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Constipation


Bowel habits are formed early in life. We may pick up poor habits and develop problems because we rarely talk about how to look after our bowels. Many people are unsure if their bowel motions are normal.

WHAT IS NORMAL?

Patients and doctors differ greatly in their understanding and use of the word ‘constipation’. For many people, it is used for the infrequent passage of stools. For others it can refer to the passage of very hard stools. There is huge variation in bowel habits and many patients go several days without opening their bowels. This is not necessarily abnormal.

Strictly speaking, ‘normal bowel action’ ranges between three times a day to three times a week. However, if you regularly open your bowels less frequently than this it does not mean that you have to seek medical attention. Stool stored in your bowel does not give off toxins, and it will not ‘poison you’ as some people believe.

Medically, we talk about constipation if you have fewer than three bowel motions per week AND if you have any two of the problems listed below:

  • The need to strain
  • Lumpy or hard stool (Bristol stool type 1 or 2)
  • Feeling that your bowel is not empty after going to the toilet
  • Feeling that your bowel is blocked
  • Need for specific manoeuvres like supporting your pelvic floor or vagina or if you need to digitate (use your fingers to get stool out)
  • Having repeated visits to the toilet to empty the bowel.

If you have had these problems in more than 25% of your bowel motions for more than three months in the past year then you may have had constipation.

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 long-term (chronic) condition that causes significant pain and discomfort and affects quality of life.

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CAUSES

Constipation can have several causes:

  • You might not be drinking enough. Every person needs to drink 1.5 litres of water a day (unless they have been told to restrict fluid by their heart/kidney specialist or GP). Caffeinated drinks are much less effective as they can dehydrate a little rather than hydrate. It is a good idea to get a re-usable water bottle to take with you wherever you go, and make sure you keep hydrated.
  • You might not be active enough. Bowel motions are greatly helped by movement. A daily
    20-minute walk should greatly improve bowel function.
  • You might be delaying the urge to go to the toilet for many hours. Naturally, after eating,
    the ‘gastro-colic reflex’ coordinates contractions of your bowel to help to clear it out. If you
    ignore these signals for a long time you might lose sensitivity to them. Try to get into a
    routine where you allow yourself sufficient time to open your bowels in the morning after
    breakfast, coffee and/or a walk.
  • Shift work and/or frequent travel can upset your bowels.
  • Stress can have severe impact on your bowel function. Yoga or meditation can often help.
  • Lack of a ‘safe-toilet environment’ can have a detrimental effect. It is very important to
    create an environment in which you are able to completely relax without disturbances from
    children, pets or other noises.
  • Your fibre intake might be wrong for you. You might not be eating enough fibre, too much,
    or the wrong type. Please see our advice on fibres. We realise this is often complex
    information and seeking help of a dietitian can be useful.

We are often told to eat more fibre for a healthy diet, and the current ‘five a day’ recommendation for fruit and vegetable intake is probably sensible for most people. For people with a low fibre diet and with some types of constipation, eating more fibre in the form of fruit, vegetables and pulses can greatly improve symptoms. If you have been advised to increase your fibre intake, your specialist nurse/dietitian will advise on diet, and you can consult the British Dietetic Association (BDA) “Fruit and Veg’ leaflet for advice on higher fibre foods to choose (ask your nurse for a copy, or visit
https://www.bda.uk.com/foodfacts/home).

However, some people who suffer from constipation, especially those with slow transit constipation or IBS constipation, may actually need to reduce their fibre intake. In these cases, the roughage does not move along the bowel as quickly as it should and reducing fibre may help relieve the symptoms of constipation. If you feel that you already eat plenty of fibre and still suffer from constipation we would recommend consulting a specialist dietitian, who will carry out a thorough assessment and work with you to adjust your fibre intake accordingly.

  • Certain drugs can cause constipation. Ask your GP for help if you are taking the following medication:
    • Painkillers (any drug containing codeine or morphine)
    • Acid-reducing medication for your stomach (Aluminium antacids)
    • Antimuscarinics (such as procyclidine, oxybutynin)
    • Iron supplements
    • Depression medication (tricyclic antidepressants)
    • Allergy medication (sedating antihistamines)
    • Parkinson’s Disease medication
    • Anti-diarrhoea medication
    • Antiepileptics (carbamazepine, gabapentin, oxcarbazepine, pregabalin, phenytoin)
    • Antipsychotics.
    • Antispasmodics (such as dicycloverine, hyoscine)
    • Calcium supplements
    • Diuretics
    • Verapamil
  • You might have an underactive thyroid. Your GP can check your bloods for this.
  • You may have a slow or lazy colon that does not propel food through the bowel at the proper speed. We call this ‘Slow Transit Constipation’.
  • You may have an outlet obstruction or evacuation problem, known as Obstructed Defaecation Syndrome (ODS). If you suffer from this you may feel that the rectum is full, but have difficulty with the actual process of passing stool through the last bit of the bowel and emptying of the rectum.

WHAT TESTS DO I NEED?

If you have noticed a change in your bowel habit combined with fatigue, weight loss or bleeding it is best to have a colonoscopy or an equivalent test performed to exclude serious disease.

With a combination of a proctogram and transit studies we are usually able to distinguish between a transit or an evacuatory (emptying) problem. These investigations are helpful to assess if there are underlying structural problems of rectal prolapseenterocoele or rectocoele .

WHAT TREATMENT CAN I EXPECT?

Surgery is not the first (or even the second) treatment for slow transit constipation.Primary treatment for constipation are diet and lifestyle changes. Medication to help you open your bowels can be prescribed by your GP or a gastroenterologist.

Other people benefit greatly from ‘rectal irrigation’, which is a self-administered treatment in which the lower bowel is washed clean with tap water introduced via a tube inserted into the bottom.

The major operation of subtotal colectomy (removal of the whole large bowel) is now rarely performed, as the results of this surgery remain unpredictable. When slow transit constipation coexists with obstructed defecation, surgery to treat the outlet obstruction may improve the overall symptoms of constipation.

Sacral nerve stimulation may have a role in the future, but further data are awaited. Currently the NHS rarely funds SNS for constipation.

If tests show that you have obstructed defaecation, diet and lifestyle changes may not be enough to sufficiently improve your symptoms and an operation may be necessary.

 

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Please be advised that the information on this website is not a substitute for professional medical advice, diagnosis or treatment