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Constipation

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Overview

Introduction

Constipation is a very common condition that affects people of all ages. When you are constipated, you feel that you are not passing stools (faeces) as often as your normally do, or that you have to strain more than usual, or that you are unable to completely empty your bowels. Constipation can also cause your stools to be unusually hard, lumpy, large or small.

The severity of constipation can vary greatly. Many people only experience constipation for a short period of time with no lasting effects on their health.

For others, constipation can be a chronic (long-term) condition which causes significant pain and discomfort. Chronic constipation can also lead to complications, such as faecal impaction (where dry, hard stools collect in your rectum) or faecal incontinence (where you involuntarily leak liquid stools around solid impacted stools).

The treatment for constipation is usually very effective, although in some cases it can take several months before a regular bowel pattern is re-established.

Constipation affects twice as many women than men, and is more common in the elderly. Approximately 40% of pregnant women experience constipation during their pregnancy.

Symptoms

Symptoms of constipation

Everyone, whether young or old, has their own normal bowel habits, and these can be quite different from other people’s habits. For example, some adults normally go to the toilet more than once a day, whereas others may normally go only every three or four days. And, some infants may normally pass stool several times a day, while others may normally pass stool only a few times a week.

When you are constipated you feel that passing stools has become more difficult than it used to be. Passing stools may feel more difficult for a number of reasons reasons. For example, passing stools may have become significantly less frequent, or significantly less effective (you feel that you are unable to completely empty your bowel).

Passing stools may also seem more difficult because your stools are:

  • dry and hard,
  • hard and lumpy,
  • abnormally large, or
  • abnormally small.


As well as causing a change in your normal bowel habits, constipation can also cause the following symptoms:

  • stomach ache and cramps,
  • feeling bloated,
  • feeling nauseous, and loss of appetite.


Children

As well as infrequent, or irregular, bowel movements, a child with constipation may also display the following signs and symptoms:

  • loss of appetite,
  • lack of energy,
  • being irritable, angry, or unhappy,
  • foul smelling wind and stools,
  • abdominal pain and discomfort,
  • soiling their clothes, and
  • generally feeling unwell.


If your child is displaying these symptoms, or has spoken to you about having difficulty in passing stools, you should speak to your GP.

Causes

Causes of constipation

Most cases of constipation are not caused by a specific condition, and it may be difficult to identify the exact cause of your constipation. However, there are several factors which can increase your chances of having constipation. These include the following:

  • not eating enough fibre, such as fruit, vegetables and cereals,
  • a change in your routine, or lifestyle, such as a change in your eating habits,
  • having limited privacy when using the toilet,
  • ignoring the urge to pass stools,
  • immobility, lack of exercise,
  • not drinking enough fluids,
  • being under, or overweight,
  • anxiety, or
  • depression.


Medication

Sometimes, constipation may be a side effect of a medicine that you are taking. Some of the most common types of medication which can cause constipation include:

  • aluminium antacids (medicine to treat indigestion),
  • antidepressants,
  • antiepileptics (medicine to treat epilepsy)
  • antipsychotics (medicine to treat schizophrenia, manic conditions and anxiety)
  • calcium supplements,
  • diuretics (water tablets), and
  • iron supplements.


If your constipation is being caused by medication, you will usually find that the condition eases once you stop taking the medicine. However, under no circumstances should you stop taking your medication unless your GP specifically advises you to.

Speak to your GP if you are experiencing constipation due to a medicine, because they may be able to prescribe an alternative medication for you.

Pregnancy

Constipation during pregnancy is very common. About 40% of women will experience some form of constipation during their pregnancy. Most pregnant women tend to be affected during the early stages of their pregnancy.

Constipation occurs during pregnancy as a result of the hormonal changes in your body. During pregnancy, your body produces more of the female hormone called progesterone. This hormone acts as a muscle relaxant.

Your bowel normally moves stools and waste products along to the anus by a process known as peristalsis. This is when the muscles which line the bowel contract and relax, in a rippling, wave-like motion. An increase in progesterone means that the bowel muscles find it more difficult to contract, making it harder to move waste products along.

If you are pregnant, there are ways that you can safely treat constipation which will not cause harm to you or your baby. See the ‘treatment’ section for more information about this.

Other conditions

The majority of constipation cases are not caused by a particular medical condition. However, constipation can very rarely be a sign of an underlying condition. In adults such conditions include:

  • colon or rectal cancer,
  • diabetes,
  • hypercalcaemia - when there is too much calcium in your bloodstream,
  • underactive thyroid,
  • muscular dystrophy - a genetic condition which causes muscle wasting,
  • multiple sclerosis - a condition which affects your nervous system),
  • Parkinson’s disease - a brain condition that affects the coordination of body movements, such as walking, talking and writing,
  • spinal cord injury,
  • anal fissures - a small tear of the skin just inside your anus,
  • inflammatory bowel disease - a condition that causes the intestines to become inflamed, and
  • irritable bowel syndrome (IBS).


