Constipation

Constipation is a common problem affecting around 1 in 7 people, causing difficulty or infrequency with bowel movements. While it can significantly impact your quality of life, most cases can be treated with simple changes in diet, fluid intake, and exercise.

Table of contents

• What is constipation?
• Recognizing the symptoms
• What causes constipation?
• Who is more likely to be affected?
• How doctors diagnose constipation
• Treatment options
• Preventing constipation
• When to see a doctor

What is constipation?

Constipation is a problem with passing stool. It means having fewer than three bowel movements a week or having difficulty passing stool^[1][3]. However, what is normal varies from person to person. Some people have bowel movements three times a day, while others go three times a week, and both can be healthy^[2][5].

Constipation is a symptom rather than a disease itself. It happens when your colon (large intestine) absorbs too much water from your waste. This makes the stool dry, hard, and difficult to push out of your body^[10]. When food moves too slowly through your digestive tract, your colon has too much time to absorb water from the waste, resulting in constipation^[10].

Constipation affects around 1 in 7 otherwise healthy people, with young women and older people being two groups most likely to experience it^[2]. In the United States, approximately 33 million adults have constipation, resulting in 2.5 million doctor visits and 92,000 hospitalizations each year^[12].

Recognizing the symptoms

Symptoms of constipation include^[1]:

• Fewer than three stools a week
• Hard, dry or lumpy stools
• Straining or pain when passing stools
• A feeling that not all stool has passed
• A feeling that the rectum is blocked
• The need to use a finger to pass stool

Chronic constipation is when you have two or more of these symptoms for three months or longer^[1].

The Bristol Stool Chart is a helpful way of identifying constipation. Constipation generally refers to stool that is type 1 or type 2 on the chart, which is often hard and difficult to pass^[2].

What causes constipation?

Constipation can be classified as primary or secondary. Primary constipation has no evident structural or organic cause, while secondary constipation is due to medications, chronic diseases, or other factors^[4].

Lifestyle factors

Common lifestyle causes of constipation include^[10]:

• Not eating enough fiber
• Not drinking enough water (dehydration)
• Not getting enough exercise
• Changes in your regular routine, such as traveling
• Consuming large amounts of milk or cheese
• Stress
• Resisting the urge to have a bowel movement

Medications

Many medicines can cause constipation as a side effect^[2][10]. These include:

• Strong pain medicines, like those containing codeine or oxycodone
• Nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen
• Antidepressants
• Antacids containing calcium or aluminum
• Iron pills
• Allergy medications, such as antihistamines
• Certain blood pressure medicines
• Antiseizure medications

If you think your constipation started or was worsened by taking a medicine, it’s important to talk to your doctor. Don’t stop taking a medicine without seeking medical advice^[2].

Other causes

There is a strong connection between your brain (including your mood) and the way your gut works. This is called the gut-brain connection. Being upset or depressed can make the bowel slow down or speed up^[2].

Ignoring the natural urges to open your bowels can change both how the bowel muscles work and the pattern of bowel opening. This can happen due to inadequate time, an aversion to public toilets, or social limits. It can also be caused by pain or fear of pain when passing stool^[2].

People who eat irregularly may be more prone to constipation. Those designated female at birth may notice that their bowels are slower at certain times of their menstrual cycle^[2].

Who is more likely to be affected?

Certain people are more likely to become constipated, including^[3]:

• Women, especially during pregnancy or after giving birth
• Older adults
• Non-Caucasians
• People who eat little to no fiber
• People who take certain medicines or dietary supplements
• People with certain health problems, including functional gastrointestinal disorders

Constipation is common among all ages and populations in the United States. About 16 out of 100 adults have symptoms of constipation, and about 33 out of 100 adults ages 60 and older have symptoms of constipation^[3].

How doctors diagnose constipation

Evaluation begins with a detailed history, medication review, and physical examination^[12]. Your doctor will likely do the following during your appointment^[8]:

• Gently press on your abdomen to check for pain, tenderness or irregular lumps
• Look at the tissue of the anus and the surrounding skin
• Use a gloved finger to check the condition of the rectum and the muscles of the anus

You’ll also be asked questions about your medical history, diet, exercise habits and stools^[8]. For some people, the information from this appointment may be enough for a diagnosis and treatment plan.

Routine use of laboratory studies or imaging, including colonoscopy, is not recommended in the absence of alarm symptoms^[12]. Patients with alarm symptoms or who are overdue for colorectal cancer screening should be referred for colonoscopy^[12].

Your doctor may send samples of your blood to a lab to test for diseases or conditions that can cause constipation^[8]. Imaging tests, such as an X-ray, CT scan or MRI, may be needed to diagnose conditions that may be causing constipation^[8].

