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Chronic constipation is defined as infrequent bowel movements or difficult stool passage that lasts for several weeks or longer.
Constipation is defined as having less than three bowel movements per week.
Though occasional constipation is common, some people suffer from chronic constipation, which can impair their ability to carry out daily tasks. Chronic constipation may also cause people to strain excessively in order to urinate.
Chronic constipation treatment is influenced in part by the underlying cause. However, in some cases, no cause is ever discovered.
WHAT ARE THE SYMPTOMS OF CONSTIPATION?
Chronic constipation is characterized by the following signs and symptoms:
- Having less than three stools per week
- Stools that are lumpy or hard
- Constantly straining to have bowel movements
- Feeling as if your rectum is blocked and preventing bowel movements
- You have the impression that you are unable to completely empty your rectum.
- Needing assistance to empty your rectum, such as pressing on your abdomen with your hands and removing stool with your finger
If you've had two or more of these symptoms in the last three months, your constipation may be considered chronic.
WHAT ARE THE CAUSES OF CONSTIPATION?
Constipation occurs most commonly when waste or stool moves too slowly through the digestive tract or is not effectively eliminated from the rectum, causing the stool to become hard and dry. There are numerous causes of chronic constipation.
Blockages in the colon or rectum
Stool movement may be slowed or stopped by obstructions in the colon or rectum. Among the causes are:
- Small tears in the skin surrounding the anus (anal fissure)
- An obstruction in the intestines (bowel obstruction)
- Colon cancer
- Narrowing of the colon (bowel stricture)
- Other types of abdominal cancer that press against the colon
- Rectal cancer
- Rectum bulge through the vaginal back wall (rectocele)
Nerve problems around the colon and rectum
Neurological issues can affect the nerves that contract the muscles in the colon and rectum, causing stool to move through the intestines. Among the causes are:
- Nerve damage that affects the control of bodily functions (autonomic neuropathy)
- Multiple sclerosis (MS)
- Parkinson's disease (PD)
- Injury to the spinal cord
- Stroke
Difficulty with the muscles involved in elimination
Chronic constipation can be caused by issues with the pelvic muscles involved in bowel movement. These issues may include:
- The inability to relax the pelvic muscles sufficiently to allow for a bowel movement (anismus)
- Pelvic muscles that do not correctly coordinate relaxation and contraction (dyssynergia)
- Pelvic musculature weakness
Conditions that have an impact on the body's hormones
Hormones aid in the balance of fluids in your body. Constipation can be caused by diseases and conditions that disrupt the hormonal balance, such as:
- Diabetes
- An overactive parathyroid gland (hyperparathyroidism)
- Pregnancy
- An underactive thyroid (hypothyroidism)
WHAT ARE THE RISK FACTORS FOR CONSTIPATION?
The following factors may increase your chances of developing chronic constipation:
- Being an older adult
- Being a woman
- Dehydration
- Consuming a fiber-deficient diet
- Physical inactivity (or lack thereof)
- Taking certain medications, such as sedatives, opioid pain relievers, antidepressants, or blood pressure medications
- Having a mental illness, such as depression or an eating disorder
WHAT ARE THE COMPLICATIONS OF CONSTIPATION?
Chronic constipation can lead to the following complications:
- Hemorrhoids (swollen veins in your anus): Straining to urinate may cause swelling in the veins in and around your anus.
- Skin tearing in your anus (anal fissure): Tiny tears in the anus can be caused by a large or hard stool.
- Stool that cannot be expelled (fecal impaction): Chronic constipation can lead to an accumulation of hardened stool in your intestines.
- Protruding intestine from the anus (rectal prolapse): Straining to urinate can cause a small portion of the rectum to stretch and protrude from the anus.
HOW IS CONSTIPATION DIAGNOSED?
Doctors use the following tests and procedures to diagnose chronic constipation and try to find the cause, in addition to a general physical exam and a digital rectal exam:
Blood tests: A systemic condition, such as low thyroid (hypothyroidism) or high calcium levels, will be looked for by your doctor.
X-ray: An X-ray can help your doctor determine if your intestines are blocked and if there is stool present throughout your colon.
A rectum X-ray taken during defecation (defecography): During this procedure, your doctor will insert a soft barium paste into your rectum. The barium paste is then passed through the body as if it were stool. X-rays can detect barium, which can reveal a prolapse or problems with muscle function and coordination.
MRI defecography: As with barium defecography, a doctor will insert contrast gel into your rectum during this procedure. The gel is then passed. The defecation muscles can be visualized and assessed using an MRI scanner. This test can also detect issues that can cause constipation, such as rectocele or rectal prolapse.
Examination of the rectum and lower, or sigmoid, colon (sigmoidoscopy): Your doctor will insert a lighted, flexible tube into your anus to examine your rectum and the lower portion of your colon during this procedure.
Examination of the rectum and entire colon (colonoscopy): With the help of a flexible, camera-equipped tube, your doctor can examine the entire colon.