Babies and Children

Constipation in babies and children is quite common. For example, poor diet, fear about using the toilet and poor toilet training can all cause constipation in babies and children.

Poor diet

Children who are overfed are more likely to have constipation, as are those who do not get enough fluids. Babies who have too much milk are also more likely to get constipation. As with adults, it is very important that your child has enough fibre in their diet.

Toilet training

Make sure that you do not make your child feel stressed, or pressured, about using the toilet. It is also important to let your children try things by themselves (when appropriate). Constantly intervening when they are using the toilet may make them feel anxious.

Toilet habits

Some children can feel stressed or anxious about using the toilet. They may have a phobia about using the toilet, or feel that they are unable to use the toilets at school.

This fear or phobia may be the result of your child experiencing pain when passing stools. This can lead to poor bowel habits, where children ignore the urge to pass stools and instead withhold them, for fear of experiencing pain and discomfort. However, this will mean that their condition only worsens.

Medication

Constipation in children can sometimes be a side-effect of medicines such as:

  • antiepileptics - medicines to treat epilepsy,
  • sedating antihistamines - medicine to relive the symptoms of allergies, such as itching and inflammation, and
  • opioids - a type of painkilling medicine.


Other conditions

The majority of constipation cases are not caused by a particular medical condition. However, constipation can rarely be a sign of an underlying condition. In children such conditions include:

  • Hirschprung’s disease - a condition that affects the large intestine, making it difficult to pass stools),
  • anorectal malformation - a condition where the baby’s anus and rectum do not form properly,
  • spinal cord abnormalities - for example, rare conditions such as spina bifida, and cerebral palsy, and
  • cystic fibrosis - a genetic condition that causes the body to produce thick and sticky bodily substances which, in the digestive system, which can lead to constipation.

Diagnosis

Diagnosing constipation

Constipation is a very common condition. Your GP will rarely need to carry out any tests or procedures to confirm your diagnosis. Instead, they will usually diagnose your condition based on your medical history and your symptoms.

Your GP will ask you some questions about your bowel habits. Do not feel embarrassed about describing your bowel pattern and stools to your GP. It is important that your GP is aware of all of your symptoms so that they can make the correct diagnosis.

Your GP may also ask questions about your diet, your level of exercise, and whether there have been any recent changes in your routines, or lifestyle.

Physical examination

If your GP suspects that you may have faecal impaction (when dry, hard stools collect in your rectum) they may decide to carry out a physical examination.

A typical examination will begin with you lying on your back while the GP feels your abdomen. You will then lie on your side while the GP performs a rectal examination using a lubricated, gloved finger. This way your GP can feel for any stools which may have collected.

Your GP will rarely have to conduct an internal physical examination on a child. Instead, the diagnosis can normally be made by feeling their abdomen (tummy).

Treatment

Treating constipation

The first way that your GP will treat your constipation is by advising you about ways you can change your diet and lifestyle. Changing what you eat and drink may mean that your constipation passes without the use of medication.

Some of the ways that you can help treat your constipation are outlined below.

  • Increasing your daily intake of fibre. You should be eating at least 18-30g of fibre a day. High fibre foods include fruit, vegetables, and cereals.
  • Add some bulking agents, such as wheat bran, to your diet. These will help make your stools softer and easier to pass.
  • Increasing your fluid intake. It is best for you to drink water, and you should be drinking at least 1.2 litres (6-8 glasses) a day.
  • Getting more exercise by going for a daily walk or run.
  • If your constipation is causing you pain, or discomfort, you may want to take a painkilling medication, such as paracetamol. Make sure that you always follow the dosage instructions carefully. Children under 16 years of age should not take aspirin.

See the ‘prevention’ section for more information about ways to change your diet and lifestyle.

If these diet and lifestyle changes do not help, your GP may prescribe an oral laxative for you.

Laxatives

Laxatives are a type of medicine that help you to pass stools. There are several different types of laxative and each one has a different effect on your digestive system.

Bulk-forming laxatives

Your GP will normally start your laxative treatment by using a bulk-forming laxative. These types of laxative work by helping your stools to retain fluid. This means that they are less likely to dry out, which can lead to faecal impaction (see ‘complications’ section). Bulk-forming laxatives also make your stools denser and softer which means that they should be easier to pass.

Commonly prescribed bulk-forming laxatives include ispaghula husk, methylcellulose, and sterculia. When taking this type of laxative, you must make sure that you drink plenty of fluids. Also, you should not take them before going to bed. It will usually be 2-3 days before you feel the effects of a bulk-forming laxative.