Treatment options

Constipation is usually treated with changes in diet and exercise or with nonprescription medicines^[1]. You can most often treat your constipation at home^[7].

Dietary changes

One of the first steps you can take is to increase your intake of fiber through your diet. Adults should get 22 to 34 grams of fiber a day^[7][16]. To help relieve your symptoms^[7]:

• Eat more high-fiber foods, including fruits, vegetables, beans, and whole grains
• Choose more whole grain breads, cereals and rice
• Select more raw fruits and vegetables—eat the peel, if appropriate

Certain fruits have added benefits for easing constipation. Apples, pears, and prunes contain natural sugars that stimulate bowel movements. Kiwis contain an enzyme that stimulates the upper digestive tract^[9].

Hydration

Drink plenty of water and other liquids. If you eat more fiber or take a fiber supplement, make sure to drink enough fluids^[7]. Most people need about four to six cups of plain water each day^[16]. Keeping hydrated is an important action to take for constipation relief. Water helps fiber work better, making stool softer and easier to pass^[16].

Exercise and lifestyle changes

Getting regular physical activity may help relieve your symptoms^[7]. Try to do weight-bearing exercise, such as walking, three or more times each week^[20]. Aerobic exercise may help reduce constipation, but you can also try yoga or take a 20-minute walk during your lunch break^[15].

Your doctor may suggest that you try to train yourself to have a bowel movement at the same time each day to help you become more regular. For example, trying to have a bowel movement 15 to 45 minutes after breakfast may help, because eating helps your colon move stool^[7]. Make sure you give yourself enough time to have a bowel movement, and use the bathroom as soon as you feel the need to go^[7].

Fiber supplements

You may be able to take a fiber supplement, such as Benefibre or Metamucil, every day^[20]. Fiber supplements are among the safest ways to promote regular bowel movements, though they do act slowly and can cause gas and bloating^[16]. You should drink plenty of fluids when taking supplements.

Over-the-counter medicines

Your health care professional may recommend using a laxative for a short time. First-line treatment for primary constipation includes osmotic laxatives^[12]. Examples include^[7]:

• Fiber supplements (Citrucel, FiberCon, Metamucil)
• Osmotic agents (Milk of Magnesia, Miralax)
• Stool softeners (Colace, Docusate)
• Lubricants, such as mineral oil (Fleet)
• Stimulants (Correctol, Dulcolax)

Polyethylene glycol (Miralax) is preferred over lactulose for the treatment of constipation because it is more effective and has fewer adverse effects^[12]. You should only use stimulants if your constipation is severe or other treatments have not worked^[7].

Prescription medicines

If self-care treatments don’t work, your doctor may prescribe a medicine to treat your constipation^[7]. Second-line therapy includes a brief trial of stimulant laxatives followed by intestinal secretagogues^[12].

Specialized treatment

If the initial treatment approach is ineffective, patients should be referred to gastroenterology for more specialized testing^[12]. Patients with refractory constipation may be considered for surgery^[12]. Those in whom pelvic floor dysfunction is identified early should be referred for pelvic floor therapy with biofeedback^[12].

Preventing constipation

A few changes in your diet and lifestyle may help you avoid ongoing constipation^[20]. Small changes to your daily routine can improve constipation^[15]:

• Nutrition: Stick to a consistent meal schedule and try to avoid processed foods. Opt for high fiber foods like bran cereal, vegetables, whole wheat bread, or legumes. Stay hydrated by keeping water with you at all times^[15].
• Exercise: Aerobic exercise may help reduce constipation. Consider attending regular fitness classes at a gym^[15].
• Sleep: Get enough sleep because insufficient sleep may be a risk factor for constipation^[15].
• Regularity: When you have the urge to have a bowel movement, use the bathroom right away. Don’t hold it. Try to schedule some uninterrupted time each day for a bowel movement^[15].

Avoid making big lifestyle changes all at once. These can be difficult to maintain in the long run. Instead, try to add a few changes to your schedule until you establish a good daily routine^[15].

When to see a doctor

Make an appointment with your health care professional if you have constipation with any of the following conditions^[1]:

• Symptoms that last longer than three weeks
• Symptoms that make it difficult to do everyday activities
• Bleeding from your rectum or blood on toilet tissue
• Blood in your stools or black stools
• Other unusual changes in the shape or color of stools
• Stomach pain that doesn’t stop
• Weight loss without trying

Call your doctor or seek immediate medical care if^[20]:

• You have new or worse belly pain
• You have new or worse nausea or vomiting
• You have blood in your stools

Most people’s constipation is temporary and will clear up with simple lifestyle measures^[2]. However, if you have severe constipation or it’s not getting better, it’s important to see your doctor to determine if there’s an underlying medical cause^[6].