Management of constipation

Definition of constipation

The frequent of bowel movement among healthy people varies greatly ranging from three movements a day to three time a week. Generally, stools should be passed without excess effort, straining or discomfort with passage.  Constipation is there by defined as the infrequent and or difficult passage of stool. Because the function of the large intestine or colon is to absorb water delayed the transit through the colon lead to constipation with hardening of the stool and infrequent bowel movement by (Free Merriam- Webster Dictionary).

As a rule, if more than three days pass without a bowel movement, the intestine content may harden to the point during that the person may have difficulty or even pain during elimination. Straining during bowel movement or the feeling of incomplete evaluation may also be reported as constipation. However, the presence of that symptom with normal frequent of stool passage may require further physiological testing for related conditions of pelvic floor dysfunction. This is a type of constipation where the muscles in the rectal area do not properly relax and they may hold back stool or lead to difficulty passage.

Types of constipation

There are two main types of constipation

  1. Occasional
  2. Chronic


  • Occasional constipation: As the name suggest, occasional constipation does not happen every day. While uncomfortable, it is a short term condition that may temporarily interrupt your usual routine. This type of constipation can only be relieved through change in your diet, exercise or through the use of over the counter medication (Bharucha, 2007).
  • Chronic constipation: Chronic constipation on the other hand, almost becomes a new routine on its own. Most people who have the chronic constipation still have the typical symptoms straining, hard or lumpy stool, feeling like you are not empty after having a bowel movement but they happen on an ongoing basis (Callum, Ong & Mercer- Jones, 2009).

Causes of constipation

  1. Poor diet: A main cause of constipation may be a diet high in animal fat (meat, dairy product, eggs) and refined sugar (rich desserts and other sweets), but low in fibre (vegetable, fruits, whole grains), especially insoluble dietary fibre, which helps move bulk through the intestines and promote bowel movement. Some studies have suggested that high fibre diet result in larger stool, more frequently bowel movement and therefore, less constipation (Locke, Remberton & Philips, 2000).
  2. Irritability of bowel syndrome (IBS): Also known as IBS with constipation or IBS-C is one of the most common causes of constipation in the US. Some people develop spasms of the colon that delay the speed with which the contents of the intestine move through the digestive tract, leading to constipation. IBS-C differs from usual constipation because it associated with abdominal pain.
  3. Poor bowel habits: A person can initiate a cycle of constipation by ignoring the urge to bowel movement. Some people do this to avoid using public toilet, others because they are too busy. After a period of time, a person may stop feeling the urge. This lead to progressive constipation. Children may also suppress the urge during toilet training or when going to unfamiliar rest room. As in school and this can progress to constipation later in life. Studies show that suppressing the urge to have a bowel movement may slow down the transit through the colon or lead to incomplete relaxation of the pelvic floor muscles, thus holding back stool (Nelson, 2010).
  4. Pseudo-constipation: The false belief that one is constipated is very common and result from misunderstanding about what is normal and what is not. If recognized early enough, this type of constipation can be cured by the patient’s physician explaining that the frequency of his or her bowel movement is normal. One example is when a person has a bowel movement less frequently. Another example is when an individual feels abdominal discomfort and tries to have a bowel movement but cannot. However, the stool has yet reached the return to be properly eliminated (Bharucha, 2007).
  5. Travelling: People often experience constipation when travelling long distance, which may relate to change in lifestyle. Schedule, diet and drinking water or some evacuation difficulties when using other toilets (Dining, 2007).
  6. Pregnancy: Pregnancy is another common cause of constipation, which may be partly due to hormonal change during pregnancy.
  7. Fissure and haemorrhoids: Painful condition of the anus can produce a spasm of the anal sphincter muscle, which can delay a bowel movement.
  8. Medication: Many medications can cause constipation. These include pain medication (especially narcotics) antacid that contain aluminium or calcium, antispasmodic drugs, antidepressant drugs, tranquilizers, iron supplement, anticonvulsant for epilepsy, anti Parkinson drug and calcium channel blockers for high blood pressure and heart condition.
  9. Colonic inertia: With this condition, the transit through the large intestine is very slow, leading to build up of stool in the large intestine and even enlargement of the colon. Individual with this condition may not have a bowel movement for week at a time. Treatment involves vigorous oral flushes of fluid or sometimes surgery. This is a relatively rare cause of constipation.
  10. Pelvic floor dysfunction: Some individual may develop spasms or an ability to properly evaluate the stool. This can be due to structural change, such as a tumour, that will require specific treatment. It may also functional problem where the muscles in the pelvic floor (levator muscles) do not properly relax to allow easy passage. This is treated by bio-feed back of these muscles.
  11. Laxative abuse: People who habitually take large dosage of stimulant laxatives become dependent upon them and may require increasing dosage until finally, the intestine becomes insensitive and fail to work properly
  12. Hormonal disturbance: Certain hormonal disturbance such as an under-active thyroid gland can produce constipation.
  13. Specific disease: Many diseases that affect the body tissue, such as scloroderma or lupus and certain neurological or muscular diseases, such as multiple sclerosis, Parkinson’s disease and stroke, can be responsible for constipation.
  14. Lose of body salts: The loss of body salt through the kidneys or through vomiting or diarrhoea is another cause of constipation.
  15. Mechanical compression: Scarring inflammation around diverticula (pouches in the intestine), tumours and cancer can produce mechanical compression of the intestine and result in constipation.
  16. Nerve damage: Injuries to the spinal cord and tumours pressing on the spinal cord can produce constipation by affecting the nerve that lead to the intestine.
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Risk factors of constipation

