Constipation? How to Get Things Moving

The word "constipation" comes from the Latin meaning "to press or crowd together." And that's just what happens in this common digestive disorder—stool becomes hard and compressed.. and/or difficult to expel from the body. There are traditional remedies—some of which can work in the right circumstances—and there's also a new drug that has been created to help with chronic constipation.

We all get constipation sometimes. Here's what you need to know to remedy constipation and keep it from becoming chronic…

What’s Normal?

While most people think of constipation as the inability to have a daily bowel movement, the definition is broader than that. Studies show that the "normal" frequency of bowel movements varies. Some people may have more than one bowel movement per day, while others may routinely have a bowel movement every couple of days. I generally consider someone constipated if he/she typically goes three or four days between bowel movements. On the other hand, you may have a daily bowel movement that involves lengthy straining-which also qualifies as constipation.

While constipation can cause discomfort and may affect your quality of life, it doesn't pose a health threat in and of itself. Until recently, it had been thought that infrequent bowel movements could increase the risk for colorectal cancer. But a recent large-scale study in Japan found that only very infrequent bowel moveĹents (every 10 to 14 days) could increase the risk. Some of the main health risks associated with constipation arise from the physical stress of passing hard stools-which may cause hemorrhoids and, in some cases, a fissure or tearing of the rectum.

Causes Of Constipation

Most people experience constipation as a temporary condition brought on by a change in diet...medication (constipation can be caused by narcotic pain relievers, high-dose iron supplements and some blood pressure drugs)...or travel (when you are thrown off your routine, not following your normal diet or not able to make regular bathroom visits). For this group, self-treatment with an over-the-counter laxative will usually restore regular bowel function.

For others, constipation is chronic—it does not go away. The two main causes of chronic constipation are…

Irritable bowel syndrome (IBS). This disorder of unknown cause is associated with the abnormal function of the muscles of the colon. It accounts for 30% to 40% of all chronic constipation and is usually associated with bloating and pain in the lower abdomen.
Pelvic floor dysfunction. This condition accounts for another 30% to 40% of chronic constipation. More common in women than men, it occurs when the muscles and nerves in the pelvic floor (the muscles under the pelvis) aren't coordinating properly. Constipation due to pelvic floor dysfunction won't respond to laxatives but can usually be cured through physical therapy.

Chronic constipation also can result from other disorders including neurological disorders (such as Parkinson's, multiple sclerosis and stroke)...metabolic and endocrine conditions (such as diabetes and an underactive thyroid) and systemic disorders (such as lupus or scleroderma). A problem in the colon, such as diverticulosis or cancer, can also cause constipation, although this is not common.

Whatever the cause, constipation becomes much more prevalent over age 65, and women are more likely than men to become constipated.

Treatments That Work

For occasional constipation or constipation due to IBS, the first line of treatment involves establishing a regular bathroom schedule, dietary changes and over-the-counter medications. What to do…

Establish a regular bathroom schedule. A wave of motility goes through everyone's GI tract around 5 a.m., which is why many people feel the urge to have a bowel movement in the morning. A similar wave occurs after eating, I encourage my patients to listen to their bodies and to arrange for scheduled bathroom times that coincide with their urges to have bowel movements. Give yourself three to four weeks to adjust to this schedule.
Add fiber to your diet. Dietary fiber speeds movement of food through the GI tract and binds with water, causing stools to become bulkier and pass out of the colon more easily. Optimal fiber intake is 25 to 30 grams a day, but the average American consumes less than half this amount.

Solution: Eat more high-fiber foods, such as legumes (split peas, lentils, black beans, lima beans, baked beans, etc.), fresh fruits and vegetables (artichokes, raspberries, pears, broccoli), whole-wheat pasta and cereals and other foods containing whole bran or oats. You can also boost fiber intake with supplements, such as psyllium husk powder (Metamucil, Serutan) or methylcellulose (Citrucel). It may take three or four days to notice positive effects.

Try an over-the-counter laxative. If regular bathroom visits and additional fiber don't solve the problem, add an over-the-counter laxative. There are different types--for example, osmotic, which draw water into the area, or lubricant, which help stools move more easily. Milk of magnesia is a safe, effective and inexpensive choice. To avoid elevated magnesium levels, however, it shouldn't be taken for longer than two weeks-and should be avoided by anyone with kidney disease. Miralax, another laxative, also is safe and effective for seven days, but some people don't like mixing the powder. Stimulant laxatives, such as bisacodyl (Dulcolax), have been shown to improve constipation with short-term use, though they may cause cramping. After two weeks, however, the body develops a tolerance to them. If your constipation is not improved within two weeks, consult your doctor.

Not recommended: Stool softeners. These popular laxatives are a waste of money. They are supposed to work by drawing water into the stool, making it softer and easier to pass. But they bulk up stool by only 3%-and that's not enough to make any difference in your bowel movements.

Also not helpful: Exercise. While regular physical activity is beneficial in many ways, studies have shown conclusively that it has no effect on chronic constipation.

When To Seek Medical Help

Most people are helped by the steps above. But if you see no improvement after several weeks, ask your primary care doctor for a prescription-strength laxative. An osmotic agent called lactulose (Chronulac. Constilac)—which is made of sugar molecules that make the gut more acidic and causes more water to be drawn in-makes bowel movements easier. Although side effects can include gas and bloating, people can take lactulose indefinitely. There is also a new medication for chronic constipation called lubiprostone (Amitiza) that has been found to be safe and effective. It is the first medication for constipation that works by stimulating intestinal fluid secretions that help the bowels move. Most patients prefer lubiprostone because it comes in a pill, not a sugary drink (like lactulose) and because there is no bloating.

If these prescriptions drugs still don't help, there may be an underlying condition that is causing the problem and you may need to see your primary care provider or a gastroenterologist for testing. This may include a complete blood count (CBC) test to make sure that you are not anemic and a thyroid-stimulating hormone (TSH) test to make sure that you do not have an underactive thyroid gland. This visit should also include a physical exam to check for pelvic floor dysfunction or any neuromuscular disorder. Since constipation can sometimes be a sign of colon cancer, a colonoscopy may be recommended.

Lastly, some patients with severe constipation swallow a capsule with markers to determine how quickly the markers pass through the gastrointestinal tract.

If pelvic floor dysfunction is detected, the patient will be referred to a physical therapist for a series of specific exercises for the pelvic floor and surrounding muscles.

If the constipation still doesn't improve and is seriously affecting quality of life, the last resort is a surgical procedure, called a colectomy, in which the colon is removed and the small intestine connected directly to the rectum. While this relieves constipation, it also results in frequent bowel movements—up to four per day.