Symptoms: Fewer than 3 bowel movements in a week, hard/dry stools, stools that are painful/difficult to pass, a feeling that bowel movement is incomplete.

Causes: Changes in diet, not drinking enough liquids, being less active/lack of exercise, certain medications and medical conditions.

Risk Factors: Age, delaying the urge to poop, low physical activity, changes in daily routine, and low-fibre food.

Prevalence: About 16 out of 100 adults have symptoms of constipation.

Severity: Mild to severe

Which doctor to consult: General physician, gastroenterologist.

OVERVIEW:

Constipation is a condition where bowel movements are infrequent, typically occurring three times or fewer per week, and are difficult to pass. However, bowel movement patterns can vary from person to person, and what is normal for one person may not be normal for another. Constipation is not a disease but can be a symptom of an underlying medical problem. 

Symptoms of constipation include stools that are generally hard, dry or lumpy, stools which are difficult or painful to pass, and a feeling of incomplete bowel movement. Constipation may be caused by a lack of fibre in the diet or insufficient fluid intake. It can also be a side effect of certain medications or related to an underlying medical condition. In many cases, the cause is not clear. 

Constipation affects people of all ages and populations and may last for a short or long period. Diet and lifestyle modifications such as increasing fluid intake, consuming fibre-rich foods, and exercising regularly may help relieve constipation. In some cases, medications may also be prescribed to treat constipation. It is important to consult a doctor if you have chronic constipation, as it could lead to complications.

SYMPTOMS:

The symptoms of constipation are:

• Fewer than 3 bowel movements in a week.

• Stools which are difficult/painful to pass.

• Stools that are hard, lumpy, or dry.

• A feeling that not all stool has passed.

• Bloating.

• Abdominal cramps/pain or discomfort.

• Trouble/strain while pooping.

CAUSES:

Some causes that may lead to constipation are:

• Dietary causes: Low fibre and inadequate fluid intake can result in constipation. Fibre is the indigestible part of plant foods that stays in the gut, adds bulk to the stools (faeces), and aids proper bowel function. When we do not drink enough fluids, stools can become hard and difficult to pass. So, it is essential to ensure that you're getting sufficient amounts of both fibre and fluid in your diet to maintain healthy bowel movements.

• Medicines: Certain drugs have the potential to cause constipation as an adverse effect. This includes analgesics like painkillers (codeine, morphine), some anti-ulcer medications, some antidepressants (such as amitriptyline), iron supplements, etc. If you suspect that a medication is causing constipation, it is essential to consult your doctor; the doctor may suggest a change of medication.

• Medical conditions: Constipation can be caused by a range of medical conditions, such as an inactive thyroid gland, irritable bowel syndrome, diverticular disease (a condition that affects large intestine), and colon cancer, as well as factors such as reduced mobility due to illness or injury, disability, frailty, or old age. Psychological factors such as depression, work patterns, and obesity may also contribute to constipation.

• Pregnancy: Approximately 20% of expectant mothers may experience constipation. This is caused by the hormonal fluctuations during pregnancy that decelerate the intestinal movements. In the later stages of pregnancy, the pressure exerted by the growing baby on the abdomen may also cause the bowels to shift to one side, leading to constipation.

• Idiopathic/unknown cause: Even with proper diet, hydration, absence of diseases, and no medication that can cause constipation, some people still suffer from constipation due to underactive bowels, also known as functional constipation or primary constipation. This condition is more common in women and usually starts in childhood or early adulthood and continues throughout life.

RISK FACTORS:

The risk factors of constipation are:

• Low-fibre food

• Not having enough liquids

• Inadequate physical activity

• Changes in daily routine

• Resisting the urge to poop

• Stress

• Pregnancy

• Overuse of laxatives

• Certain medicines and medical conditions

POSSIBLE COMPLICATIONS:

The most common complications associated with constipation are discomfort and irritation that can lead to:

• Haemorrhoids/Piles: Too much strain during constipation may cause haemorrhoids, a condition that causes swollen and inflamed veins in the rectum & anus, causing discomfort and bleeding.

• Rectal bleeding: Constipation and straining to poop may cause tearing of the skin inside the anus leading to rectal bleeding.

