.

Prokinetic agents (e.g. prucalopride)

These medications, available by prescription only, improve the motility (movement) and contraction of the bowel which speeds up the passage of stool through the bowel and increases stool frequency to relieve constipation.

How often should I have a bowel movement?

It is important to realize that the frequency of bowel movements varies from person to person. Some people may empty their bowels several times a day while others may only have a bowel movement once every few days. Whatever is normal for you, is fine. You should take note however, when your bowel patterns change.

Will a cleansing enema program help me?

There is no evidence that there is a build-up of harmful toxins in the bowel when one has an irregular bowel pattern. The most important factor in treating irritable bowel syndrome is what you do on a daily basis including eating, physical exercise and stress management.