Constipation
What Is Constipation?
Technically, constipation is the passage of less one stool every three to four days. In reality, people have very individual ideas about what constipation is and what constitutes "normal" bowel function. While it may be normal for one person to have a bowel movement three times a day, the next person may have one every three days. Other patients will describe themselves as constipated whenever they pass dry, hard stools. An alternative definition of constipation is the inability or difficulty in eliminating the fecal matter on a regular basis. Having to strain excessively more than 25% of the time to eliminate is also a legitimate definition of constipation.
What Causes Constipation?
In trying to understand why you sometimes experience constipation, remember that your body's needs are unique. From time to time these needs change, sometimes as a result of diet and exercise. In turn, your body responds with certain symptoms, including constipation.
Common causes of occasional constipation include:
- Poor eating habits (for example, too much junk food, too much caffeine, irregular eating times)
- Diet lacking in fiber and/or liquids
- Lack of exercise
- Some medications
- Stress
- Pregnancy
- Travel
More serious causes such as surgery or disease are not often responsible for the mild constipation most people occasionally experience. However, if you are constipated frequently and non-prescription medications do not improve your condition, be sure to tell your doctor.
What Can I Do About Constipation?
Help yourself maintain regularity by adding some of these simple steps to your daily routine:
- Gradually add high-fiber foods to your diet, including
- fruit (unpeeled when appropriate)
- dried fruits (apricots, prunes, raisins, and dates)
- unpeeled raw vegetables
- bran cereals and whole-grain breads
- Drink 6 to 8 glasses of juice or water each day.
- Follow a regular exercise program. Walking is good for the heart and body, and abdominal exercises help improve abdominal muscle tone. Ask your doctor about a program that would be right for you.
- Respond to the urge to have a bowel movement. Putting off going until you can use your own toilet at home will often result in more water being absorbed from the stool resulting in hard difficult to pass stools. When you feel the urge, go to whichever rest room is nearby, relax and let your body take the time it needs. If you ignore the urge, you could prolong the problem.
- If one is recommended by your doctor, take a high-fiber supplement (such as Benefiber, Metamucil, Citricel) to help you stay regular.
Use other laxatives only as your doctor recommends.
Should I Take a Laxative?
Your doctor may prescribe a laxative for you. There are many types of laxatives, each one having benefits and drawbacks for certain patients.
Bulk-forming laxatives absorb liquid in the intestine and then swell to form a soft, bulky mass which stimulates a bowel movement. Because bulk laxatives mimic the body's own actions, they are said to work naturally. However, they may lead to increased gas and can take up to three days to have an effect.
Stool softeners do not cause a bowel movement but ease the difficult passage often associated with hard stool. They may work in one or two days but may take up to five days.
Stimulant laxatives are effective and predictable. They increase the muscle contractions in the intestine that lead to a bowel movement. While all stimulant laxatives work basically in this way, they are not all the same; some are more likely to cause cramping or irritation and rarely nausea and vomiting. These types of laxatives should not be taken for prolonged periods of time.
Saline laxatives ("salts") draw water into the intestine, causing pressure to build up and sending the bowel the message to empty. Too much water can be drawn in, though, resulting in loose bowel movements and upsetting the body's balance of fluids.
Enemas fill the colon with fluid, which softens the stool and stimulates a bowel movement.
With so many products available, it is not easy to know which laxative is best for you. Follow your doctor's recommendation.
It is always a good idea to look for natural ways to meet your body's needs and avoid long-term use of medication. Excessive use of stimulant laxatives can actually cause constipation and dependence upon laxatives because the colon loses it normal tone and the ability to contract. Bulk-forming agents are safe to take for a long time. They are essentially a substitute for fiber in your diet.
Chronic Constipation
Most constipation issues can be managed by the patient themselves or with the advise of their primary care physician. However there are numerous patients in whom constipation is a daily, chronic problem that plagues them and causes continual feelings of fullness, bloating, rectal or abdominal discomfort. Their inability to regularly empty their bowels impacts their ability to participate fully in life either because they feel poorly or they spend such an excessive time trying to move their bowels. These chronic constipation patients are those that may benefit from a evaluation by the doctors at Fairfax Colon and Rectal Surgery.
Causes of Chronic Constipation
There are two broad categories of problems for which patients with chronic constipation need to be evaluated. These are colonic inertia and pelvic floor dysfunction. Colonic inertia is the least common of the surgically correctable causes of constipation. In this condition the innate ability of the colon to push fecal matter through the bowel has been lost. The stool stagnates within the colon leading to very infrequent stools and a great deal of abdominal bloating, cramps and discomfort. The reason this occurs is unknown. The second category of problems – pelvic floor issues – can involve a wide variety of diagnoses that involve problems at or just above the rectal opening which can prevent the stool from being eliminated easily. The hallmark of these patients is that they feel as if they need to have a bowel movement but wind up pushing and straining, endlessly trying to get the stools to pass. The underlying causes are numerous and include rectocele, non-relaxing puborectalis syndrome, internal intussusception, perineal descent syndrome, anal fissure, and rectal tumors.
Evaluation of Chronic Constipation
When seen in our office the surgeon will review the medical history to be sure that any medical causes such as hypothyroidism and hypercalcium have been ruled out. Also the list of medications the patient has been taking is also reviewed. Antidepressants, psychotropic drugs and chronic use of narcotic pain medications are notorious contributors to bowel dysfunction. If the surgeon feels that colonic inertia is a possibility, a colonic transit study will be ordered. This is a simple x-ray test in which the patient is asked to swallow a capsule containing 24 small markers that can be seen on a plain x-ray. The patient then undergoes a x-ray of the abdomen on the first, third and fifth day after taking the capsule. The progression of the markers through the colon can be assessed by review of these x-rays. The evaluation of pelvic floor issues is much more complex. After a thorough examination, the patient will need to undergo anorectal physiology tests. These are done in our office and are described elsewhere on this website. If appropriate the patient may be asked to undergo a defecography and/or a Dynamic Pelvic MRI. These tests are done for us by the radiologists at INOVA Fairfax Hospital and are a means to view the movement of the rectum as the patient attempts to strain and push. In addition, if a colonoscopy has not already been done on the patient this will usually also be performed by our surgeons.
Treatment of Chronic Constipation
Treatment, of course, will depend on what is uncovered by the examinations and tests. For those patients whose tests fail to uncover an identifiable abnormality, the treatment centers on improving diet, increasing exercise and utilizing fiber supplements and laxatives as directed by their physician. Patients who are found to have colonic inertia are managed with a variety of laxatives and diet adjustments in hopes of improving function. However, if all else fails and the patient’s constipation is impacting their life significantly, consideration can be given to undergo a subtotal colectomy. In this operation all of the large intestine except the rectum (the last 8 inches of so of the large intestine) is removed and the small intestine is connected to the top of the rectum. This is a major abdominal operation and may seem a drastic option for constipation. For patients who have usually suffered most of their adult life with pain and bloating, it holds real hope for obtaining very reasonable bowel function (about 3-4 bowel movements a day) and return to a normal lifestyle. If the patient’s evaluation uncovers a problem with the pelvic floor, their treatment attempts to correct it. Some of these abnormalities will require an operation to fix (such as a rectocele repair) but the majority can be helped non-operatively. Many of these patients are candidates for a course of Anorectal biofeedback training. This teaches the patient how better to control their pelvic floor and relax the appropriate muscle to permit easier elimination. If it is determined that biofeedback might be helpful, our doctors will arrange for this therapy with a nearby therapist.