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Constipation - A Guide

Affecting people of all ages, constipation is a very common condition. It can mean that you are not passing stools (faeces) as often as you normally do and you may have to strain more than usual or you are unable to completely empty your bowels.

Introduction
Symptoms
Causes
Diagnosing constipation
Treating constipation
Complications with constipation
Preventing constipation

Introduction

Constipation can cause your stools to be unusually hard, lumpy, large or small.

The severity of constipation can vary greatly. Many people only experience constipation for a short period of time with no lasting effects on their health.

Chronic constipation

For others, constipation can be a chronic (long-term) condition that causes significant pain and discomfort. Chronic constipation can also lead to complications, such as faecal impaction (where dry, hard stools collect in your rectum) or faecal incontinence (where you leak liquid stools).



Who is affected?

Constipation can occur in babies, children and adults, and affects twice as many women than men.

Older people are five times more likely than younger adults to have constipation, usually because of dietary factors, lack of exercise, use of medication and poor bowel habits.

Approximately 40% of pregnant women experience constipation during their pregnancy.

Outlook

Treatment for constipation is usually effective, although in some cases it can take several months before a regular bowel pattern is re-established (seeTreating constipation for more information).

Constipation rarely causes any complications or long-term health problems.

Clinical definition

Doctors define constipation in a number of ways:

•opening the bowels less than three times a week
•needing to strain to open your bowels on more than a quarter of occasions
•passing a hard or pellet-like stool on more than a quarter of occasions

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Symptoms of constipation

Everyone has their own normal bowel habits, whichcan be different from other people's habits.

For example, some adults normally go to the toilet more than once a day, whereas others normally go only every three or four days. Some infants pass stools several times a day, while others normally pass stools only a few times a week.

Difficulty passing stools

When you are constipated, you feel that passing stools has become more difficult than it used to be. It may feel more difficult for several reasons. For example, you may be going significantly less frequently or much less effectively (you feel you are unable to completely empty your bowel).

Passing stools may also seem more difficult because your stools are:

  • dry, hard and lumpy
  • abnormally large
  • abnormally small

As well as causing a change in your normal bowel habits, constipation can also cause the following symptoms:

  • stomach ache and cramps
  • feeling bloated
  • feeling nauseous
  • loss of appetite


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Children

As well as infrequent or irregular bowel movements, a child with constipation may also have the following signs and symptoms:

  • loss of appetite
  • lack of energy
  • being irritable, angry or unhappy
  • foul-smelling wind and stools
  • abdominal pain and discomfort
  • soiling their clothes
  • generally feeling unwell

If your child has these symptoms or has spoken to you about having difficulty passing stools, speak to your GP.

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Causes of constipation

Most cases of constipation are not caused by a specific condition and it may be difficult to identify the exact cause. However, several factors can increase your chances of having constipation, including:

  • not eating enough fibre, such as fruit, vegetables and cereals
  • a change in your routine or lifestyle, such as a change in your eating habits
  • having limited privacy when using the toilet
  • ignoring the urge to pass stools
  • immobility or lack of exercise
  • not drinking enough fluids
  • being underweight or overweight
  • anxiety or depression
  • psychiatric problems brought on by sexual abuse, violence or trauma, for example

Medication

Sometimes, constipation may be a side effect of a medicine that you are taking. Common types of medication that can cause constipation include:

  • aluminium antacids (medicine to treat indigestion)
  • antidepressants
  • antiepileptics (medicine to treat epilepsy)
  • antipsychotics (medicine to treat schizophrenia and other mental health conditions)
  • calcium supplements
  • diuretics (water tablets)
  • iron supplements

If your constipation is caused by medication, the condition usually eases once you stop taking the medicine. However, under no circumstances should you stop taking your medication unless your GP advises you to.

Speak to your GP if you experience constipation due to a medicine.They may be able to prescribe an alternative.

Pregnancy

About 40% of women experience some form of constipation during their pregnancy, mostlyduring the early stages of their pregnancy.

Constipation occurs during pregnancy as a result of hormonal changes. During pregnancy, your body produces more of the female hormone progesterone. This hormone acts as a muscle relaxant.

Your bowel normally moves stools and waste products along to the anus by a process known as peristalsis. This is when the muscles that line the bowel contract and relax in a rippling, wave-like motion. An increase in progesteronemakesit more difficult for the bowel musclesto contract, making it harder to move waste products along.