Evaluation of the efficiency with which food moves through the colon (colonic transit study): You may be asked to swallow a capsule containing either a radiopaque marker or a wireless recording device during this procedure. The capsule's passage through your colon will be tracked for 24 to 48 hours and will be visible on X-rays.
In some cases, you may consume radiocarbon-activated food while a special camera monitors its progress (scintigraphy). Your doctor will examine your colon for signs of intestinal muscle dysfunction as well as how well food moves through it.
Evaluation of anal sphincter muscle function (anorectal manometry): Your doctor will insert a narrow, flexible tube into your anus and rectum, then inflate a small balloon at the tip of the tube. After that, the device is pulled back through the sphincter muscle. Your doctor can use this procedure to assess the coordination of the muscles you use to move your bowels.
Anal sphincter muscle speed evaluation (balloon expulsion test): This test, which is frequently used in conjunction with anorectal manometry, determines how long it takes you to push out a balloon filled with water and placed in your rectum.
WHAT ARE THE TREATMENTS FOR CONSTIPATION
Chronic constipation treatment typically begins with dietary and lifestyle changes designed to increase the rate at which stool moves through your intestines. If those changes are ineffective, your doctor may suggest medications or surgery.
Changes in diet and lifestyle
To relieve constipation, your doctor may advise you to make the following changes:
- Increase your fiber consumption: Increasing the weight of your stool and hastening its passage through your intestines by including fiber in your diet. Each day, gradually increase your intake of fresh fruits and vegetables. Whole-grain breads and cereals are preferable.
Your doctor may advise you to consume a certain number of grams of fiber per day. In general, aim for 14 grams of fiber per 1,000 calories consumed.
A sudden increase in fiber consumption can cause bloating and gas, so start slowly and gradually work your way up to your goal over a few weeks.
- Most days of the week, engage in some form of physical activity: Physical activity increases the activity of the muscles in your intestines. Try to get some exercise in on most days of the week. If you don't already exercise, consult your doctor to see if you're in good enough shape to begin.
- Don't ignore the urge to go to the bathroom: Allow yourself enough time in the bathroom to have a bowel movement without distractions and without feeling rushed.
Laxatives
There are various types of laxatives. Each one works in a slightly different way to make it easier to have a bowel movement. The following are available over-the-counter:
Supplements for fiber: Fiber supplements add bulk to your stool. Stools that are bulky are softer and easier to pass. Psyllium (Metamucil, Konsyl, and others), calcium polycarbophil (FiberCon, Equalactin, and others) and methylcellulose are examples of fiber supplements (Citrucel).
Stimulants: Bisacodyl (Correctol, Dulcolax, and others) and sennosides (Senokot, Ex-Lax, and Perdiem) are stimulants that cause your intestines to contract.
Stool softeners: Docusate sodium (Colace) and docusate calcium (Surfak) are stool softeners that draw water from the intestines to moisten the stool.
Suppositories and enemas: Tap water enemas, with or without soapsuds, can be beneficial in softening stool and eliciting a bowel movement. By providing lubrication and stimulation, glycerin or bisacodyl suppositories also aid in the movement of stool out of the body.
Osmotics: Osmotic laxatives aid in the passage of stool through the colon by increasing fluid secretion from the intestines and stimulating bowel movements. Oral magnesium hydroxide (Phillips' Milk of Magnesia, Dulcolax Milk of Magnesia, and others), magnesium citrate, lactulose (Cholac, Constilac, and others), and polyethylene glycol are some examples (Miralax, Glycolax).
Lubricants: Mineral oil and other lubricants help stool move more easily through your colon.
Other medications
If over-the-counter medications do not relieve your chronic constipation, your doctor may prescribe a medication, especially if you have irritable bowel syndrome.
- Medications that draw water into your intestines: There are several prescription medications available to treat chronic constipation. Lubiprostone (Amitiza), linaclotide (Linzess), and plecanatide (Trulance) work by drawing water into the intestines and increasing stool movement.
- Serotonin 5-hydroxytryptamine 4 receptors: Prucalopride (Motegrity) aids in the passage of stool through the colon.
- Peripherally acting mu-opioid receptor antagonists (PAMORAs): If opioid pain medications are causing constipation, PAMORAs such as naloxegol (Movantik) and methylnaltrexone (Relistor) reverse the opioid's effect on the intestine to keep the bowel moving.
Pelvic muscle training
Working with a therapist who uses devices to help you learn to relax and tighten the muscles in your pelvis is what biofeedback training entails. Relaxing your pelvic floor muscles at the right time during defecation can make it easier to pass stool.
During a biofeedback session, a special tube (catheter) is inserted into your rectum to measure muscle tension. The therapist walks you through exercises that alternate between relaxing and tightening your pelvic muscles. A machine will measure your muscle tension and use sounds or lights to indicate when your muscles have relaxed.
Surgery
If you have tried all other treatments and your chronic constipation is caused by a blockage, rectocele, or stricture, surgery may be an option.
For people who have tried other treatments and have abnormally slow stool movement through the colon, surgical removal of a portion of the colon may be an option. The removal of the entire colon is rarely necessary.