Osmotic laxatives

If your stools remain hard after you have taken a bulk-forming laxative, your GP may prescribe you an osmotic laxative instead. Osmotic laxatives work by increasing the amount of fluid in your bowels. This helps to stimulate your body to pass stools. Osmotic laxatives can also help by softening your stools.

Commonly prescribed osmotic laxatives include lactulose and macrogols. As with bulk-forming laxatives, you should make sure that you are drinking enough fluids. It will usually be 2-3 days before you feel the effect of the laxative.

Stimulant laxatives

If your stools are soft, but you are still having difficulty passing them, your GP may prescribe you a stimulant laxative. This type of laxative works by stimulating the muscles which line your digestive tract, helping them to move stools and waste products along the large intestine (colon) to the anus.

The most commonly prescribed stimulant laxatives are senna, bisacodyl and sodium picosulphate. These types of laxative are usually only used on a short-term basis, and you will usually start to feel them working within 6-12 hours.

According to your individual preference, and the speed with which you require relief, your GP may decide to combine different laxatives.

How long will I take laxatives for?

If you have only experienced constipation for a short period of time, your GP will normally recommend that you can stop taking the laxative once your stools are soft and easily passed.

However, if you have constipation due to a constipating medicine, or an underlying medical condition, you may have to take laxatives for much longer. Sometimes, you will have to take them for many months, even years.

If you have been taking laxatives for some time, you may have to gradually reduce your dosage, rather than coming off them straight away. If you have been prescribed a combination of laxatives, you will normally have to reduce the dosage of each laxative, one at a time, before you can stop taking them. This can take several months.

Your GP will advise you about when it is best to stop taking your laxatives. You should never stop taking any form of medication unless your GP advises you to.

Faecal impaction

Faecal impaction occurs when stools become hard and dry and collect in your rectum. This obstructs the rectum, making it more difficult for stools to pass along.

If you have faecal impaction, you will initially be treated with a high dose of the osmotic laxative, macrogol. After a few days of using this laxative, you may also have to start taking a stimulant laxative.

If you do not respond to these laxatives, you may require one of the medications described below.

  • Suppository - this type of medicine is designed to be inserted into your anus. The suppository gradually dissolves at body temperature and is then absorbed into your bloodstream. Bisacodyl, or glycerol, are two medicines which can be given in suppository form.
  • Mini enema - this is when a medicine in fluid form is injected through your anus and into your colon. Docusate and sodium citrate are two types of medicine which can be given in this way.


Pregnancy or breastfeeding

If you are pregnant, there are ways for you to safely treat constipation without causing any harm to you or your baby. As with most adults who are constipated, your GP will first advise you to change your diet by increasing your fibre and fluid intake. You will also be advised to take gentle exercise.

If dietary and lifestyle changes fail to work, you may be prescribed a laxative to help you pass stools more regularly. There are lots of laxatives that are safe for pregnant women to use because most are not absorbed by the digestive system. This means that your baby will not feel the effects of the laxative.

Laxatives that are safe to use during pregnancy include the bulk-forming laxatives lactulose, and macrogols. If these laxatives do not work, your GP may advise a small dose of bisacodyl, or senna (stimulant laxatives).

However, senna may not be suitable if you are in your third trimester of pregnancy (27 weeks to birth) because this medicine is partially absorbed by your digestive system.

Babies who have not yet been weaned

If your baby is constipated but has not yet started to eat solid foods, the first way to treat them is to give them extra water between their normal feeds. If you are using formula milk, make sure that you still make the formula as directed by the manufacturer - do not dilute the mixture.

You might want to try gently moving your baby’s legs in a bicycling motion, or carefully massaging their abdomen (tummy) to help stimulate their bowels.

Babies who are eating solids

If your baby is eating solid foods, make sure that you give them plenty of water, or diluted fruit juice. Try to encourage them to eat fruit which can be pureed, or chopped, depending on their ability to chew. The best fruits for babies to eat to treat constipation are:

  • apples,
  • apricots,
  • grapes,
  • peaches,
  • pears,
  • plums,
  • prunes,
  • raspberries, and
  • strawberries.


Never force your baby to eat food if they do not want to. If you do, it can turn mealtimes into a battle, and your child may start to think of eating as being a negative and stressful experience.

If your baby is still constipated after a change in diet, they may have to be prescribed a laxative. Bulk-forming laxatives are not suitable for babies, so they will usually be given an osmotic laxative. However, if this fails to work, they can be prescribed a stimulant laxative.

Children

As with babies and adults, children with constipation will first be advised to change their diet. If this fails to work, laxatives can be prescribed, usually an osmotic laxative followed, if necessary, by a stimulant laxative.