If you are pregnant, there are ways that you can safely treat constipation without harming you or your baby. SeeTreating constipation for more information about this.

Other conditions

Most cases of constipation are not caused by a particular medical condition. However, in rare cases, constipation canbe a sign ofan underlying condition, such as:

  • colon or rectal cancer
  • diabetes
  • hypercalcaemia, when there is too much calcium in the bloodstream
  • underactive thyroid
  • muscular dystrophy, a genetic condition that causes muscle wasting
  • multiple sclerosis, a condition that affects the nervous system
  • Parkinson's disease, a brain condition that affects the co-ordination of body movements
  • spinal cord injury
  • anal fissure, a small tear of the skin just inside the anus
  • inflammatory bowel disease, a condition that causes the intestines to become inflamed (irritated and swollen)
  • irritable bowel syndrome (IBS)

Babies and children

Constipation in babies and children is quite common. About one in three British parents report constipation at some time in their child's life.Poor diet, fear about using the toilet and poor toilet training can all be responsible.

Poor diet

Children who are over-fed are more likely to have constipation, as are those who do not get enough fluids. Babies who have too much milk are also more likely to get constipation. As with adults, it is very important that your child has enough fibre in their diet.

Toilet training

Make sure that you do not make your child feel stressed or pressured about using the toilet. It is also important to let your children try things by themselves (when appropriate). Constantly intervening when they are using the toilet may make them feel anxious.

Toilet habits

Some children can feel stressed or anxious about using the toilet. They may have a phobia about using the toilet or feel that they are unable to use the toilets at school.

This fear or phobia may be the result of your child experiencing pain when passing stools. This can lead to poor bowel habits, where children ignore the urge to pass stools and instead withhold them for fear of experiencing pain and discomfort. However, this will mean that their condition only worsens.

Other conditions

In rare cases, constipation in babies andchildren can be a sign of an underlying condition such as:

  • Hirschsprung's disease, which affects the bowel, making it difficult to pass stools
  • anorectal malformation,where the baby's anus and rectum do not form properly
  • spinal cord abnormalities,including rare conditions such as spina bifida and cerebral palsy
  • cystic fibrosis,a genetic condition that causes the body to produce thick and stickymucus, which can lead to constipation.

Psychological and behavioural link

There is a strong connection between emotions and how the gut works. Feeling upset can make your bowel slow down or speed up. Emotional upset, even in childhood, may result in constipation years later.

Ignoring the natural urge to openyour bowels (because you want to avoid public toilets or because you are too busy at work) can result in long-term changes in how your bowel muscles work.

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Diagnosing constipation

Constipation is a very common condition. Your GP will not usually need to carry out any tests or procedures, but will confirm a diagnosis of constipation based on your medical history and your symptoms.

Your GP will ask you some questions about your bowel habits. Do not feel embarrassed about describing your bowel pattern and stools to your GP. It is important that your GP is aware of all of your symptoms so they can make the correct diagnosis.

Your GP may also ask questions about your diet, level of exercise and whether there have been any recent changes in your routines.

Doctors define constipation in a number of ways:

  • opening the bowels less than three times a week
  • needing to strain to open your bowels on more than a quarter of occasions
  • passing a hard or pellet-like stool on more than a quarter of occasions

Physical examination

If your GP suspects that you may have faecal impaction (when dry, hard stools collect in your rectum), they may carry out a physical examination.

A typical examination will begin with you lying on your back while the GP feels your abdomen. You will then lie on your side while the GP performs a rectal examination using a lubricated, gloved finger. Your GP can feel for any stools that may have collected.

Your GP willrarely have to conduct an internal physical examination on a child. Instead, the diagnosis can normally be made by feeling their abdomen (tummy).

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Treating constipation

Lifestyle advice

Your GP will firstadvise you abouthow you can change your diet and lifestyle, which may mean that your constipation passes without the use of medication.

Some ways you can help treat your constipation include:

  • Increase your daily intake of fibre. You should eat at least 18-30g of fibre a day. High-fibre foods include fruit, vegetables and cereals.
  • Add some bulking agents, such as wheat bran, to your diet. These will help make your stools softer and easier to pass.
  • Increase your fluid intake. Drink at least 1.2 litres (six to eightglasses) of fluid a day.
  • Get more exercise by going for a daily walk or run.
  • If your constipation is causing pain or discomfort, you may want to take apainkiller such as paracetamol. Make sure you always follow the dosage instructions carefully. Children under 16 years of age should not take aspirin.
  • Identify a routine of a place and time of day when you are comfortably able to spend time in the toilet. Respond to your bowel's natural pattern: when you feel the urge, do not delay.

