Constipation

Constipation affects between 2% & 28% of adults (women more than men) but only about 1/3 seek health care for it. Around 5-30% of children suffer constipation – the wide range is due to various criteria used for diagnosis. Chronic constipation occurs in about one third of people who become constipated.

Constipation, as defined by the Rome Criteria, leads to significant impairment of quality of life, with implications that this is a serious condition in most people afflicted. Constipation may have other serious consequences; for example, an increased risk of colon cancer has been reported.

Symptoms of Constipation

Constipation can be infrequent bowel movements, hard or dry stool, or difficulty in passing stool. Symptoms of constipation may include:

  • stools that are hard, dry, or lumpy
  • stools that are difficult or painful to pass
  • a feeling that not all stool has passed,
  • Irregular bowel pattern, with some days of no bowel motion.

Any delay or disruption in the normal movement of stool through the bowel can lead to a variety of symptoms, including excessive, noisy, and/or smelly gas (flatulence), and discomfort. To understand constipation, it’s good to have an overview of some basics of the digestive process.

Digestion and Absorption

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After you eat, your food is digested by chemical and mechanical processes in the stomach. Then it is called chyme.

After passing from the stomach into the small bowel, further enzymatic digestion happens to chyme. Nutrients are absorbed into the bloodstream as it moves down the narrow intestine.

As chyme passes through the stomach and intestine, it picks up cellular debris and other types of waste products. This, and any remaining undigested or indigestible material, then moves into the large bowel (also called the colon or large intestine).

What Takes Place on the Way Through

Bacterial Fermentation

The large bowel is the main place that bacteria act upon chyme. They enzymatically and fermentatively break down any proteins, starches, and some plant fibres that were not totally digested already.

Water Absorption

In both the small and the large intestine, water is slowly absorbed into the bloodstream, so the chyme gradually gets thicker. A primary function of the large bowel is to absorb water from chyme, consolidating the material into stool (faeces). However, excessive water absorption can lead to dry and hard stool.

Peristalsis

Chyme, and then faecal material, is moved along the length of the intestines by coordinated muscular contractions, passing the stool to then end of the large intestine (the sigmoid colon and the rectum), where it is stored until ready for excretion. Normal peristaltic contractions are essential for regular bowel movements.

The Emptying Procedure

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Rectal Sensation

When the rectum becomes distended with stool, stretch receptors on the rectal walls signal the brain that it’s time for a bowel movement. This sensation, that prompts the urge to empty the bowels, can pass quite quickly if the signal does not result in bowel emptying. It is peristaltic waves that propel the faeces toward the anus and out of the body. The final act involves opening of the anal canal, pelvic floor muscles get involved, and a coordinated action of two separate anal sphincters results in successful evacuation.

If the signal to defaecate is not felt or ignored, and emptying the bowels is delayed again and again, the faeces returns to the colon, where it becomes drier, more compacted and constipation is the result.

Causes of Constipation

There is often no single causative factor, making constipation difficult to treat. However, there are many factors that influence the risk for becoming constipated. The most common are outlined below.

Eating Habits

Having regular mealtimes aids regularity in the bowel. Therefore, a lack of routine can contribute to erratic patterns. Inadequate dietary fibre, and excessive use of laxatives can contribute to worsening of constipation over time.

Digestive Disorders

Constipation may also be caused by weakness of the abdominal muscles, spasms of the large intestine, or more seriously, intestinal obstruction by tumours.

Changes in routine

Temporary constipation most often occurs when there has been a change or interruption in one’s usual activities. This might be due to travel, reduction in usual exercise levels, or a change in eating or sleeping habits.

Metabolic Diseases

Having low thyroid function, such as Hashimoto’s’, or diabetes can contribute to constipation.

Neurological Disorders

Having a stroke, head injury,  or Parkinsons’ disease are examples of centrally mediated problems with bowel function – the messages don’t get through or get misinterpreted. Some medications including certain pain killers, antidepressants, and antispasmodics can interfere with normal bowel activity.

Dysbiosis

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You have trillions of microorganisms living within you, and for the most part, they are working for you. Constantly. Until they aren’t – and then they can work against you.

Dysbiosis is the term used to refer to an imbalance in the composition and function of these organisms.

Dysbiosis can have various effects on gastrointestinal health, including contributing to constipation.

Here’s how dysbiosis may contribute to constipation:

