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Home , Constipation, Fecal impaction, Functional constipation

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Constipation

National Digestive Diseases Information Clearinghouse

Constipation is defined as having a bowel movement fewer than three times per week. (colon) With constipation stools are usually hard, dry, small in size, and difficult to eliminate. National Stomach Institute of Some people who are constipated find it and painful to have a bowel movement and Digestive often experience straining, , and and Kidney Small Diseases the sensation of a full bowel. intestine NATIONAL Some people think they are constipated if INSTITUTES OF HEALTH they do not have a bowel movement every day. However, normal stool elimination Illeum may be three times a day or three times a week, depending on the person.

Constipation is a symptom, not a disease. Sigmoid Almost everyone experiences constipation Anus at some point in their life, and a poor diet colon typically is the cause. Most constipation is Lower digestive system. temporary and not serious. Understanding its causes, prevention, and treatment will Self-treatment of constipation with over­ help most people find relief. the-counter (OTC) is by far the most common aid. Around $725 million Who gets constipated? is spent on products each year in America. Constipation is one of the most common gastrointestinal complaints in the United States. More than 4 million Americans What causes constipation? have frequent constipation, accounting To understand constipation, it helps to for 2.5 million physician visits a year. know how the colon, or large intestine, Those reporting constipation most often works. As food moves through the colon, are women and adults ages 65 and older. the colon absorbs water from the food while Pregnant women may have constipation, it forms waste products, or stool. Muscle and it is a common problem following child­ contractions in the colon then push the birth or . stool toward the rectum. By the time stool reaches the rectum it is solid, because most of the water has been absorbed.

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Constipation occurs when the colon absorbs Americans eat an average of 5 to 14 grams too much water or if the colon’s muscle con­ of fiber daily,* which is short of the 20 to tractions are slow or sluggish, causing the 35 grams recommended by the American stool to move through the colon too slowly. Dietetic Association. Both children and As a result, stools can become hard and dry. adults often eat too many refined and Common causes of constipation are processed foods from which the natural fiber has been removed. • not enough fiber in the diet • lack of physical activity (especially in A low-fiber diet also plays a key role in con­ the elderly) stipation among older adults, who may lose interest in eating and choose foods that are • quick to make or buy, such as fast foods, or • milk prepared foods, both of which are usually • low in fiber. Also, difficulties with chewing • changes in life or routine such as preg­ or swallowing may cause older people to nancy, aging, and travel eat soft foods that are processed and low in fiber. • abuse of laxatives • ignoring the urge to have a bowel Not Enough Liquids movement Research shows that although increased • fluid intake does not necessarily help relieve constipation, many people report • specific diseases or conditions, such as some relief from their constipation if they stroke (most common) fluids such as water and juice and • problems with the colon and rectum avoid dehydration. Liquids add fluid to the • problems with intestinal function colon and bulk to stools, making bowel (chronic idiopathic constipation) movements softer and easier to pass. People who have problems with constipation should Not Enough Fiber in the Diet try to drink liquids every day. However, liq­ People who eat a high-fiber diet are less uids that contain caffeine, such as coffee and likely to become constipated. The most cola will worsen one’s symptoms by common causes of constipation are a diet causing dehydration. Alcohol is another low in fiber or a diet high in fats, such as beverage that causes dehydration. It is cheese, eggs, and meats. important to drink fluids that hydrate the body, especially when consuming caffeine Fiber—both soluble and insoluble—is the containing drinks or alcoholic beverages. part of fruits, vegetables, and grains that the body cannot digest. Soluble fiber dissolves *National Center for Health Statistics. Dietary Intake easily in water and takes on a soft, gel-like of Macronutrients, Micronutrients, and Other Dietary texture in the intestines. Insoluble fiber Constituents: United States, 1988–94. Vital and passes through the intestines almost Health Statistics, Series 11, Number 245. July 2002. unchanged. The bulk and soft texture of fiber help prevent hard, dry stools that are difficult to pass.

