This factsheet is about constipation
Constipation is a symptom that can mean different things to different people but the usual meaning is that a person has difficult in opening their bowels. It affects around one in seven otherwise healthy people and the two groups of people most likely to be trouble by constipation are young women and the elderly – especially those who need to take regular medicines. Symptoms can constantly fluctuate and only 3% of adults have persistent constipation over 20 years. It is a common problem and does not usually mean that anything is seriously wrong. Most cases are temporary and will clear up with simple lifestyle measures.
Why does constipation occur?
There are two main physical causes, most commonly the muscles of the intestine and colon stop working properly; this results in slow movement of contents through the bowel down to the rectum (leading to a reduced urge to empty the bowel and hard stools). Alternatively, the problems can stem from the way in which the rectum squeezes out its contents and results in the normal co-ordination of bowel emptying being compromised (resulting in straining). Some people can have a combination of both.
What are the causes of Constipation?
- Medicines: over the counter or prescription medicines (e.g. opioids, a type of pain relief drugs) often carry a side effect of constipation (see box). If symptoms began (or got worse) after starting one of these drugs, ask your doctor to see if there are any alternatives.
- Emotion: there is a strong connection between feelings and how the gut works. Being upset or depressed can make the bowel slow down or speed up. Emotional upsets, even in childhood, may result in constipation many years later.
- Eating disorders: these can result in constipation, even if eating behaviour becomes normal again.
- Ignoring the natural urges to open bowels: ignoring bowel urges because of an aversion to public toilets or time or social constraints can result in changes to both how the bowel muscles work and the pattern of bowel opening.
- Excessive straining: this can be because of difficulty co-ordinating the muscles that empty the bowel.
- Irregular meal times, reduced liquid intake and reduced physical activity: these can all worsen symptoms in patients with a tendency towards constipation.
- Pain, or fear of pain, on passing stools.
- Menstrual constipation: some women notice that their bowels are more sluggish at certain times of their menstrual cycle.
- Pelvic floor weakness: some women develop a weakness of the pelvic floor allowing the bowel to bulge abnormally during attempting rectal emptying (“rectoceole”), further interfering with the emptying mechanism.
- Dilated bowel: the bowel becomes abnormally large (dilated) creating a condition called megacolon or megarectum, which cause constipation. This condition is rare and only usually seen in people with a condition called Inflammatory Bowel Disease (IBD).
What are the symptoms of constipation?
- Opening the bowels less than three times a week.
- Needing to strain to open your bowels on more than a quarter of occasions.
- Passing a hard or pellet-like stool on more than a quarter of occasions.
- Experiencing a sense of incomplete emptying after a bowel opening.
- Needing to use manual manoeuvres to achieve bowel emptying.
The more of these symptoms you have the more likely you are to be constipated. If abdominal pain is also present, constipation may be part of Irritable Bowel Syndrome (IBS) (see our separate leaflet). Abdominal bloating is often part of many bowel complaints, including constipation.
How is Constipation diagnosed?
Constipation is bothersome but usually not serious. If the simple measures described later do not help and your symptoms persist, then you will need to consult your GP. Also, a sudden slowing up of your bowel, especially if you are aged over 40, should also be reported. Try not to take laxatives before seeing your doctor.
If you also experience any of the following symptoms, you should see you GP immediately:
- Unexplained weight loss
- Bleeding in the stool
- Abdominal or rectal pain
Your doctor will diagnose you according to the number or severity of symptoms as above. They may also want to examine your abdomen to check for any tenderness, swelling or blockage. Further investigation is usually unnecessary and will depend on your symptoms, age and possibly whether you have a history of bowel problems in your family. In rare cases the bowels may not be working properly because the bowel itself is diseased. If your doctor has any concerns they may organise one or more of the following investigations:
- Blood tests: these are usually to look for anaemia, thyroid hormone or metabolic problems.
- Flexible sigmoidoscopy, colonoscopy, barium enema or CT scan: these are tests which allow doctors to examine the lining of your bowel and are routine procedures which are extremely safe. Bowel preparation is required prior to these procedures.
- Transit studies: a simple test involving an X-ray which shows the speed of passage through the intestines. A highlighting substance is ingested which shows up on X-ray. Laxatives cannot be taken during the test.
- Anorectal physiology testing and proctography: rarely carried out, they indicate how the pelvic floor and the nerves and muscles around the back passage work. No bowel preparation is required.
What treatment is available for constipation?
Most treatment is self-managed and based around dietary and lifestyle changes:
- Dietary changes: Regular meals and an adequate fluid intake (approximately 10 cups a day) are the mainstays of treating and preventing constipation.
