Constipation in Adults explained
Constipation is a common problem and does not mean that you necessarily have a disease. 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. Doctors define constipation in a number of ways:
- 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
If you have any of these complaints you may be one of the approximately one in seven otherwise normal people who are just constipated. Two particular groups of people who are most likely to be troubled by constipation are young women and the elderly – especially those who need to take regular medicines. Constipation may be part of the irritable bowel syndrome (see our separate leaflet), especially if abdominal pain is also present.
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 any toxins leak from your bowel into any other part of the body. Another common idea is that constipation may lead to cancer. There is no evidence at all that long-term constipation increases your chances of getting bowel cancer. Patients can be alarmed if they notice blood when they open their bowels. You may notice some blood on the tissue after straining or passing a hard stool – this is usually due to haemorrhoids (or rarely a painful tear at the anus). This explanation will need to be confirmed by a doctor. 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.
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. The urge to open your bowels may not be felt very often since, when the bowel is sluggish, the stool can become hard and small. In some people there can be a problem just inside the anus with the way that the rectum squeezes out its contents.
A large number of drugs or medicines that you may have been prescribed or have bought over-the-counter can cause constipation (see box). 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.
- Pain-killers (especially codeine-containing compounds)
- Antacids (especially if containing aluminium)
- Iron tablets
- Blood pressure medications (not all)
- Antidepressants (not all)
- Anti-epilepsy and anti-Parkinson’s disease drugs
There is a strong connection between emotional feelings and how the gut works. Feeling upset can make your bowel slow down or speed up. Emotional upsets, even in childhood, may result in constipation many years later. 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 in how your bowel muscles work and so cause lasting changes in the pattern of opening your bowels. In addition, some patients strain excessively because they have difficulty co-ordinating the muscles that empty the bowel and they just end up by straining even more. Irregular meal times, reduced liquid intake, inactivity and fear of pain on passing stool may worsen symptoms in patients with a tendency towards constipation. Some women notice that their bowels are more sluggish at certain times of their menstrual cycle.
In rare cases the bowels may not be working properly because the bowel itself is diseased by being narrowed or even blocked as a result of scarring, diverticular disease or inflammation. Even more rarely, a colonic tumour may cause constipation. It is important to emphasise that cancer is an extremely rare cause of constipation. There are also some uncommon abnormalities that happen when the gut just seems to widen (megacolon) or ends up pushing itself in the wrong direction (rectocoele). Sometimes problems with hormones (such as an under-active thyroid gland) or with the metabolism (such as a high level of calcium in the blood) may cause the gut to be sluggish, leading to constipation. These conditions are easily diagnosed by simple tests.
When do you need to see a doctor?
If the following simple measures do not help, you will need to consult your GP. A sudden slowing up of your bowel, especially if you are aged over 40, should also be reported. If you are inexplicably losing weight or notice bleeding you should see your GP straight away. Try not to take laxatives before seeing your doctor.
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). This is because insoluble fibre may lead to bloating and can worsen any discomfort. Fibre is most helpful for patients with mild symptoms of constipation – if you are severely troubled, you will not benefit from progressively higher doses of fibre, and may even be made worse. Regular meals and an adequate fluid intake (approximately 10 cups a day) are the mainstays of treating and preventing constipation. It is also 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. Keeping active and mobile helps some people whose bowel is sluggish.
The decision to perform investigations depends on your symptoms, your age and possibly whether you have a history of bowel problems within your family. It is often unnecessary to carry out tests for constipation, but if your doctor is worried they may organise one or more of the following:
- Blood tests.
- 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.
- 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.
- Anorectal physiology testing and proctography – these are specialist tests that are only rarely needed. They indicate how the nerves and muscles around the back passage work.
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. The balance of scientific evidence suggests that laxatives do not cause permanent changes in the way the colon works. There is no evidence that using laxatives 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.
A key point is that certain types of laxative will work in some patients but not others. Unless your constipation improves with fairly simple measures, it might 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. A technique used only in some specialist centres is called ‘biofeedback’, where patients are trained to co-ordinate their tummy 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.
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 rather better how to influence the process to the benefit of our patients. This would lead to far more effective ways of regulating our bowel habit than we have at present.