  • Altered Fermentation: As stated above, gut microbes have an important role in fermenting and breaking down dietary fibres and complex carbohydrates that are not digestible by our enzymes. Outputs from this fermentation are compounds called short-chain fatty acids (SCFAs), such as acetate, propionate, and butyrate. SCFAs help by stimulating bowel movements – a key mechanism being providing fuel for the muscle cells that generate the necessary contractions in the bowel. Dysbiosis can lead to reduced production of SCFAs, contributing to problems in the movement of stool through the intestines.
  • Bacterial (or Methanogenic) Overgrowth: Dysbiosis can lead to an overgrowth of certain types of bacteria, such as archaea, or methane-producing bacteria. These organisms, or their by-products (one of which is methane gas), can slow down gut transit time, leading to constipation.
  • Reduced Fibre Metabolism: Dysbiotic changes in the gut microbial composition may result in decreased ability to metabolise dietary fibres, resulting in a lack of bulk in the stool. Adequate stool bulk is essential for regular and efficient bowel movements.
  • Inflammation: As SCFAs also have anti-inflammatory effects, dysbiosis, as well as specific bacteria, can trigger an inflammatory response in the gut, affecting the motility of the intestines. Chronic inflammation may lead to alterations in the smooth muscle function of the colon, making it harder for stool to pass through.
  • Altered Gut-Brain Communication: The gut-brain axis is a bidirectional communication system between the gut. This pathway is key to many functions of the digestive system, including regulating bowel movements. Dysbiosis can cause disruptive signals on this communication pathway, potentially leading to abnormal motility patterns in the digestive tract and contributing to constipation.
  • Reduced Mucous Production: Mucous acts as a lubricant along the length of the intestinal lining, enhancing smooth passage of stool. A healthy gut microbiota contributes to the healthy turnover of this mucous in the intestines, and dysbiosis can lead to disruption to this balance, making it more difficult for stool to move through the colon.
  • Changes in Gut Hormones: A key neurotransmitter in regulating intestinal motility is serotonin. Dysbiosis may also affect the release of serotonin, resulting in a slowing of digestive processes.

It’s important to note that while dysbiosis can contribute to constipation, the relationship between gut microbiota and gastrointestinal health is complex, and the specific mechanisms may vary from person to person.

Drop in to our Constipation Clinic
Tuesdays 10:00am – 2:30 pm and Wednesdays 10:00am – 5:00pm (no appointment necessary).
Appointments required outside these times.

Impact of Constipation

Constipation can impact people physically, psychologically, and socially. Here are some examples of how this manifests:

  • Physical Discomfort: Constipation can cause abdominal pain, bloating, feeling full and cramping. In short, it’s very uncomfortable.
    • Straining during bowel movements can lead to haemorrhoids (which are basically prolapsed blood vessels, like varicose veins).
    • In severe or prolonged cases, anal fissures, and even rectal prolapse can occur.
    • Passing a bowel motion can cause pain and discomfort, making one reluctant to even attempt to poop.
  • Reduced Quality of Sleep: Sometimes constipation can cause discomfort or disturbance during the night due pain or to the need to have a bowel movement. This can lead to disrupted sleep patterns and poorer sleep quality.
  • Headaches: Headaches are a commonly associated with constipation, which can occur via several mechanisms, including:
    • Insufficient fluid intake is associated with both headaches and constipation.
    • Muscle tension and fatigue due to increased abdominal pressure, caused by straining to pass hard stool are major contributors to tension-type headaches.
    • Toxin Accumulation. The bowels are one of the main mechanisms of waste disposal. Prolonged retention of faecal material in the bowel can lead to a build-up of waste products and toxins, contributing to headaches.
  • Impact on Appetite: Some people with constipation may experience a reduced appetite, which can lead to inadequate nutrition and further complicate their overall health. This may evolve to nausea, which is a signal from the body that it is not successfully processing the digesta.
    • People may avoid certain foods, especially if they think specific foods are the reason for their digestive distress. Ultimately, this approach is not an ideal long-term solution as it can cause restriction of important food groups and thus lead to nutrient insufficiency.
  • Psychological Unease: Being chronically constipated can cause frustration, and a reduced quality of life.
    • Persistent discomfort and constipation-associated inconvenience can lead to feelings of irritability, mood swings, and reduced overall emotional well-being.
    • It can also be a source of stress and increased anxiousness, which can trigger headaches.
    • Effects via the gut-brain axis may further contribute to constipation.
  • Impact on Relationships & Social Life
    • Social Limitations: Persistent constipation can contribute to avoiding travel or social activities due to concerns about needing to use (or find) a bathroom. Experiencing discomfort or feeling embarrassed also contributes to social isolation and reduced participation in activities.
      • Constipation-related discomfort can affect personal relationships, including intimacy communication and tolerance.
    • Decreased Productivity & Increased Costs: Abdominal discomfort and distraction due to constipation can reduce productivity at work or school.
      • Severe constipation can lead to days off work, more medical visits, costs of medications, dietary changes and/or supplements, adding to financial stress.
Drop in to our Constipation Clinic
Tuesdays 10:00am – 2:30 pm and Wednesdays 10:00am – 5:00pm (no appointment necessary).
Appointments required outside these times.

You should see a doctor without delay if you have constipation AND any of the following symptoms:

Bleeding from your rectum or blood in your stool

Constant pain in your abdomen

Inability to pass gas

Vomiting

Fever

Lower back pain

Losing weight without trying

What to Do if You Can’t Poo

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If you are constipated and looking for relief, there are several steps you can take to alleviate the condition.

Check out these tips on what to do if you’re constipated:

Increase Your Fibre Intake

Add fibre-rich foods to your diet. Fibre helps soften the stool and promote regular bowel movements. Foods high in fibre include fruits, vegetables, whole grains, beans, and legumes.