Factors that may increase the risk of constipation include:

  1. Being an older adult
  2. Being a woman
  3. Being dehydrated
  4. Eating a diet that is low in fibre
  5. Getting little or no physical activity
  6. Taking certain medication including sedatives, narcotives, or certain medication to lower blood pressure

Diagnostic tests of constipation

Constipation may be caused by abnormalities or obstruction of the digestive system in some people. A doctor can perform test to determine if constipation is the symptom of an underlying disorder. In addition to routine blood, urine and stool test, several other test may be consider by your gastroenterologist.

An abdominal X-ray can be helpful to determine if there is a large amount of stool present due to constipation , when a very large amount is present your doctor may ask you to take flush, much like what is used to prepare for a colonoscopy  to empty your colon. This may help restore more normal functioning or allow proper treatment.

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A colonoscopy or sigmoidoscopy may help detect disease like colon cancer, or diverticular disease in the reaction and colon. With this procedure, the bowel is first prepared with a solution that is drunk the day before or several hours earlier. Then the doctor will usually insert a flexible, lighted instrument through the anus to examine the rectum and intestine. The doctor will usually perform a colonoscopy to inspect the entire colon, but in younger individual, a more limited sigmoidoscopy using a shorter instrument may be sufficient.

A radio-opaque marker (“sitzmark”) study can be done to determine how severe the constipation is, the patient swallow capsules, each containing about 24 tiny pellets or marker that disperse in the large intestine. After several days, an X-ray is taken to determine how many pellets have not been evacuated and their location. There are several ways to do this test and your physician will determine which is best for you (Saunder, 2011).

When there is evidence for pelvic floor dysfunction (excessive staining, in complete evacuation or sitzmark study showing retained marker in the rectum), an anorectal motility study is done. This study is used to evaluate the contraction and relaxation of the pelvic floor muscles. For this test, a small tube is placed in the rectum and the patient is asked to contract and relax the muscles while the technician records the pressures on a computer. If this condition is identified, your physician may prescribe bio-feedback treatment of pelvic floor muscles.

Prevention of constipation

Have at least 8 drinks a day example water, tea, coffee, squash, fruit juice, milk. Eat food high in fibre example fruit and vegetable, whole grain, cereals, whole wheat bread. Be more active. Make sure the toilet is clean and comfortable.

Treatment of constipation

Although treatment depends on the cause, severity, and duration, in most cases dietary and lifestyle changes will help relieve symptoms and help prevent constipation

The first step in treating and constipation is to understand that normal frequency varies widely, from three bowel movements a day to three times a week. Each person must determine what is normal to avoid becoming dependent on laxative (Hsieh, 2005)

For most people, dietary and lifestyle improvement can lessen the chances of constipation. A well balanced diet that includes fibre- rich food, such as unprocessed brain, whole grain bread, and fresh fruit and vegetable is recommended. Drinking plenty of fluids and exercising regular will help to stimulate intestinal activity.