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Lack of Physical Activity Abuse of Laxatives A lack of physical activity can lead to The common belief that people must constipation, although doctors do not know have a daily bowel movement has led to precisely why. For example, constipation self-medicating with OTC laxative products. often occurs after an accident or during Although people may feel relief when they an illness when one must stay in bed and use laxatives, typically they must increase cannot . Lack of physical activity is the dose over time because the body grows thought to be one of the reasons constipa­ reliant on laxatives in order to have a bowel tion is common in older people. movement. As a result, laxatives may become habit-forming. Medications Some medications can cause constipation, Ignoring the Urge to Have a including Bowel Movement • pain medications (especially narcotics) People who ignore the urge to have a bowel movement may eventually stop feeling the • that contain aluminum need to have one, which can lead to consti­ and calcium pation. Some people delay having a bowel • blood pressure medications (calcium movement because they do not want to use channel blockers) toilets outside the home. Others ignore the • antiparkinson drugs urge because of emotional or because they are too busy. Children may postpone • having a bowel movement because of stress­ • ful toilet training or because they do not • iron supplements want to interrupt their play. • • Changes in Life or Routine During , women may be consti­ pated because of hormonal changes or because the uterus compresses the intestine. Aging may also affect bowel regularity, because a slower metabolism results in less intestinal activity and muscle tone. In addi­ tion, people often become constipated when traveling, because their normal diet and daily routine are disrupted.

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Specific Diseases Problems with Intestinal Diseases that cause constipation include Function neurological disorders, metabolic and The two types of constipation are idiopathic endocrine disorders, and systemic conditions constipation and . that affect organ systems. These disorders Irritable bowel syndrome (IBS) with pre­ can slow the movement of stool through the dominant symptoms of constipation is cate­ colon, rectum, or anus. gorized separately. Conditions that can cause constipation are Idiopathic—of unknown origin—constipa­ found below. tion does not respond to standard treatment. • Neurological disorders Functional constipation means that the – multiple sclerosis bowel is healthy but not working properly. – Parkinson’s disease Functional constipation is often the result of poor dietary habits and lifestyle. It occurs in – chronic idiopathic intestinal pseudo- both children and adults and is most com­ obstruction mon in women. Colonic inertia, delayed – stroke transit, and dysfunction are – spinal cord injuries three types of functional constipation. Colonic inertia and delayed transit are • Metabolic and endocrine conditions caused by a decrease in muscle activity in – diabetes the colon. These syndromes may affect the – uremia entire colon or may be confined to the – hypercalcemia lower, or sigmoid, colon. – poor glycemic control is caused by a weak­ – ness of the muscles in the pelvis surround­ ing the anus and rectum. However, because • Systemic disorders this group of muscles is voluntarily con­ – trolled to some extent, training – is somewhat successful in retraining the – muscles to function normally and improving the ability to have a bowel movement. Problems with the Colon Functional constipation that stems from and Rectum problems in the structure of the anus and Intestinal obstruction, scar tissue—also rectum is known as anorectal dysfunction, called adhesions—, tumors, or . These abnormalities result in colorectal stricture, Hirschsprung’s disease, an inability to relax the rectal and anal mus­ or can compress, squeeze, or narrow cles that allow stool to exit. the intestine and rectum and cause consti­ People with IBS having predominantly con­ pation. stipation also have pain and bloating as part of their symptoms.

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How is the cause of Physical Examination constipation identified? A physical exam may include a rectal exam with a gloved, lubricated finger to evaluate The tests the doctor performs depend on the tone of the muscle that closes off the the duration and severity of the constipa­ anus—also called anal sphincter—and to tion, the person’s age, and whether blood detect tenderness, obstruction, or blood. In in stools, recent changes in bowel habits, some cases, blood and tests may be or weight loss have occurred. Most people necessary to look for and with constipation do not need extensive serum calcium or to rule out inflammatory, testing and can be treated with changes in metabolic, and other disorders. diet and exercise. For example, in young people with mild symptoms, a medical his­ Extensive testing usually is reserved for tory and physical exam may be all that is people with severe symptoms, for those needed for diagnosis and treatment. with sudden changes in the number and consistency of bowel movements or blood Medical History in the stool, and older adults. Additional The doctor may ask a patient to describe tests that may be used to evaluate constipa­ his or her constipation, including duration of tion include symptoms, frequency of bowel movements, consistency of stools, presence of blood in • a colorectal transit study the stool, and toilet habits—how often and • anorectal function tests where one has bowel movements. A record • a of eating habits, , and level of physical activity will also help the doctor Because of an increased risk of colorectal determine the cause of constipation. cancer in older adults, the doctor may use tests to rule out a diagnosis of cancer, The clinical definition of constipation is including a having any two of the following symptoms for at least 12 weeks—not always consecu­ • barium x ray tive—in the previous 12 months: • or colonoscopy • straining during bowel movements Colorectal transit study. This test shows • lumpy or hard stool how well food moves through the colon. The patient swallows capsules containing • sensation of incomplete evacuation small markers that are visible on an x ray. • sensation of anorectal The movement of the markers through the blockage/obstruction colon is monitored by abdominal x rays taken • fewer than three bowel movements several times 3 to 7 days after the capsule is per week swallowed. The patient eats a high-fiber diet during the course of this test.