• Anal fissures: Constipation and straining to poop or passing hard or large stools during a bowel movement may cause tears in the skin around the anus leading to anal fissures.

Sometimes, the difficulty passing a bowel movement can cause more serious complications, such as:

• Rectal prolapse: The large intestine detaches inside the body and pushes out of the rectum.

• Faecal impaction: A hard, dry stool is stuck in the body and cannot be expelled naturally.

PREVENTION:

Diet and lifestyle modifications may help prevent constipation. These include:

• Fibre-rich food: Be sure to add fibre to your diet a little at a time so your body gets used to the change. Good fibre sources are whole grains (oatmeal, whole wheat bread, and bran flake cereals), legumes (black beans, lentils, soybeans, kidney beans, and chickpeas), fruits (apples, oranges, berries, and pears), vegetables (broccoli, carrot, green peas, and collard greens), and nuts (peanuts, almonds, pecans).

• Fluid intake: Consuming an adequate amount of water and other fluids prevents dehydration. Maintaining hydration levels is beneficial for one's well-being and can prevent constipation. Consuming fluids like water, naturally sweetened fruit and vegetable juices and clear soups can aid in improving the effectiveness of fibre in the body. This can lead to softer stools that are easier to pass.

• Exercise: To maintain good health, it is recommended that adults engage in moderate-intensity exercise for 150 minutes (2 hours and 30 minutes) each week. If you are new to exercising, you can break this down into shorter 10-minute periods throughout the day. Activities that involve movement, such as taking a walk, doing some gardening, or cleaning your house, also count towards your exercise goals. These simple activities can significantly improve how you feel.

• Empty your bowels when your body tells you: Resisting the urge to empty your bowels may lead to constipation. Therefore, allow time for your bowel movements.

• Try to empty your bowels at the same time every day: Try going to the bathroom at the same time every day, this helps train your body to have regular bowel movements.

• Health conditions and medications: Consult the doctor if you think your health conditions or the medications you are taking are causing constipation.

• Manage stress: Stress directly influences bowel movements by affecting body processes. Thoughts and emotions triggered by stress can affect your stomach and bowels. Therefore, it is important to manage stress to prevent constipation.

• Avoid certain foods: To relieve or prevent constipation, it is advisable to avoid consuming foods with low fibre, such as chips, meat, fast food, frozen meals, and processed foods.

WHEN TO SEE A DOCTOR:

It is advised to consult a doctor if your symptoms do not go away with self-care, if you have a family history of colon/rectal cancer, or if you notice any of these symptoms:

• Bleeding from the rectum

• Blood in stool

• Inability to pass gas

• Constant pain in the abdomen

• Fever

• Vomiting

• Lower back pain

• Weight loss

DIAGNOSIS:

The doctors will recommend the patient's medical and family history, physical exam, or medical tests to diagnose and determine the cause of constipation.

Medical and family history: 

The doctor may ask questions about a patient's medical background, like if they’ve had surgery on their digestive tract, weight fluctuations, and anaemia history. They may also ask about the frequency of bowel movements, the duration of symptoms, stool appearance, and if there are any red streaks in the stool or blood on the toilet paper when wiping. 

Additionally, they may ask about the patient's routines, such as eating habits, physical activity, and medications, including supplements and alternative treatments. It may be helpful to track bowel movements and stool appearance for several days or weeks before an appointment with the doctor. 

If a patient has been constipated for a long time, the doctor may inquire about any family history of anatomic problems, intestinal obstruction, diverticular disease, colon or rectal cancer, or any other conditions that could cause long-lasting constipation.

Physical examination: During a physical exam, the doctor may check your blood pressure, heart rate, and temperature, and look for signs of dehydration, abdominal swelling, pain, tenderness, lumps or masses. A rectal exam may also be performed.

Medical tests:

• Lab tests: The doctor may recommend lab tests to look for signs of diseases that might be causing constipation. The doctor may advise blood tests (to look for signs of celiac disease, hypothyroidism and anaemia), stool tests (to determine the presence of blood and signs of infection and inflammation) and urine tests (to show signs of diseases like diabetes).

• Endoscopy: To check for signs of problems in your lower digestive system, the doctor may perform endoscopy on the anus, rectum, and colon. Endoscopies for constipation include colonoscopy & flexible sigmoidoscopy. The doctor may also perform a biopsy (a procedure that involves examining tissues under a microscope) to look for signs of cancer or other problems.

