What is constipation?

Constipation causes one or more of the following:

• Stools (sometimes called faeces or motions) become hard and difficult or painful to pass
• The time between toilet trips increases compared to usual. (There is a large range of normal “bowel habit”. Some people normally go to the toilet to pass stools 2-3 times per day. For others, 2-3 times per week is normal. It is a change from your usual pattern that usually indicates that constipation has developed).
• Sometimes crampy pains occur in the lower abdomen. Abdominal bloating and nausea (feeling sick) may occur if constipation is severe.

What are the causes of constipation?

• Not eating enough fibre (roughage) is the main cause. The average person in the UK eats about 20/30g of fibre each day. 30grams per day is recommended. Fibre is the part of plant food that is not digested. It remains in your gut. It adds bulk to the stools and helps your bowels to work well. Foods high in fibre include: fruit, vegetables, cereals, etc
• Special “slimming diets” are often low in fibre and are one cause of constipation
• Not drinking enough may make constipation worse. Stools will usually be soft and easily passed if you eat enough fibre and drink enough fluid
• Medication may cause constipation. For example: painkillers (particularly those with codeine such as co-codamol), some antacids, some anti-depressants, iron tablets, some diuretics (“water tablets”), some cough suppressants and some medicines for Parkinson’s disease
• Medical Problems occasionally cause constipation. For example, an underactive thyroid, irritable bowel syndrome and conditions causing poor mobility, particularly in the elderly
• Some diseases such as Irritable Bowel Syndrome (the bothersome bowel), diverticular disease or an illness affecting the nerves in the bowel
• Regular use of stimulant laxatives can cause constipation. Some people take a stimulant laxative each day to “regulate” their bowel. After years of a daily laxative the bowel gradually becomes “lazy”, a vicious cycle develops. Constipation becomes worse and more and more laxatives are needed
• During Pregnancy about 1 in 5 pregnant women become constipated. It is due to the hormone changes of pregnancy that slow down the gut movements
• Strong tea or coffee may make constipation worse. This is because they have a diuretic effect. This means they can increase the amount of fluid in the urine and leave less in the bowel
• Delaying the first feelings of wanting to go to the toilet or maintaining a posture that is inappropriate to pass a motion
• Unknown or idiopathic reasons cause some people who have a good diet and have no bowel disease to become constipated. Their bowels are said to be “underactive”. This is quite common

What can I do to ease constipation?

• Eat more fibre by eating more fruit, vegetables, cereals, fruit juice, wholemeal bread, etc.
• Drink an appropriate amount of fluids - at least 6 mugs or 8 cups per day. You might need to increase this amount in warm weather, during exercising and in any situation leading to loss of fluids. Most drinks will do but strong tea and coffee may not be advisable as the only or main type of drink. Tea and coffee drinking do not need to stop but cutting down excessive amounts and having other types of drink such as water or fruit juice, may help
• Exercise regularly (if possible). Activities such as walking, going upstairs and light physical exercises where you bend and stretch to do things, improve the natural movement of the gut considerably. Your doctor, physiotherapist, occupational therapist or nurse specialist can advise you on exercises appropriate for you
• Do not ignore the feeling of needing the toilet. Some people suppress this feeling if they are busy. It may result in a backlog of stools forming that are difficult to pass later. Also ensure your posture is correct when sitting on the toilet.

What are the treatments for constipation?

The self-help measures above (fibre, fluid, etc) usually ease constipation. Other treatments are needed only if they do not work well.

Fibre supplements such as bran or “bulking agents” can be taken. These are available at pharmacies, health food shops and on prescription. Fibre works by providing extra bulk to the faeces. It also absorbs water a bit like blotting paper. The combination of fibre and fluid produces soft, bulky stools. When taking a high fibre diet or fibre supplements:

• It is important to have plenty to drink. At least 6 mugs or 8 cups a day is advised. The fibre may become “dry” and difficult to pass if you do not have enough to drink. Very rarely, lots of fibre and not enough fluid can cause an obstruction in the bowel
• An increase in wind (flatulence) and stomach bloating may occur. This is normal and tends to settle down after a few months as the gut becomes used to the increase in fibre
• Some fibres can be dry to swallow. Be extra careful if you are affected by any degree of swallowing difficulties
• Eating too much fibre can fill you up and take away your appetite. Ensure that you eat an appropriate amount without overdoing it

Laxatives can be bought from pharmacies or prescribed by a doctor. They are best used as a temporary remedy if constipation becomes severe. There are different types of laxatives that work in different ways.

Oral laxatives if dietary measures are ineffective, or while waiting for them to take effect:

• Start treatment with a bulk-forming laxative (adequate fluid intake is important) e.g. Fybogel
• If stools remain hard, add or switch to an osmotic laxative which soften your stools and make them easier to pass by increasing the amount of water in your bowels e.g. Lactulose
• If stools are soft but you still find them difficult to pass or you complain of inadequate emptying, add a stimulant laxative which speeds up the movement of your bowels by stimulating the nerves that control the muscles lining your digestive tract e.g. Bisacodyl or Senna

If you have opioid-induced constipation:

• Avoid bulk-forming laxatives
• Use an osmotic laxative (or docusate, which also softens stools) and a stimulant laxative

Laxatives can be stopped once the stools become soft and easily passed again.

If the response to oral laxatives is insufficient or not fast enough, consider:

• Using a suppository: Bisacodyl for soft stools; Glycerol alone, or Glycerol plus Bisacodyl for hard stools

A change of medication may be possible if a medicine is the cause of your constipation. Do not stop a prescribed medicine without first discussing with a doctor

Do I need any tests?

Usually not. However, tests may be advised if any of the following occur.

• Constipation is a new symptom and there is no apparent cause such as a change in diet, lifestyle or medication
• Symptoms are severe and persistent
• Other worrying symptoms also develop. For example, if you pass blood, mucus or pus from your bowel or if you have pain, weight loss, bouts of diarrhoea or other unexplained symptoms in addition to constipation

References Constipation | Health topics A to Z | CKS | NICE

NHS Choices Constipation