Treatment of Constipation

A day without a bowel movement is no cause for concern. The notion that a daily bowel movement is a necessity of life is rooted in folklore, not science. However, bowel movements should be effortless and of soft consistency. Defecation is a physiologic necessity, and need not cause embarrassment. Furthermore, defecation is a priority. When the sensation of the urge to defecate is felt (the call to stool), it is important to respond promptly, and not postpone it unnecessarily for social or other reasons.

The treatment of constipation includes dietary and lifestyle changes, fiber supplements, and laxatives. For very difficult cases prescription medications and behavioral techniques such as biofeedback may be tried. In very rare instances surgery may be necessary for carefully defined neuromuscular abnormalities. The first step is to determine the underlying cause of constipation. A constipated individual may use a daily diary and worksheet to record bowel movements, stool characteristics, and other factors to help the physician and patient work in partnership in pursuing effective treatment.

Occasional Constipation

For occasional, short-lived, or mild constipation the best treatment is prevention. Dietary measures usually accomplish this. Dietary fiber can prevent constipation, and may benefit individuals with relatively minor or occasional constipation. Regular ingestion of fruits and vegetables, especially if uncooked, will provide dietary fiber and natural laxatives such as that found in prunes. Whole grain breads and cereals are also helpful. Many find it difficult to take sufficient quantities of these foods in their diet. In this case raw wheat bran may be given as a supplement.

For those who find that bran causes bloating or excessive gas, a fiber substitute such as psyllium (a natural soluble fiber that tends to form a gel in water and act as a bulking agent) may help. If gas is still a problem, methylcellulose (Citrocel) or polycarbophil (e.g., FiberCon, Equalactin) may help. These do not undergo bacterial fermentation and so create less gas.

The need for regular exercise and extra fluids to prevent constipation is controversial. Nevertheless, these are safe and justified for other health reasons. Certainly, inactivity when ill, or dehydration provoke constipation. It also makes sense to drink a generous glass of water to wash the fiber down. (Be sure to drink plenty of water with psyllium.)

Laxatives should be reserved for temporary constipation due to illness, incapacity, or travel. Talk to a doctor about selecting a laxative.

Chronic Constipation

If constipation becomes chronic or persistent, consultation with a physician is in order. While structural abnormalities or diseases of the colon or rectum can cause constipation, it is usually of unknown cause. The doctor will double-check to make sure all constipating medicines have been stopped, switched to an alternative, or reduced in dosage if possible. The consumption of plenty of fluids, as well as fruits and vegetables should be encouraged.

A high-fiber diet may improve gut transit, stool frequency, and stool consistency in persons with mild to moderate constipation. Most people consume only a fraction of the recommended 20-35 gm of fiber daily. On the other hand, some persons with constipation are already consuming adequate quantities of fiber. Many others tolerate fiber supplementation poorly, especially if fiber intake is dramatically increased over a short time period. Side effects can include bloating, gassiness, and cramping, any of which a person may feel is worse than the constipation itself.

Individuals may tolerate dietary and various commercial fiber supplements differently, so new fiber sources should be tried for a few weeks each until the most satisfactory is found. Patients should gradually increase dietary fiber intake until an effect is achieved or until it becomes apparent that no further benefit is gained. Bulking agents, such as psyllium, are an alternative for persons who have difficulties consuming enough dietary fiber to treat constipation. These products hold water, which bulks and softens the stool. Individuals are encouraged to increase the dose of fiber gradually over a couple of weeks to help minimize any side effects, such as distention and bloating. A physician or registered dietitian can help sort this out.

Should simple measures fail, the addition of a laxative is the next step. There are several types of laxatives and, whether over-the-counter or by prescription, consultation with a physician is advised before long-term or chronic use of them.

The doctor may recommend starting with an osmotic laxative, which works by drawing water into the colon. The sugars lactulose, lactitol, and sorbitol are not absorbed by the intestine. Through osmotic forces they increase stool bulk and stimulate peristalsis (contractions of the muscles that propel food content through the GI tract). They are safe and perhaps are the preferred all-purpose laxatives. Note that these sugars sometimes cause gaseousness, abdominal cramping, and bloating.

The drug polyethylene glycol (MiraLax) is an osmotic laxative that first became available after receiving FDA approval in 1999 as a prescription drug and later, in 2006, as an over-the-counter medicine; it is well accepted for the treatment of occasional constipation.[3] It is generally reserved for those who do not respond to other agents. Side effects may include upset stomach, bloating, cramping, and gas.

Stimulant laxatives such as bisacodyl (e.g., Dulcolax, Bisco-Lax), or senna (e.g., Senecott, Senexon) work by signaling the muscles and nerves of the intestine to contract. These laxatives work relatively quickly, but tend to produce more cramping. Although chronic use of these drugs has been thought to cause damage to the intestine's nervous system, it is now believed this concern has been overstated.

Many patent or herbal medicines contain laxatives. These are unregulated, and the dose of any contained drug is often unknown. Some can cause diarrhea and are best avoided.

New Medications

The prominent role of the neurotransmitter serotonin (a chemical that acts on the nervous system to help transmit messages along the nervous system) in gut motility and sensation has led to the development of new prescription agents such as tegaserod (Zelnorm).

Tegaserod was originally approved by the FDA in 2002 for the short-term treatment of women with irritable bowel syndrome (IBS) whose primary bowel symptom is constipation. The safety and effectiveness of tegaserod in men with IBS have not been established. Tegaserod has been shown to be effective in relieving multiple symptoms of IBS with constipation.[4] The drug should not be used by persons who have or frequently experience diarrhea. It should be discontinued immediately and a physician called if symptoms develop of new or worsening abdominal pain.