See Preventing constipation for more information about ways to change your diet and lifestyle.

If these diet and lifestyle changes do not help, your GP may prescribe an oral laxative.

Laxatives

Laxatives are a type of medicine that help you pass stools. There are several different types and each one has a different effect on your digestive system.

Bulk-forming laxatives

Your GP will normally startyou ona bulk-forming laxative. These laxatives work by helping your stools to retain fluid. This means they are less likely to dry out, which can lead to faecal impaction (seeComplications of constipation). Bulk-forming laxatives also make your stools denser and softer, which means they should be easier to pass.

Commonly prescribed bulk-forming laxatives include ispaghula husk, methylcellulose and sterculia. When taking this type of laxative, you must drink plenty of fluids. Also, do not take them before going to bed. It will usually betwo to threedays before you feel the effects of a bulk-forming laxative.

Osmotic laxatives

If your stools remain hard after you have taken a bulk-forming laxative, your GP may prescribe an osmotic laxative instead. Osmotic laxatives increase the amount of fluid in your bowels. This helps to stimulate your body to pass stools and also softens stools.

Commonly prescribed osmotic laxatives include lactulose and macrogols. As with bulk-forming laxatives, make sure you drink enough fluids. It will usually betwo to threedays before you feel the effect of the laxative.

Stimulant laxatives

If your stools are soft but you still have difficulty passing them, your GP may prescribe a stimulant laxative. This laxative stimulates the muscles that line your digestive tract, helping them to move stools and waste products along your large intestine to your anus.

The most commonly prescribed stimulant laxatives are senna, bisacodyl and sodium picosulphate. These laxatives are usually only used on a short-term basis, and they will usually start to work within 6 to 12 hours.

According to your individual preference and the speed with which you require relief, your GP may decide to combine different laxatives.

Treating faecal impaction

Faecal impaction occurs when stools become hard and dry and collect in your rectum. This obstructs the rectum, making it more difficult for stools to pass along.

If you have faecal impaction, you will initially be treated with a high dose of the osmotic laxative macrogol. After a few days of using this laxative, you may also have to start taking a stimulant laxative.

If you do not respond to these laxatives, you may need one of the medications described below.

  • Suppository: this type of medicine isinserted into your anus. The suppository gradually dissolves at body temperature and is then absorbed into your bloodstream. Bisacodyl and glycerol are two medicines that can be given in suppository form.
  • Mini enema: this is when a medicine in fluid form is injected through your anus and into your large bowel. Docusate and sodium citrate can be given in this way.

Pregnancy or breastfeeding

If you are pregnant, there are ways for you to safely treat constipation without harming you or your baby. Your GP will first advise you to change your diet by increasing fibre and fluid intake. You will also be advised to do gentle exercise.

If dietary and lifestyle changes do not work, you may be prescribed a laxative to help you pass stools more regularly.

Lots of laxatives are safe for pregnant women to use because most are not absorbed by the digestive system. This means that your baby will not feel the effects of the laxative.

Laxatives that are safe to use during pregnancy include the bulk-forming laxatives lactulose and macrogols. If these do not work, your GP may advise a small dose of bisacodyl or senna (stimulant laxatives).

However, senna may not be suitable if you are in your third trimester of pregnancy (27 weeks to birth) because this medicine is partially absorbed by your digestive system.

Babies who have not yet been weaned

If your baby is constipated but has not yet started to eat solid foods, the first way to treat them is to give them extra water between their normal feeds. If you are using formula milk, make the formula as directed by the manufacturer anddo not dilute the mixture.

You may want to try gently moving your baby's legs in a bicycling motion or carefully massaging their abdomen (tummy) to help stimulate their bowels.

Babies who are eating solids

If your baby is eating solid foods, give them plenty of water or diluted fruit juice. Try to encourage them to eat fruit, which can be pureed or chopped, depending on their ability to chew. The best fruits for babies to eat to treat constipation are:

  • apples
  • apricots
  • grapes
  • peaches
  • pears
  • plums
  • prunes
  • raspberries
  • strawberries

Never force your baby to eat food if they do not want to. If you do, it can turn mealtimes into a battle and your child may start to think of eating as a negative and stressful experience.