• Colorectal transit studies: To determine how well the stools move through the colon, the doctor may recommend examinations like radiopaque markers (an x-ray tracks radioactive markers whilst they pass through the digestive system) and scintigraphy (the doctor tracks radioactive substances taken via meals using computers and cameras as the substances pass through the intestine).

Other bowel function tests: The doctor may advise the following tests to look for signs of certain diseases/conditions that may be causing constipation.

• Defecography: In this test, an x-ray of the area around the anus and rectum is taken to determine how well it can hold and release stool.

• Anorectal manometry: This is a test to check how sensitive the rectum is and how well the rectum and anal sphincters work.

• Balloon expulsion test: This test involves pushing a small water balloon from the rectum to see if there is a problem pushing out a stool.

Imaging tests: The doctor may suggest imaging tests to look for other problems that might be causing constipation.

• Lower gastrointestinal series/Barium enema: It is a procedure that examines the rectum, the large intestine, and the lower part of the small intestine using a contrast dye containing barium (a metallic chemical). The barium coats the inside of the organs so that it will appear on an X-ray, showing narrowed areas, obstructions/blockages, and other problems.

TREATMENT:

Dietary and lifestyle modifications:

• Dietary changes: Dietary modifications may be effective in reducing the occurrence of constipation. Include fibre-rich foods such as whole grains, bran cereals, fresh fruits and vegetables in your diet. Also, drink plenty of water and other liquids. Limit dairy (milk, cheese, ice-creams), processed food, and animal protein (fish, meat).

• Physical activity: Exercise may help strengthen abdominal muscles and stimulate intestinal contractions, which aid in stool movement through the digestive system. Exercising also helps reduce stress, which is also one of the causes of constipation. 150 minutes of moderate-intensity aerobic exercises or 75 minutes of vigorous-intensity aerobic activity per week is recommended. 

• Bowel training: Train yourself to have a bowel movement at the same time every day to establish a regular pattern. For instance, aiming to have a bowel movement 15-45 minutes after breakfast can help since eating aids the colon in moving stool. Make sure to allocate enough time for yourself to use the bathroom when you feel the urge to go. You can try to relax your muscles or use a footstool to make yourself more comfortable.

• Supplements: Talk to the doctor if you think certain medicines or supplements are causing constipation. Your doctor may prescribe alternatives based on your condition. Do not stop taking any medicine without consulting the doctor.

Medications: The doctor may prescribe medications to help treat constipation. These include

• Lubricant laxatives: Lubricant laxatives coat the bowel and stool mass with a waterproof film, thereby encouraging bowel movement. Examples are:

   Mineral oil

• Stimulant laxatives: They trigger contractions in the bowel that push stool along. Thereby, they help treat constipation. Stimulant laxative examples include:

  Sodium picosulphate

  Senna

  Bisacodyl

• Osmotic laxatives: Osmotic laxatives make the stools softer by drawing water into the intestines. Examples include:

  Milk of magnesia (Magnesium hydroxide)

  Lactitol

  Polyethylene glycol

  Macrogol

• Fibre supplements: They absorb water and make the stool bulky, which helps with bowel movement. It is advised to drink plenty of water while taking fibre supplements to prevent blockage. Fibre supplement examples include:

  Methylcellulose fibre

  Psyllium

  Wheat dextrin

  Calcium polycarbophil

• Stool softeners: They facilitate easy passage of stools by increasing the amount of water and fat absorbed by the stool. This makes the stools soft and easier to pass. Examples include:

  Docusate sodium

• Chloride channel activators: This medicine is generally prescribed to treat chronic constipation. It works by increasing the amount of fluid that flows into the bowel and allowing the stool to pass more easily. 

  Lubiprostone

• Serotonin receptor agonists: This medicine is used to treat chronic idiopathic constipation. It increases colon contractions, leading to more bowel movements.­­­

  Prucalopride

Surgery: In certain cases, if other treatments do not work, the doctor may advise surgery to treat an anorectal blockage caused by rectal prolapse. The doctor may perform surgery to remove the colon if your colon muscles do not work correctly.