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Anorectal function tests. These tests diag­ a special liquid to flush out the bowel. A nose constipation caused by abnormal func­ clean bowel is important, because even a tioning of the anus or rectum—also called small amount of stool in the colon can hide anorectal function. details and result in an incomplete exam. • evaluates anal Because the colon does not show up well sphincter muscle function. For this on x rays, the doctor fills it with barium, a test, a catheter or air-filled balloon is chalky liquid that makes the area visible. inserted into the anus and slowly pulled Once the mixture coats the inside of the back through the sphincter muscle to colon and rectum, x rays are taken that show measure muscle tone and contractions. their shape and condition. The patient may • Balloon expulsion tests consist of fill­ feel some abdominal cramping when the ing a balloon with varying amounts of barium fills the colon but usually feels little water after it has been rectally inserted. discomfort after the procedure. Stools Then the patient is asked to expel may be white in color for a few days after the balloon. The inability to expel a the exam. balloon filled with less than 150 mL Sigmoidoscopy or colonoscopy. An exami­ of water may indicate a decrease in nation of the rectum and lower, or sigmoid, bowel function. colon is called a sigmoidoscopy. An exami­ Defecography is an x ray of the anorectal nation of the rectum and entire colon is area that evaluates completeness of stool called a colonoscopy. elimination, identifies anorectal abnormali­ The person usually has a liquid dinner ties, and evaluates rectal muscle contractions the night before a colonoscopy or sigmoi­ and relaxation. During the exam, the doc­ doscopy and takes an enema early the next tor fills the rectum with a soft paste that is morning. An enema an hour before the the same consistency as stool. The patient test may also be necessary. sits on a toilet positioned inside an x-ray machine, then relaxes and squeezes the To perform a sigmoidoscopy, the doctor uses anus to expel the paste. The doctor studies a long, flexible tube with a light on the end, the x rays for anorectal problems that called a sigmoidoscope, to view the rectum occurred as the paste was expelled. and lower colon. The patient is lightly sedated before the exam. First, the doctor Barium enema x ray. This exam involves examines the rectum with a gloved, lubri­ viewing the rectum, colon, and lower part cated finger. Then, the sigmoidoscope is of the to locate problems. inserted through the anus into the rectum This part of the digestive tract is known as and lower colon. The procedure may cause the bowel. This test may show intestinal abdominal pressure and a mild sensation of obstruction and Hirschsprung’s disease, wanting to move the bowels. The doctor which is a lack of nerves within the colon. may fill the colon with air to get a better The night before the test, bowel cleansing, view. The air can cause mild cramping. also called bowel prep, is necessary to clear the lower digestive tract. The patient drinks