If your baby is still constipated after a change in diet, they may have to be prescribed a laxative. Bulk-forming laxatives are not suitable for babies, so they will usually be given an osmotic laxative. However, if this does not work, they can be prescribed a stimulant laxative.

Children

As with babies and adults, children with constipation will first be advised to change their diet. If this does not work, laxatives can be prescribed, usually an osmotic laxative followed if necessary by a stimulant laxative.

As well as eating fruit, older children should have a well-balanced diet, which also contains vegetables and wholegrain foods such as wholemeal bread and pasta.

Try to minimise stress or conflict associated with using the toilet or meal times. It is important to be positive and encouraging when it comes to establishing a toilet routine. Your child should be allowed at least 10 minutes on the toilet to make sure they have passed as many stools as possible.

To encourage a positive toilet routine, try making a diary of your child's bowel movementslinked to a reward system. This can help them focus on using the toilet successfully.

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Complications with constipation

Constipation rarely causes any complications or long-term health problems. Treatment is usually effective, particularly if it is started promptly.

However, if you have chronic (long-term) constipation, you may be more at risk of experiencing complications.

Haemorrhoids

If you continually strain to pass stools, it can cause pain, discomfort and bleeding. Excessive straining can also lead to haemorrhoids. More commonly known as piles, haemorrhoids are swollen blood vessels that form in the lower rectum and anus.

Haemorrhoids can cause

  • itching around the anus
  • swelling of the anus
  • pain
  • bleeding from the anus

Faecal impaction

Chronic constipation can increase the risk of faecal impaction (where dried, hard stools collect in your rectum and anus). Once you have faecal impaction, it is very unlikely that you will be able to get rid of the stools naturally.

Faecal impaction worsens constipation because it makes it harder for stools and waste products to pass out of your anus as the path is obstructed.

If you experience faecal impaction, it can lead to a number of other complications. These include:

  • swelling of the rectum
  • losing sensation in and around your anus
  • faecal incontinence, when you uncontrollably leak soft or liquid stools
  • bleeding from your anus
  • rectal prolapse, when part of your lower intestine falls out of place and protrudes from your anus

Psychological effects

If your child experiences faecal incontinence, it may affect them psychologically.

Faecal incontinence can be very upsetting and embarrassing for children. If they are at school, they may find themselves teased or socially excluded. This can make a child feel withdrawn, alone and unable to talk about what they are experiencing.

If you notice a change in your child's behaviour, talk openly and honestly with them and encourage them to tell you how they are feeling.

Alsotry to speak to your child's teacher to make sure they understand the situation. The teacher can help ensure your child is not upset or left feeling excluded by other children.

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Preventing constipation

Although constipation is common, you can take several stepsto prevent it.

Fibre

Make sure you have enough fibre in your diet. Most adults do not eat enough fibre. You should have approximately 18g of fibre a day. You can increase your fibre intake by eating more:

  • fruit
  • vegetables
  • wholegrain rice
  • wholewheat pasta
  • wholemeal bread
  • seeds
  • nuts
  • oats

Eating more fibre will keep your bowel movements regular because it helps food pass through your digestive system more easily. Foods high in fibre also make you feel fuller for longer.

If you are increasing your fibre intake, it is important to increase it gradually. A sudden increase may make you feel bloated. You may also produce more wind (flatulence) and have stomach cramps.

Fluids

Make sure that you drink plenty of fluids to avoid dehydration. You should drink at least 1.2 litres (six to eightglasses) of fluids a day and more when you are exercising or when it is hot. Try to cut back on the amount of caffeine, alcohol and fizzy drinks that you have.

Toilet habits

Never ignore the urge to go to the toilet. Ignoring the urge can significantly increase your chances of having constipation. The best time for you to pass stools is first thing in the morning, or about 30 minutes after a meal.

When you use the toilet,make sure you have enough time and privacy to pass stools comfortably.

Exercise

Keeping mobile and active will greatly reduce your risk of getting constipation. Ideally, do at least30 minutes of physical exercise every day.

Not only will regular exercise reduce your risk of becoming constipated, but it will also leave you feeling healthier and improve your mood, energy levels and general fitness.



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