As well as eating fruit, older children should have a well balanced diet, which also contains vegetables and wholegrain foods, such as wholemeal bread and pasta.

Try to minimise any stress or conflict associated with using the toilet, and with meal times. It is important to be positive and encouraging when it comes to establishing a toilet routine. Your child should be allowed at least 10 minutes on the toilet, to make sure they have passed as many stools as possible.

To encourage a positive toilet routine, you might want to try making a diary of your child’s bowel movements which is linked to a reward system. This can help them to focus on using the toilet successfully, rather than the more negative aspects, such as faecal incontinence (when you uncontrollably leak solid or liquid stools).

Top tips for parents

  • A diet rich in fibre and with plenty of fluids will help even if your child is being treated with laxatives.
  • Children with chronic constipation don’t normally have anything physically wrong with them. However, it can take time to correct the problem, so be patient.
  • Encourage your child to have a regular toilet habit, allow them plenty of time and make sure they don’t feel rushed.
  • A reward chart for passing a stool can be useful if your child is prone to ‘holding on’.

Complications

Complications with constipation

Constipation rarely causes any complications, or long term health problems. Treatment is usually very effective, particularly if it is started promptly. However, if you have chronic (long-term) constipation, you may be more at risk of experiencing complications.

Haemorrhoids

If you have to continually strain to pass stools, it can cause pain, discomfort and bleeding. Excessive straining can also lead to haemorrhoids. More commonly known as piles, haemorrhoids are swollen blood vessels which form in the lower rectum and anus.

When you strain to pass stools, it can damage the anal canal, making the blood vessels which line it, sore and inflamed. Haemorrhoids can cause

  • itching around the anus,
  • swelling of the anus,
  • pain, and
  • bleeding from the anus.

See the ‘useful links’ section for more information about haemorrhoids.

Faecal impaction

Chronic constipation can increase the risk of faecal impaction (where dried, hard stools collect in your rectum and anus). Once you have faecal impaction, it is very unlikely that you will be able to get rid of the stools naturally. Faecal impaction worsens constipation because it makes it harder for stools and waste products to pass out of your anus because the path is obstructed.

If you experience faecal impaction, it can lead to a number of other complications. These include:

  • swelling of the rectum,
  • loosing sensation in and around your anus,
  • faecal incontinence - when you uncontrollably leak soft, or liquid, stools,
  • bleeding from your anus, and
  • rectal prolapse - when part of your lower intestine falls out of place and protrudes from your anus.


Psychological effects

If your child is experiencing faecal incontinence (as a result of their constipation) it may affect them psychologically.

Faecal incontinence can be a very upsetting and embarrassing problem for children to deal with. If they are at school, they may find themselves teased, or socially excluded. This can make a child feel withdrawn. They may feel very alone, and struggle to talk about what they are experiencing.

You may notice a change in your child’s behaviour. If you do notice a change, try to talk openly and honestly with them, and encourage them to tell you how they are feeling.

You should also try and speak to your child’s teacher, to make sure that they understand the situation. The teacher will be able to help make sure that your child is not upset, or left feeling excluded by other children.

Prevention

Preventing constipation

Although constipation is a common condition, there are several steps you can take to prevent it.

Fibre

Make sure that you have enough fibre in your diet - most adults do not eat enough. You should be having approximately 18g of fibre a day. You can increase your fibre intake by eating more:

  • fruit,
  • vegetables,
  • wholegrain rice,
  • wholewheat pasta,
  • wholemeal bread,
  • seeds,
  • nuts, and
  • oats.

Eating more fibre will keep your bowel movements regular because it helps food to pass through your digestive system more easily. Foods which are high in fibre will also make you feel fuller for longer.

If you are increasing your fibre intake, it is important to increase it gradually. A sudden increase may make you feel bloated. You may also produce more wind (flatulence), and have stomach cramps.

Fluids

Make sure that you drink plenty of fluids, to avoid dehydration. You should be drinking at least 1.2 litres (6-8 glasses) of water a day, and more when you are exercising, or when it is hot. Try to cut back on the amount of caffeine, alcohol and fizzy drinks that you have.

Toilet habits

Never ignore the urge to go to the toilet. Ignoring the urge can significantly increase your chances of having constipation. The best time for you to pass stools is first thing in the morning, or about 30 minutes after a meal.

When you use the toilet, you should try to make sure that you have enough time and privacy to pass stools comfortably. Do not feel as though you have to rush.

Exercise

Keeping mobile and active will greatly reduce your risk of getting constipation. Ideally, you should do a minimum 30 minutes of physical exercise every day.

Not only will regular exercise reduce your risk of becoming constipated, it will also leave you feeling healthier, and improve your mood, energy levels and general fitness.

Useful links

NHS Choices links

External links

This article was originally published by NHS Choices

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