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To perform a colonoscopy, the doctor uses Laxatives a flexible tube with a light on the end, called Most people who are mildly constipated do a colonoscope, to view the entire colon. not need laxatives. However, for those who This tube is longer than a sigmoidoscope. have made diet and lifestyle changes and are During the exam, the patient lies on his or still constipated, a doctor may recommend her side, and the doctor inserts the tube laxatives or for a limited time. These through the anus and rectum into the colon. treatments can help retrain a chronically If an abnormality is seen, the doctor can sluggish bowel. For children, short-term use the colonoscope to remove a small treatment with laxatives, along with retrain­ piece of tissue for examination (biopsy). ing to establish regular bowel habits, helps The patient may feel gassy and bloated prevent constipation. after the procedure. A doctor should determine when a patient How is constipation treated? needs a laxative and which form is best. Laxatives taken by mouth are available in Although treatment depends on the cause, liquid, tablet, gum powder, and granule severity, and duration of the constipation, in forms. They work in various ways: most cases dietary and lifestyle changes will help relieve symptoms and help prevent • Bulk-forming laxatives generally are them from recurring. considered the safest, but they can interfere with absorption of some med­ Diet icines. These laxatives, also known as A diet with enough fiber (20 to 35 grams fiber supplements, are taken with each day) helps the body form soft, bulky water. They absorb water in the intes­ stool. A doctor or dietitian can help plan an tine and make the stool softer. Brand appropriate diet. High-fiber foods include names include Metamucil, Fiberall, beans, whole grains and bran cereals, fresh Citrucel, Konsyl, and Serutan. These fruits, and vegetables such as asparagus, agents must be taken with water or they brussels sprouts, cabbage, and carrots. For can cause obstruction. Many people people prone to constipation, limiting foods also report no relief after taking bulking that have little or no fiber, such as ice agents and suffer from a worsening in cream, cheese, meat, and processed foods, bloating and . is also important. • Stimulants cause rhythmic muscle contractions in the intestines. Brand Lifestyle Changes names include Correctol, Dulcolax, Other changes that may help treat and pre­ Purge, and Senokot. Studies suggest vent constipation include drinking enough that phenolphthalein, an ingredient in water and other liquids, such as fruit and some stimulant laxatives, might increase vegetable juices and clear soups, so as not a person’s risk for cancer. The Food to become dehydrated, engaging in daily and Drug Administration has proposed exercise, and reserving enough time to a ban on all over-the-counter products have a bowel movement. In addition, the containing phenolphthalein. Most lax­ urge to have a bowel movement should not ative makers have replaced, or plan to be ignored. replace, phenolphthalein with a safer ingredient.

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• Osmotics cause fluids to flow in a spe­ • Saline laxatives act like a sponge to cial way through the colon, resulting in draw water into the colon for easier bowel distention. This class of drugs is passage of stool. Brand names include useful for people with idiopathic Milk of Magnesia and Haley’s M-O. constipation. Brand names include Saline laxatives are used to treat acute Cephulac, Sorbitol, and Miralax. Peo­ constipation if there is no indication of ple with diabetes should be monitored . imbal­ for electrolyte imbalances. ances have been reported with extended • Stool softeners moisten the stool and use, especially in small children and prevent dehydration. These laxatives people with renal deficiency. are often recommended after childbirth • Chloride channel activators increase or surgery. Brand names include Colace intestinal fluid and motility to help and Surfak. These products are sug­ stool pass, thereby reducing the symp­ gested for people who should avoid toms of constipation. One such agent straining in order to pass a bowel is Amitiza, which has been shown to be movement. The prolonged use of this safely used for up to 6 to 12 months. class of drugs may result in an electrolyte Thereafter a doctor should assess the imbalance. need for continued use. • Lubricants grease the stool, enabling People who are dependent on laxatives it to move through the intestine more need to slowly stop using them. A doctor easily. is the most common can assist in this process. For most people, example. Brand names include Fleet stopping laxatives restores the colon’s natural and Zymenol. Lubricants typically ability to contract. stimulate a bowel movement within 8 hours.

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Other Treatments Can constipation be serious? Treatment for constipation may be directed Sometimes constipation can lead to compli­ at a specific cause. For example, the doctor cations. These complications include hem­ may recommend discontinuing medication orrhoids, caused by straining to have a or performing surgery to correct an anorectal bowel movement, or anal fissures—tears in problem such as , a condition the skin around the anus—caused when in which the lower portion of the colon turns hard stool stretches the sphincter muscle. inside out. As a result, rectal bleeding may occur, appearing as bright red streaks on the sur­ People with chronic constipation caused by face of the stool. Treatment for hemor­ anorectal dysfunction can use biofeedback rhoids may include warm tub baths, ice to retrain the muscles that control bowel packs, and application of a special cream to movements. Biofeedback involves using a the affected area. Treatment for anal fis­ sensor to monitor muscle activity, which is sures may include stretching the sphincter displayed on a computer screen, allowing for muscle or surgically removing the tissue or an accurate assessment of body functions. skin in the affected area. A health care professional uses this informa­ tion to help the patient learn how to retrain Sometimes straining causes a small amount these muscles. of intestinal lining to push out from the anal opening. This condition, known as rectal Surgical removal of the colon may be an prolapse, may lead to secretion of mucus option for people with severe symptoms from the anus. Usually eliminating the caused by colonic inertia. However, the cause of the prolapse, such as straining or benefits of this surgery must be weighed coughing, is the only treatment necessary. against possible complications, which Severe or chronic prolapse requires surgery include abdominal pain and . to strengthen and tighten the anal sphincter muscle or to repair the prolapsed lining. Constipation may also cause hard stool to pack the intestine and rectum so tightly that the normal pushing action of the colon is not enough to expel the stool. This condition, called , occurs most often in children and older adults. An impaction can be softened with mineral oil taken by mouth and by an enema. After softening the impaction, the doctor may break up and remove part of the hardened stool by insert­ ing one or two fingers into the anus.