- A high fibre diet: this may help some patients with constipation. This should include a mixture of high fibre foods such as fruit, vegetables, nuts, wholemeal bread and pasta, wholegrain cereals and brown rice. The aim should be to include a high fibre food at each meal along with five portions of fruit or vegetables each day. Some people may find that it helps to eat more fruit and vegetables while others might prefer cereals and grains. Eating more fibre may lead to bloating and can worsen discomfort, so it is important to increase it slowly. Fibre is most helpful for patients with mild symptoms of constipation, however if the condition is severe then continuing to increase fibre may make symptoms worse.
- Listening to your body: it is important to identify a routine of a place and time of day when you are comfortably able to spend time in the toilet. Respond to your bowel’s natural pattern so when you feel the urge, don’t delay. A warm drink with breakfast can help encourage the bowel into a pattern of regular working.
- Exercise: keeping active and mobile may help some people whose bowel is sluggish.
- Colonic irrigation: some people visit a natural therapist for a process called colonic irrigation, which uses warm liquid to flush out the faeces. Whilst this is not dangerous and can help in the short term, it will not address the causes of chronic constipation.
Should I take laxatives and are they safe?
Regular use of laxatives is generally not encouraged but occasional use is not harmful. Things to consider:
- The effects of laxatives are unpredictable – a dose that works today may not produce an effect tomorrow.
- Laxatives can cause pain and result in the passage of loose stools especially if the dose is too high.
- Long term use can lead to the bowel becoming progressively less responsive so the longer you take them, the less likely it is that your bowel will work well on its own.
- Certain laxatives will not work in some patients.
- While laxatives and suppositories may ease bowel opening, they don’t often help the common problems of pain and bloating.
Nevertheless, the balance of scientific evidence suggests that laxatives do not cause any damage to the bowel and there is no evidence that using them puts you at risk of getting colon cancer. Suppositories or mini-enemas are more predictable than laxatives and tend to be very well tolerated and effective. They are especially useful for people who have difficulty with needing to strain to evacuate their bowel. It may be best to use laxatives only with proper guidance.
If you remain troubled with constipation despite strict adherence to the measures described before, you may need further treatment. These can include:
- Medicines: novel non-laxative drug therapies are proving helpful for some patients who don’t tolerate or don’t respond to laxatives. Some of these are licensed for use in selected patients with constipation symptoms despite lifestyle changes and use of laxatives. Adult patients with constipation caused by opioids who do not respond to laxatives might respond to a drug called naloxegol: ask your GP if this applies to you.
- Biofeedback: available in some centres, patients are trained to co-ordinate rectal and abdominal muscles better in order to help the bowel empty rather more effectively.
- Surgery: it is usually best to avoid surgery because many patients do not have a successful outcome. Indeed there are some patients who develop new symptoms after an operation such as diarrhoea, bowel obstruction or incontinence. Pelvic floor surgery for conditions like rectocele and rectal prolapse (see above) may be a possibility but would need a specialist assessment to decide this.
- Psychological treatments: These can be extremely helpful in reducing the symptom burden of some patients who experience emotional influences on their constipation.
How can constipation affect you?
Although people often worry about it, there is no reason to believe that constipation causes a ‘poisoning’ of the system. It can cause feelings of sluggishness and bloating, but there is no evidence that bugs or toxins leak from the bowel into any other part of the body. Another common idea is that constipation may lead to cancer but there is no evidence that long-term constipation increases the chances of getting bowel cancer.
It is important to remember that the vast majority of cases of constipation are easily resolved with simple diet, lifestyle or medication change. However if constipation does not respond to different treatments there can be medium to long term effects including:
- Haemorrhoids or fissures: bleeding from haemorrhoids, or more rarely a fissure (painful tear) at the anus, is the commonest complication of constipation.
- Rectal prolapse: chronic straining can lead to the rectal wall protruding out through the anus.
- Faecal impaction: elderly or immobile patients may get so badly constipated that they quite literally get bunged up and this will need prompt treatment by either the GP or hospital.
- Diverticular disease: this is where small hard stools lead to increased intestinal contractions, creating pressure which causes the inner section of the intestine to bulge through the protective outer tube of muscle which surrounds it, creating a little pouch of intestine (see our leaflet on Diverticular Disease).
What to ask your doctor?
- Could any of my medications be causing my constipation and if so is there an alternative.
- What dietary or lifestyle changes do you suggest I introduce?
- Are laxatives suitable for me and if so which one would be best for me to use?
- How will my constipation be monitored?
- Are there any over the counter remedies which will reduce the chances of me getting haemorrhoids or an anal tear?
Recent research suggests that doctors & patients have differing views on the definition of constipation. To read further, click here.