Constipation is a common problem and does not mean that you necessarily have a disease.

Most cases of constipation are temporary and will clear up with simple lifestyle measures.

It is a symptom that can mean different things to different people but the usual meaning is that a person has difficulty in opening their bowels. Normal frequency and form of bowel movements vary widely but in general, if you pass fewer than three stools a week, and the stools are often hard and dry, then you could be counted as being constipated. Symptoms can constantly fluctuate and those that are persistent over 20 years affect only 3% of adults.

What are the symptoms of constipation?

Doctors define constipation in a number of ways, and the more of these you report your problem, the more likely you are to be constipated. The main symptoms leading to a diagnosis of constipation include:

  • 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.

If you have these complaints you may be one of the approximately one in seven otherwise normal people who are constipated. Two groups of people most likely to be troubled by constipation are young women and the elderly – especially those who need to take regular medicines. If abdominal pain is also present, constipation may be part of Irritable Bowel Syndrome (IBS). Abdominal bloating is often part of many bowel complaints, including constipation.

When do you need to see a doctor?

Constipation is bothersome, but it is not usually 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. If you also experience any of the following symptoms, you should see your GP immediately.

  • Unexplained weight loss
  • Bleeding in the stool
  • Abdominal or rectal pain

Try not to take laxatives before seeing your doctor.

Can being constipated cause any complications?

Although people often worry about it, there is no reason to believe that constipation causes a ‘poisoning’ of the system. You may feel sluggish and bloated, but there is no evidence that bugs or toxins leak from your bowel into any other part of the body. Another common idea is that constipation may lead to cancer but there is no evidence at all that long-term constipation increases your chances of getting bowel cancer.

Complications that may occur include:

  • Bleeding from haemorrhoids, or more rarely a fissure (painful tear) at the anus, is the commonest complication of constipation.
  • A rectal prolapse (where the rectal wall protrudes through the anus) can occur with chronic straining – this may result in some rectal tissue protruding from the anus, or may lead to passage of mucus.
  • Elderly or immobile patients may get so badly constipated that they quite literally get bunged up (‘faecal impaction’) and this will need prompt treatment by either the GP or hospital.

What goes wrong with the body to cause constipation?

Two main problems can occur to cause constipation.

  • Most commonly the muscles of the intestines and colon do not seem to work properly and this results in slow movement of contents through the bowel down to the rectum (resulting in a reduced urge to empty the bowel and hard stools).
  • The second sort of problem that can occur is in the way that the rectum squeezes out its contents and results in the normal coordination of bowel emptying being compromised (resulting in straining).

Some patients may have a combination of both problems.

What are the commonest causes of constipation?

  • A large number of drugs or medicines that you may have been prescribed or have bought over-the-counter can cause constipation. If your symptoms began (or got worse) after starting one of these drugs, it may be worth asking your doctor if there are any less constipating alternatives.
  • There is a strong connection between emotional feelings and how the gut works. Feeling upset or depressed can make your bowel slow down or speed up. Emotional upsets, even in childhood, may result in constipation many years later.
  • A history of previous eating disorders may result in constipation, even if eating behaviour becomes normal again.
  • Ignoring the natural urge to open your bowels (because you want to avoid public toilets or because you are too busy at work) can result in changes to how your bowel muscles work and can cause lasting changes in the pattern of opening your bowels.
  • In addition, some patients strain excessively because they have difficulty coordinating the muscles that empty the bowel.
  • Irregular meal times, reduced liquid intake and reduced physical activity may worsen symptoms in patients with a tendency towards constipation.
  • Pain, or fear of pain, on passing stool can cause constipation.
  • Avoiding public toilets for a length of time can result in future constipation.
  • Some women notice that their bowels are more sluggish at certain times of their menstrual cycle.
  • Some women develop a weakness of the pelvic floor allowing the bowel to bulge abnormally during attempted rectal emptying (“rectocoele”), further interfering with the emptying mechanism.
  • In some rare cases the bowel becomes abnormally large (dilated), and a condition called megacolon or megarectum can be the explanation for the symptoms of constipation.