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Hope Through Research The Division of Digestive Diseases and Points to Remember Nutrition at the National Institute of Dia­ • Constipation affects almost every­ betes and Digestive and Kidney Diseases one at one time or another. supports basic and clinical research into • Many people think they are consti­ gastrointestinal conditions, including pated when, in fact, their bowel constipation. Researchers are studying the movements are regular. anatomical and physiological characteristics of rectoanal motility and the use of new • The most common causes of medications and behavioral techniques, constipation are poor diet and lack such as biofeedback, to treat constipation. of exercise. • Other causes of constipation include medications, irritable bowel syndrome, abuse of laxatives, and specific diseases. • A medical history and physical exam may be the only diagnostic tests needed before the doctor suggests treatment. • In most cases, following these simple tips will help relieve symp­ toms and prevent recurrence of constipation: – Eat a well-balanced, high-fiber diet that includes beans, bran, whole grains, fresh fruits, and vegetables. – Drink plenty of liquids. – Exercise regularly. – Set aside time after breakfast or dinner for undisturbed visits to the toilet. – Do not ignore the urge to have a bowel movement. – Understand that normal bowel habits vary. – Whenever a significant or pro­ longed change in bowel habits occurs, check with a doctor. • Most people with mild constipation do not need laxatives. However, a doctor may recommend laxatives for a limited time for people with chronic constipation.

10 Constipation For More Information You may also find additional information about this International Foundation for Functional topic by visiting MedlinePlus at www.medlineplus.gov. Gastrointestinal Disorders This publication may contain information about medications. When prepared, this publication P.O. Box 170864 included the most current information available. Milwaukee, WI 53217 For updates or for questions about any medications, contact the U.S. Food and Drug Administration Phone: 1–888–964–2001 or 414–964–1799 toll­free at 1–888–INFO–FDA (1–888–463–6332) Fax: 414–964–7176 or visit www.fda.gov. Consult your doctor for more Email: [email protected] information. Internet: www.iffgd.org American Gastroenterological Association National Office The U.S. Government does not endorse or favor any 4930 Del Ray Avenue specific commercial product or company. Trade, Bethesda, MD 20814 proprietary, or company names appearing in this document are used only because they are considered Phone: 301–654–2055 necessary in the context of the information provided. Fax: 301–654–5920 If a product is not mentioned, the omission does not Email: [email protected] mean or imply that the product is unsatisfactory. Internet: www.gastro.org

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National Digestive Diseases Information Clearinghouse 2 Information Way Bethesda, MD 20892–3570 Phone: 1–800–891–5389 Fax: 703–738–4929 Email: [email protected] Internet: www.digestive.niddk.nih.gov The National Digestive Diseases Information Clearinghouse (NDDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health under the U.S. Department of Health and Human Services. Established in 1980, the Clearinghouse provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. The NDDIC answers inquiries, develops and dis­ tributes publications, and works closely with pro­ fessional and patient organizations and Government agencies to coordinate resources about digestive diseases.

Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. This fact sheet was reviewed by Michael Camilleri, M.D., Mayo Clinic.

This publication is not copyrighted. The Clearinghouse encourages users of this fact sheet to duplicate and distribute as many copies as desired. This fact sheet is also available at www.digestive.niddk.nih.gov.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health

NIH Publication No. 07–2754 July 2007