Chronic Constipation

Having recurring waves of constipation is a very common health issue that disproportionately affects women and older men. For example, up to 40% of people over the age of 60 report suffering from difficulty passing stools.

While there are no precise statistics on the frequency of chronic constipation, it is estimated to affect about 15% of the European population.

There are many possible causes of chronic constipation. Many people think that the causes are specific lifestyle factors such as a low-fiber diet, not drinking enough liquids, not getting enough movement, and frequently suppressing the urge to go to the bathroom. However, these factors are often overemphasized, as none of them have been scientifically shown to be direct causes of constipation.

Nevertheless, these lifestyle factors may worsen a pre-existing tendency toward constipation. People who often cannot find the time to go to the bathroom and therefore suppress the need will eventually get used to this condition and no longer feel the urge. When this happens, stools remain in the intestines longer and become denser. This makes bowel movements even more difficult and often painful, potentially leading to chronic constipation.

Other conditions may also be the cause of chronic constipation. For example, many patients with irritable bowel syndrome suffer from chronic constipation and irregular stools. The exact causes of irritable bowel syndrome are still not known. Other conditions that may cause gastrointestinal symptoms and lead to chronic constipation include hormone imbalances or pelvic floor dysfunction.

Medications may also be responsible for constipation. Digestive issues or chronic constipation are the side effects of a number of drugs, including certain potent pain medications, blood pressure medications, or antidepressants.

The classical symptoms of chronic constipation are bowel movements that occur too infrequently, painful bowel movements, hard or lumpy stools, a sensation of incomplete bowel evacuation, and sometimes even the need for manual maneuvers to aid in passing stools. Other symptoms that may accompany constipation include a feeling of bloating, gastrointestinal symptoms such as abdominal pain, cramps, or flatulence, and even back or rectal pain. These symptoms leave a major impact on patients’ quality of life.

Major warning signs are any symptoms of constipation that indicate a serious underlying condition requiring immediate treatment. These may include, for example, bloody or dark stools, anemia, unintended weight loss, enlarged lymph nodes, a family history of gastrointestinal cancer, fever, signs of nutritional deficiency, age >50 years old, worsening constipation with significant symptoms, or even alternating between constipation and diarrhea.

The first step in diagnosing the condition is to collect the patient’s medical history, which involves a conversation between the doctor and the patient that covers the history of the symptoms in as much detail as possible. This discussion will address which symptoms and potential secondary symptoms are currently present, when they first started, and how the digestive issues developed. The doctor will also ask about stool habits such as the frequency of bowel movements, stool consistency, and also whether there is any straining, abdominal pain, or flatulence.

There will also be questions about lifestyle habits, other diseases (such as diabetes), and whether the patient regularly takes any medications.

During this conversation, the patient may be asked to keep a stool diary in which he or she writes down every time they have a bowel movement and whether it is accompanied by any symptoms.

The initial tests also include a physical examination, during which the doctor will probe the rectum with his or her finger (digital rectal examination). The medical history and the physical examination will provide the doctor with some initial hints about possible causes of the chronic constipation. This will guide the way for the next diagnostic steps. For example, the doctor may suspect irritable bowel syndrome if the patient also mentions frequent abdominal pain in addition to the digestive issues. This would then require the appropriate diagnostic procedures for irritable bowel syndrome.

If there are no “red flags”, the doctor may attempt to manage the chronic constipation using lifestyle measures and medication in accordance with medical guidelines.

If additional diagnostic procedures are required to determine the cause of the illness, the doctor will first order laboratory tests. Other tests will include an ultrasound examination, possibly an X-ray examination, a CT or MRI scan (e.g. defecography), a proctoscopy or possibly a colonoscopy. In some cases, it may also be necessary to measure the pressure in the digestive tract (anorectal manometry), test the ability of food to move through the large intestine (colonic transit test), or perform a gynecological examination for women. Certain breathing tests or microscopic examination of the lining of the intestines may also be performed.

Even though lifestyle factors are rarely the actual cause of chronic constipation, changes in daily behaviors may nonetheless significantly improve constipation. A high-fiber diet including lots of fruits, vegetables, legumes, and whole grains is very important.

People who have frequent digestive or gastrointestinal issues should also make sure they are drinking enough liquids. Because normal stool is made up of 70% to 80% water, not drinking enough can easily lead to constipation. Everyone should drink at least two to three liters of water each day, preferably in the form of mineral water or unsweetened tea - and taken together with dietary fiber to ensure that the liquids are brought into the intestines. Black tea, on the other hand, can actually make constipation worse.

Frequent movement is also very important, since prolonged sitting slows down the digestive tract while physical activity stimulates bowel movements. The intestines also need the mechanical stimulation that occurs during exercise and especially high-impact exercises like jogging. In order to function properly, the intestines must be “massaged” by the diaphragm, which occurs when we breathe deeply, for example by walking upstairs.

Lifestyle changes can also involve developing proper bathroom habits. To overcome constipation, it is obviously necessary to go to the bathroom regularly and to avoid suppressing the urge to have a bowel movement just because there is no “good time” to go or because stress and a busy schedule impact priorities. Bowel movements should take place whenever there is an urge to go to the bathroom. The entire bowel movement process should not last longer than three minutes.

When treating constipation, it is also a good idea to check whether any medications that might promote constipation can be replaced by other medications.

If general lifestyle changes alone do not result in adequate improvement, the guidelines recommend adding soluble fibers such as psyllium to the diet. Psyllium (Plantago ovata) is a member of the plantain family whose seed husks contain plant fibers with a very high capacity to absorb water. This promotes bowel movements through swelling and pushing out constipated bowels.

By swelling up, these plant fibers act as stool softeners, since their absorbed water increases the concentration of water in the stool. This makes the stool smoother and easier to pass. The mucilage in the seed husks also improves the gliding of the stool along the intestine. Because soluble fibers are partially digested by bacteria in the intestines, they can promote healthy gut bacteria and help supply nutrients to the intestinal mucosa.

Soluble fibers such as psyllium are usually tolerated better than insoluble fibers like wheat bran. Although insoluble fibers also promote digestion and improve constipation, they may be accompanied by unpleasant symptoms such as flatulence or abdominal cramps.

If constipation does not improve with either general lifestyle changes or adding soluble fiber to the diet, constipation medications called laxatives and stool softeners are also available. These laxatives include e. g. polyethylene glycol (PEG)-containing products that are dissolved in water for drinking. PEG absorbs the liquids normally taken up by the intestines, thereby increasing the water content in stool without triggering any loss of fluids or electrolytes.

Other plant-based and synthetic laxatives are also available. Some of these drugs increase the concentration of water in stool by reducing the amount of water absorbed by the intestines into the body (osmotic laxatives containing salt or sugar), while others promote the influx of water into the intestines. Another type of laxative exerts direct effects on the movement of the intestines, thus helping move the stool towards the rectum.

If none of the treatment measures described here are able to improve or cure the chronic constipation yet the patient is still suffering greatly, surgery is also a possibility to consider. There are several surgical approaches to constipation that range all the way to removal of the large intestine (colectomy).