Constipation is a condition characterized by inability to pass stools that become hard and more difficult to pass.
Bowel habits are unique to all individuals. For some passing stools once in two or three days may be normal while for others passing stools every day is normal.
Constipation affects all individuals at any age or at least once in their lifetime. Inability to empty the bowels completely also may lead to constipation.
Constipation can lead to hard, lumpy, large or small stools passage as well. Severity of the condition may vary from person to person.
While constipation may be resolved in a short duration in some individuals, with others it may take longer with pain and discomfort.
Prolonged periods of on and off constipation severely affects the quality of life of individuals.
The cause of constipation is difficult to identify but there are several risk factors that raise the likelihood of constipation. Some of the risk factors of constipation include:-
Diagnosis of constipation is based mainly on history of the condition. Criteria for constipation are included in the ROME criteria. This includes:-
Laxatives are medications that are prescribed to help empty the bowels. Treatment for constipation is effective but it may take weeks before there is a regular bowel pattern.
Prevention of constipation involves making diet and lifestyle changes. This includes eating high-fibre foods, drinking plenty of fluids and regularly exercising.
Good toilet habits and giving time and privacy to pass stools comfortably without ignoring the urge to go to the toilet also helps in preventing constipation.
Constipation affects people of all ages at least once in their life time. It is a common condition. Diagnosis usually involves detailed history of the condition from the patient about the signs and symptoms.
Tests and diagnostic procedures are usually not needed for diagnosis of constipation.
Diagnosis of constipation involves:-
Patients should not be embarrassed or shy in describing their normal bowel habits and the changes experienced. Diagnosis is made from the significant change in the bowel habits. Details of ignoring urges to pass stool and inadequacy of time and privacy for passing stools are also asked.
The patient is asked to detail the amount of fibres (from fruits and vegetables and whole grains) that they get in their daily diet. Lack of fluids and increased amount of red meats, processed meats and canned foods also leads to increased risk of constipation
Several medications may cause constipation as a side effect. Laxative abuse is also an important cause of constipation and needs to be detected while diagnosing constipation.
Criteria for constipation are included in the ROME criteria. This includes:-
Physical examination involves examination for fecal or stool impaction. Abdomen is examined for abnormalities as well.
Neurological disorders or spinal disorders are examined as they may lead to delay in bowel transit time and constipation. Spinal cord injury, multiple sclerosis, Parkinson’s disease etc. has to be ruled out.
Blood tests may be advised to rule out other conditions. If inflammatory bowel disease or bowel cancer is suspected a colonoscopy or sigmoidoscopy is advised.
Psychiatric evaluation is made to detect underlying cause of constipation. Previous history of sexual abuse, violence, trauma, fear or unusual attitude towards bowel motions, depression and eating disorders have to be ruled out or detected.
Anorectal function tests may be advised to detect increased muscle tone of the anus sphincter. Tests include Manometry for Hirschsprung’s disease and Electromyography for spastic pelvic floor dysfunction. Rectal mucosa may be taken for biopsy to examine for abnormalities.
The exact cause of constipation is not clear. However, there are several factors that may lead to an increased risk of constipation.
Some of these are irreversible for example age, pregnancy status and post-operative constipation. Some of these, however, are preventable by adopting life style and dietary modifications.
Causes and risk factors associated with constipation include:-
Constipation is common among infants and young children. Possible causes include lack of fluids in diet, lack of fibres, over feeding, malnutrition etc.
Another problem is inadequate and faulty toilet training. The child should not feel stressed or pressured about using the toilet. Constantly intervening while the child is using the toilet interferes with passing stools and may lead to constipation.
Phobia of toilets and using the toilets also plays a role in childhood constipation. The fear may result from the pain when passing stools. This leads to poor bowel habits when the child ignores the urge to pass stools and withholds the stools for fear of experiencing pain and discomfort. This worsens the condition.
Some disease conditions also lead to constipation among which is Hirschsprung’s disease, anus and rectum deformities at birth and spinal cord abnormalities at birth and cystic fibrosis.
Treatment for constipation is dependent on the cause of constipation, how long the condition has been present and the severity of the symptoms. However, basics of treatment are similar for most cases.
In a large majority of cases it is possible to relieve symptoms through dietary and lifestyle changes alone. Management of constipation involves the following steps and measures.
Some of the major lifestyle changes advised are those suggested for prevention of constipation. These measures can prevent recurrence of constipation as well. They include:-
These are medications that help pass stools more comfortably. They lead to formation of soft formed stools after a couple of days of use and ease the process of passing stools.
There are three major classes of laxatives. These include:-
Bulk-forming laxatives – These agents increase the bulk of the stools formed and soften them to ease passage. They soften the stools by retaining the fluids within the stools. Softening the stools help in their passage and prevents stool impaction or fecal impaction. Commonly prescribed bulk-forming laxatives include ispaghula husk or psyllium, polycarbophill, methylcellulose and sterculia. These should be taken with plenty of water. These agents take around two to three days to be effective.
Osmotic laxatives – Osmotic laxatives work by drawing the water into the intestines and thus make the stools soft. These are prescribed if the bulk laxatives fail to work. Commonly prescribed osmotic laxatives include lactulose.
Stimulant laxatives – These laxatives are used if the other two agents have failed to cause softening and passage of stools. These agents stimulate the muscles of the gut to contract and expel the feces. The most commonly prescribed stimulant laxatives are senna, bisacodyl and sodium picosulphate. These agents take around 6 to 12 hours to work and should be used on short term basis only. They are also useful for clearing the bowel in patients who are to undergo surgery (especially abdominal surgery) or radiological investigations and imaging of the abdomen.
Fecal impaction or stool impaction occurs when stools become hard and dry and get stuck in the rectum. This may lead to severe pain and a lump like sensation.
Initially osmotic laxatives are tried and if there are no results, a stimulant purgative may be added.
If these fail a suppository (capsule containing bisacodyl or glycerol) is inserted into the anus and this helps in softening of the lump and easy passage.
When this fails an enema may be tried to cleanse the rectum. Agents used include docusate and sodium citrate.
Infants who are not yet weaned may be given water in between feeds to ease constipation. Gentle movement of the baby’s legs in a bicycle motion also helps the baby pass stools.
Babies who have begun solids may be given plenty of fluids like water or diluted fruit juice to prevent and treat mild constipation. They may be given fibres in diet in the form of fruits like apples, apricots, pears, peaches, grapes, plums, bananas, raspberries, strawberries etc. that are pureed or chopped.
In severe cases osmotic laxatives are prescribed. However, if this does not work, they can be prescribed a stimulant laxative. Bulk forming laxatives are not suitable for babies.
Children with constipation are treated almost similarly as adults with the condition by making lifestyle and dietary changes. In severe cases osmotic laxatives are prescribed. However, if this does not work, they can be prescribed a stimulant laxative. Bulk forming laxatives are not suitable for children.
Good toilet habits and toilet training and removal of fears associated with passing stools is important to prevent constipation in preschoolers.
Pregnant women are at a greater risk of constipation. The first method is to change the diet and lifestyle. Increased fibres and fluids in diet and more physical activity is advised.
If dietary and lifestyle changes do not work, a laxative may be prescribed. Laxatives that are safe to use during pregnancy include the osmotic laxatives lactulose and macrogols. When this fails a small dose of bisacodyl or senna may be prescribed. Senna is not advisable after 27 weeks of pregnancy (third trimester).