If increasing your dietary fibre causes digestive distress, please drop in to our dedicated constipation clinic, open Tuesdays 10:00am – 2:30 pm and Wednesdays 10:00am – 5:00pm (no appointment necessary). Appointments required outside these times.

1. Stay Hydrated

Drinking ample fluid over the course of the day is essential for maintaining soft and easily passable stools. Aim for at about 6-8 cups (1.5 – 2.0L) of water daily.

2. Set Regular Mealtimes

As inherent signals for colonic contractions are stimulated by eating a meal, establishing a regular eating schedule with healthy, nutritionally balanced meals can help regulate your body’s natural bowel movements.

3. Exercise

Engage in regular physical activity. Exercise supports good abdominal muscle tone and stimulates the muscles of the digestive tract.  Even a daily brisk walk can help move stool through the intestines.

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Exercise aids normal digestive function.

4. Obey the Call of Nature

Pay attention to your body’s natural signals. When you feel the urge to have a bowel movement, don’t delay or ignore it. Responding promptly can help prevent constipation. If these signals are occurring too often, and evacuation is ineffective, please visit our dedicated constipation clinic.

5. Limit Processed Foods

Processed foods such as fast food, sugary snacks, baked goods, white flour, pasta, and white rice are inherently low in fibre. Reducing your consumption these low-fibre foods can improve gut function and reduce constipation.

6. Prunes or Prune Juice

Prunes and prune juice are natural laxatives and can be effective for relieving constipation. You can try eating a few prunes or drinking a glass of prune juice daily – but be aware that this carries a notable sugar load. If prunes increase your digestive distress, please visit our dedicated constipation clinic, open Tuesdays 10:00am – 2:30 pm and Wednesdays 10:00am – 5:00pm (no appointment necessary). Appointments required outside these times.

7. Natural Remedies

Some people find relief from natural remedies like psyllium husk or ground flaxseed. These can add bulk to the stool and improve bowel regularity. For personalised guidance on the use of these, visit our dedicated constipation clinic, open Tuesdays 10:00am – 2:30 pm and Wednesdays 10:00am – 5:00pm (no appointment necessary). Appointments required outside these times.

8. Note Your Trigger Foods

If you notice that certain foods, beverages, or dietary supplements consistently worsen your constipation, try to limit them until you have consulted with one of our team. Avoiding healthy food is not a recommended long-term strategy unless you are allergic to them or have other medical reasons such as coeliac disease. If you are avoiding food to control symptoms, we strongly advise you to consult with a gut-health expert.

Drop in to our Constipation Clinic
Tuesdays 10:00am – 2:30 pm and Wednesdays 10:00am – 5:00pm (no appointment necessary).
Appointments required outside these times.

Summary

It’s essential to address constipation promptly through lifestyle changes, dietary modifications, increased fluid intake, and, if necessary, supplements. Early intervention can help alleviate the impacts of constipation and improve overall well-being.  We aim to provide long-term solution by determining the underlying cause and develop an appropriate treatment plan.

A range of treatment approaches for constipation are available, depending on the interplay of these various contributors. For example, if related to dysbiosis, dietary changes, specific probiotics, and/or prebiotics, and other interventions aimed at restoring a healthy balance of gut bacteria may be selected. Consulting with a gut health expert can help determine the most appropriate course of action.

Make an appointment to see one of our clinicians if constipation persists. Be cautious about using laxatives excessively, as they can lead to dependency and worsen constipation over time.

Drop in to our Constipation Clinic
Tuesdays 10:00am – 2:30 pm and Wednesdays 10:00am – 5:00pm (no appointment necessary).
Appointments required outside these times.

References

  1. Pare P, et al. An epidemiological survey of constipation in Canada: definitions, rates, demographics, and predictors of health care seeking. Am J Gastroenterol. 2001 Nov;96(11):3130-7. PMID: 11721760.
  2. Constipation in children and young people: diagnosis and management. London: National Institute for Health and Care Excellence (NICE); 2017 Jul. PMID: 32200591.
  3. Talley NJ, Lasch KL, Baum CL. A gap in our understanding: chronic constipation and its comorbid conditions. Clin Gastroenterol Hepatol. 2009 Jan;7(1):9-19. doi: 10.1016/j.cgh.2008.07.005.
  4. What are the symptoms of constipation? (2018) https://www.niddk.nih.gov/health-information/digestive-diseases/constipation/symptoms-causes
  5. Takakura W, Pimentel M. Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome – An Update. Front Psychiatry. 2020 Jul 10;11:664. PMID: 32754068
  6. Johanson JF, Sonnenberg A, Koch TR. Clinical epidemiology of chronic constipation. J Clin Gastroenterol. 1989 Oct;11(5):525-36. PMID: 2551954
  7. Rao SSC, Brenner DM. Efficacy and Safety of Over-the-Counter Therapies for Chronic Constipation: An Updated Systematic Review. Am J Gastroenterol. 2021 Jun 1;116(6):1156-1181. PMID: 33767108
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