Special exercise may be necessary to tone up abdominal muscles are laxative. Bowel habit is also important.  Sufficient time should be set aside to allow for undisturbed visits to the bathroom. In addition, the urge to have a bowel movement should not be ignored. If an underlying disorder is causing constipation treatment will be directed toward the specific cause for example, if an under active thyroid is causing constipation, the doctor may prescribe thyroid hormone replacement therapy.

Dietary management of constipation

Constipation means being unable to move your bowels, having movement less often than is normal for you, or having to push harder to move your bowels than you have in the past, it may be a side effect of the chemotherapy that you are on, or a result of the medication you are taking to manage nausea and pain. Constipation can also be caused by being less active and eating or drinking less. However, there are many things that can be done to help with bowel regulation (Emmanuel, et al., 2009).

It is important that you maintain open communication with your doctor, and nurses. Use laxative only at the advice of your doctor, and contact your health care team if you have not had a bowel movement on 3 or more days.

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It is very important to stay well-hydrated (8-10 cup of liquid each day). Prune juice, warmed juices or ciders, tea, and hot lemonade may offer relief. If you are struggling to maintain your weight, talk to the nutritionist about high- calories supplement and drinks that contain fibre.

If you are having problem with gas, eat slowly (take time to eat) and drink without using straw, it also help to avoid chewing gum. Theses change will lessen the amount of air that is swallowed at meal times thus decreasing gas production.

Be as active as possible, even if you are just taking a light walk one a day activity can help establish regular bowel pattern.

When to add fibre

If you are not having nausea, gas or bloating, try to include high-fibre and “bulk” food. Eat a good breastfeed, including a lot drink and high fibre food at the start of your day.

If gas becomes a problem, limit carbonated drinks, broccoli cabbage, cauliflower, cucumbers, dried beans, peas, and onions. (Selby, 2010)

Increase the fibre you are eating gradually. Start by adding 5 grams of fibre daily. Increasing gas or bloating. If you are already eating the goal amount (25-30 gram) of fibre, further increasing your fibre intake will likely provide no additional benefit (Avundut, 2008).

High fibre foods to choose more often

Grains Serving size Amount of fibre
Bran cereal  ½          cup 3 to 13
Raw bran ¼           cup     6
Brown rice ½           cup 3 to 13
Pop corn 2            cup popped     5
Whole wheat bread 1            slice 2 to 5
Corn ½           cup     5
Broccoli ½           cup     4
Sprouts ½           cup     3
Potatoes with skin 1            medium     4
Green peas ½           cup     3
Carrots ½           cup     2
Pear with skin 1           medium 5
Apple with skin 1          medium 4
Banana 1          medium 3
Prunes 3 3
Orange 1          medium 3
Raisins ¼         cup 3
Strawberries 1          cup 3
Blue berries ½         cup 2
Navy beans ½         cup 9
Kidney beans ½         cup 8


Constipation is one of the topics few like to talk about. If you have suffered from this problem, though, you know it can be both painful and frustrating. Almost everyone get constipation at some time during his or her life. It affects approximately 2% of the population in the US. Women and the elderly are more commonly affected. Though not usually serious, constipation can be a concern.


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Andromanakos, N, Skandalakis, P., Troupis, P. & Filippou, D. (2006). Incidence of Constipation among pregnant women in Karachi. Pakistan Journal of Gastroenterology, 24(8):34-42.

Bharucha, A.E. (2007). Constipation. Best practice & research clinical Gastroenterology 21 (4): 703-31

Callum, I. D., Ong, S. & Mercer- Jones, M. (2009). “ Chronic constipation in adults” BMJ 338:b831.

Cohn, A. (2010). Stool with holding” Journal of Paediatric Neurology 8(1): 29-31

Dining, P.G. (2007). “Colonic Monometry and Sacral Nerve Stimulation in Patient with severe Constipation pelvic. Perincology 26(3):114-116.

Emmanuel, A.V., Tack, J., Quigley, E.M. & Talley, N.J. (2009), Pharmacological Management of constipation. Lancet 569 (43):762-85.

Filippou, D. (2006),”Constipation of anorectal outlet obstruction: Pathophysiology, evaluation and Management “Journal of Gastroenterology and Herpetology 21 (4): 638-646.

Hsieh C (2005). Treatment of constipation on older adults” Am Fam Physician 72 (11): 2277-84

Locke, G.R., Remberton, J.H. & Phillips, S.F. (2000). American Gastroenterological Association Medical Position Statement; guide line on constipation “Gastroenterology 119 (6): 1761-6.

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