In 2004 the FDA approved the use of tegaserod for treating chronic constipation in both men and women under the age of 65. The drug has been shown to improve stool frequency and consistency, and reduce other constipation-related complaints.[3] [NOTE: On March 30, 2007 U.S. marketing and sales of Zelnorm was voluntarily discontinued by the manufacturer at the request of the FDA. A 9-month restricted access program ended April 2, 2008, and the drug is no longer available in the U.S.]

In January 2006 the FDA approved another new drug for constipation treatment. This drug affects intestinal fluid secretion (as a selective chloride channel activator). The drug, lubiprostone (AMITIZA™), is an oral treatment (capsule) that works by increasing fluid secretion in the small intestine, and thereby helping to ease the passage of the stool and improving symptoms associated with chronic idiopathic (of unknown cause) constipation.

When Constipation is Unresponsive to Treatment

"Intractable" constipation means that the symptom does not respond to the treatments described above. Patients who have intractable constipation may be referred to a specialist who may wish to perform transit time or other studies.

Transit time, the time it takes for stool to move through the colon, can be evaluated by any physician by taking x-rays of the abdomen 5 days after the patient swallows a capsule containing 24 tiny plastic "markers". Markers are substances that allow stool to show up on x-rays. As a rule of thumb, if more than 20% of the markers remain in the gut after 5 days, the transit time is abnormally prolonged, and further investigation may be helpful.

If the transit time is prolonged, patients may undergo further testing at highly specialized centers. Colonic scintigraphy is a test that uses a small amout of a radioactive substance ingested in a meal to measure transit time; images are then recorded at intervals over a 24–48 hour period to measure progress of the meal through the colon. Defecography uses x-rays to look at the behavior of the rectum and anus during attempts to defecate. It evaluates completeness of rectal expulsion and puborectalis muscle relaxation, and identifies structural problems (such as rectocele)

Anorectal manometry can be used to measure resting and squeezing anal sphincter pressures, rectal sensation and compliance, and sphincter response. With manometry, balloons are positioned in the rectum and anal canal. Doctors inflate the balloons and then measure the response. Hirschsprung's disease and other disorders are detected this way.

Behavioral Treatments

Bowel retraining may help persons who have very difficult symptoms. Such training involves sitting on the toilet for 15 to 20 minutes at the same time each day so the body can get into the habit of having regular bowel movements. The ideal time is following breakfast and coffee. Since the normal human position for human defecation is the squat, elevation of the feet by placing a footstool before the toilet may simulate that position. The doctor will recommend discontinuing stimulant laxatives and consuming a high-fiber diet or a dietary fiber supplement if needed. For severe constipation, enemas may be used occasionally as part of a bowel retraining program.

Biofeedback therapy is sometimes helpful to treat a variety of bowel disorders including constipation and pelvic floor dysfunction. In this procedure, special sensors measure bodily functions of which we are usually unaware of. A therapist helps use this information to modify or change abnormal responses to more normal patterns.

Surgical Treatment

Surgery is a rare "last resort" for constipation when a surgically remediable cause of constipation can be identified. Hirschsprung's disease (below) is an unusual example of a remediable condition in adults. In some cases, even if a local neuromuscular abnormality can be identified, surgery makes matters worse. Therefore, surgery should be considered only after careful evaluation by physicians and surgeons who are experts in this field (e.g., gastroenterologist, colorectal surgeon) and after all other prescribed treatments have been adequately tried and failed. It is important to discuss any recommended surgery thoroughly with the doctors in order to be familiar with the procedure and understand the potential risks as well as proposed benefits.

Transit time that is greatly prolonged may indicate colon inertia. Here, surgical intervention is sometimes considered. Colon inertia may be part of a generalized gut neurological or muscular disorder, in which case removal of the colon will not correct the problem.

When the internal anal sphincter fails to relax after rectal distention, the patient may have Hirschsprung's disease. This disease is usually, but not always, discovered in childhood. The treatment is surgical removal of a segment of the colorectum.

Surgical repair can be helpful in women with large rectoceles who must support the back of the vagina with their fingers in order to effect defecation. Complete preoperative evaluation (preferably including defecography to demonstrate improved rectal emptying with vaginal support) and careful patient selection are necessary to ensure optimal outcomes.

A new operation using a special surgical stapler (STARR procedure) may help some with obstructed defecation that is caused by a combination of rectocele and internal intussusception (infolding of the rectum). As with any surgery, a thorough assessment of causes and symptoms prior to the operation is important so that those individuals best suited for the procedure are selected. Studies are underway to assess safety and effectiveness, and additional data are needed before this operation can be advocated outside specialized research centers. Go to this IFFGD web page to view a list of specialized centers in the U.S. studying the STARR procedure.

Summary

Prevention of occasional constipation can usually be accomplished through dietary measures and responding to the call to stool. Adding fiber to the diet may benefit those with occasional, temporary, and mild constipation. Consultation with a physician is recommended when constipation is chronic or persistent.

After a thorough medical evaluation to determine the underlying cause of the constipation various treatment options can be considered. This often includes a review of dietary and lifestyle factors. Other treatment options include medications and behavioral approaches. In some well defined cases surgery may be considered, but only after other appropriate and more conservative options have been tried unsuccessfully.

Constipation is common, yet clearly there is a need for better understanding of this condition, and for improved treatments. Unbiased studies are needed that look at the incidence, natural history and quality of life in individuals with constipation. While several novel therapeutic agents are in different stages of development, continued and additional research is needed to establish their safety and effectiveness, to develop new treatments, and to advance our understanding of this chronic troublesome disorder.