What can you do to help yourself if you are constipation?

  • Regular meals and an adequate fluid intake (approximately 10 cups of fluid a day) are the mainstays of treating and preventing constipation.
  • A high fibre diet may help some patients with constipation. Try to eat a mixture of high fibre foods. Fruit, vegetables, nuts, wholemeal bread and pasta, wholegrain cereals and brown rice are all good sources of fibre. Aim to have a high fibre food at each meal and eat five portions of fruit or vegetables each day. Some people may find that it helps to take fibre in the form of fruit and vegetables (soluble fibre) rather than that in cereals and grains (insoluble). Insoluble fibre may lead to bloating and can worsen discomfort. Fibre is most helpful for patients with mild symptoms of constipation, however if you are severely troubled you will not benefit from progressively higher doses of fibre, and increasing fibre in the diet may make symptoms worse. You will need to see a doctor to aid defecation.
  • 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 – when you feel the urge, don’t delay. A warm drink with breakfast can help encourage the bowel into a pattern of regular working.
  • Keeping active and mobile may help some people whose bowel is sluggish.

Will you need to have any tests?

It is usually unnecessary to carry out tests for constipation. The decision to perform investigations depends on your symptoms, your 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 is worried they may organise one or more of the following:

  • blood tests (looking for anaemia, thyroid hormone or metabolic problems).
  • flexible sigmoidoscopy, colonoscopy, barium enema or CT scan – these tests show doctors how the lining of your bowel looks and are routine procedures which are extremely safe. Bowel preparation is required prior to these procedures.
  • transit studies – these are very simple tests, involving an X-ray after you have swallowed some capsules or tablets which show up how quickly things move through your intestines. Laxatives must be stopped during the test.
  • anorectal physiology testing and proctography – these are specialist tests that are only rarely needed. They indicate how the pelvic floor and the nerves and muscles around the back passage work. No bowel preparation is required.

Should I take laxatives and are they safe?

Regular use of laxatives is generally not encouraged, but occasional use is not harmful. The commonest problem with laxatives is that their effects are unpredictable – a dose that works today may not produce an effect tomorrow. Also, they can cause pain and result in the passage of loose stools if the dose is high. One further problem with long-term use of laxatives is that the bowel becomes progressively less responsive, meaning that gradually higher doses are needed. The longer you take laxatives, the less likely it is that your bowel will work well on its own. Nevertheless the balance of scientific evidence suggests that laxatives do not cause any damage to the bowel.

There is no evidence that using laxatives puts you at risk of getting colon cancer. Certain laxatives will not work in some patients, and it might be best to use laxatives only with proper guidance.

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. However, while laxatives and suppositories may ease bowel opening, they don’t often help the common problems of pain and bloating.

What other treatments are available?

If you remain troubled with constipation despite strict adherence to the measures described before, you may need further treatment. 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 laxatives. A technique available in some centres is called ‘biofeedback’, where patients are trained to coordinate rectal and abdominal muscles better in order to help the bowel empty rather more effectively.

Some other methods that your doctor might suggest are still far from established. It can be very frustrating for patients as well as their doctors when constipation does not respond to different treatments. However, it is usually best to avoid surgery for constipation 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 rectocoele and rectal prolapse (see above) may be indicated, but would need a specialist assessment to decide this. Sometimes psychological treatments are extremely helpful in reducing the symptom burden of some patients who experience emotional influences on their constipation.

What research is needed?

We still have much to learn about how what we eat and drink moves through our insides. If we knew more clearly how this happens, then we would hope to understand better how to influence the process to the benefit of patients. This would lead to more effective ways of regulating our bowel habit than we have at present. Understanding why the new classes of drugs help some patients and others should lead to improved future therapies and more selective use of these new agents.

core information about constipation leaflet download as a pdfThe information on this page about constipation is based on the leaflet produced by CORE (a charity fighting gut and liver disease).

Download the pdf leaflet.

To book a consultation with the Exeter Gut Clinic please contact us on 01392 272951 or get in touch using our online form.