What is Constipation

Constipation is when you have infrequent bowel movements and stool that may be hard, dry and difficult to pass. You may also have stomach cramps, bloating, and nausea when you are constipated ¹⁾.

Constipation is the slow movement of feces through the large intestine that results in the passage of dry, hard stool. This can result in discomfort or pain ²⁾. The longer the transit time of stool in the large intestine, the greater the fluid absorption and the drier and harder the stool becomes.

Constipation is a condition in which you typically have:

• fewer than three bowel movements a week,

• bowel movements with stools that are hard, dry, and small, making them painful or difficult to pass.

Some people think they are constipated if they don’t have a bowel movement every day. However, people can have different bowel movement patterns. Some people may have three bowel movements a day. Other people may only have three bowel movements a week ³⁾.

It is estimated that in the United States, constipation is one of the most common gastrointestinal (GI) problems affecting about 42 million people ⁴⁾.

People who are more likely to become constipated

Constipation is common among all ages and populations in the United States, yet certain people are more likely to become constipated, including

• Being dehydrated
• Eating a diet that’s low in fiber
• Getting little or no physical activity
• Having a mental health condition such as depression or an eating disorder
• Women, especially during pregnancy or after giving birth
• Older adults
• Non-Caucasians
• People with lower incomes
• People who just had surgery
• People taking medicines to treat depression or to relieve pain from things such as a broken bone, a pulled tooth, or back pain – certain medications, including sedatives, narcotics, some antidepressants or medications to lower blood pressure.

What is Fecal Impaction

A fecal impaction is a large lump of dry, hard stool that stays stuck in the rectum. Fecal impaction is defined as a large mass of compacted feces at any intestinal level that cannot be evacuated spontaneously ⁵⁾.  Fecal impaction occurs because of hardened fecal matter retained in the large bowel which cannot be evacuated by regular peristaltic activity. Patients with fecal impaction often give a history of inability to evacuate stools spontaneously and complain of total constipation. In most instances, an associated history of progressive abdominal distension with increasing abdominal discomfort or pain is present. Occasionally, patients may also present with a spurious or overflow diarrhea. If fecal impaction is not recognized and treated early, it can give rise to the formation of fecoliths or stone-like feces. Fecal impaction can be life-threatening, patient with a fecal impaction may present with circulatory, cardiac, or respiratory symptoms rather than with gastrointestinal symptoms ⁶⁾. If the fecal impaction is not recognized, the signs and symptoms may progress and resulting in death ⁷⁾.

Fecal impaction is most often seen in people who are constipated for a long time (chronic constipation). Constipation is when you are not passing stool as often or as easily as is normal for you. Your stool becomes hard and dry. This makes it difficult to pass.

Fecal impaction commonly occurs among elderly individuals and other at-risk groups, such as children and patients with a neuro-psychiatric disease ⁸⁾, rarely presenting as an acute emergency to a hospital. Severe constipation is a significant problem that affects almost 70% of elderly people who are under care in nursing homes ⁹⁾. Among those affected, about 7% will have the condition detected during a digital rectal examination. Fecal impaction is more common among older women who are in institutional care and have associated neuropsychiatric disorders. It is a cause for increased morbidity among the elderly, and if allowed to progress, this can lead to complications causing mortality in the older age group ¹⁰⁾.

Fecal impaction is a cause for increased morbidity and a significant cause of a decrease in quality of life among the elderly ¹¹⁾.

Physical examination findings often reveal a distended abdomen. In thinly built or emaciated individuals, hard fecal mass masses may be palpable along the colon. The diagnosis of fecal impaction is primarily based on clinical signs. A detailed history of bowel habits and a full physical examination which includes a digital rectal exam is mandatory.

Treatment for fecal impaction starts with removal of the impacted stool. After that, steps are taken to prevent future fecal impactions.

A warm mineral oil enema is often used to soften and lubricate the stool. However, enemas alone are not enough to remove a large, hardened impaction in most cases.

The fecal mass may have to be broken up by hand. This is called manual removal:

• Your doctor or nurse will need to insert one or two fingers into the rectum and slowly break up the mass into smaller pieces so that it can come out.
• This process must be done in small steps to avoid causing injury to the rectum.
• Suppositories inserted into the rectum may be given between attempts to help clear the stool.

Surgery is rarely needed to treat a fecal impaction. An overly widened colon (megacolon) or complete blockage of the bowel may require emergency removal of the impaction.

Most people who have had a fecal impaction will need a bowel retraining program. Your doctor and a specially trained nurse or therapist will:

• Take a detailed history of your diet, bowel patterns, laxative use, medicines, and medical problems
• Examine you carefully.
• Recommend changes in your diet, how to use laxatives and stool softeners, special exercises, lifestyle changes, and other special techniques to retrain your bowel.
• Follow you closely to make sure the program works for you.

What is Intestinal Obstruction

Unlike constipation or fecal impaction, an intestinal obstruction is a partial or complete occlusion of the bowel lumen by a process other than fecal impaction. Intestinal obstructions can be classified by the following three means:

1. The type of obstruction.
2. The obstructing mechanism.
3. The part of the bowel involved.

Structural disorders, such as intraluminal and extraluminal bowel lesions caused by primary or metastatic tumor, postoperative adhesions, volvulus of the bowel, or incarcerated hernia, affect peristalsis and the maintenance of normal bowel function. These disorders can lead to total or partial obstruction of the bowel.

Patients who have colostomies are at special risk of developing constipation. If stool is not passed on a regular basis (once a day to several times a day), further investigation is warranted. A partial or complete blockage may have occurred, particularly if no flatus has been passed ¹²⁾.

What is Chronic Constipation ?

Constipation most often lasts for only a short time (hours to days) and is not dangerous. You can take steps to prevent or relieve constipation.

However with chronic constipation, the infrequent bowel movements or difficult passage of stools can persists for several weeks or longer ¹³⁾.

People who experience chronic constipation often find it can interfere with their ability to go about their daily tasks. Chronic constipation may also cause excessive straining to have a bowel movement and other signs and symptoms.

Treatment for chronic constipation depends in part on the underlying cause. However, in some cases, a cause is never found ¹⁴⁾.

Constipation in Pregnancy

Pregnancy triggers many physical changes in your body — some quite aggravating, including constipation. Constipation in pregnancy and after delivery can happen to anyone.

Pregnancy constipation can often be prevented with lifestyle changes. For example:

• Drink plenty of fluids. Water is a good choice. Fruit juice — especially prune juice — also can help.
• Include physical activity in your daily routine. Daily walks and other aerobic activities can help prevent pregnancy constipation.
• Include more fiber in your diet. Choose high-fiber foods, such as fruits, vegetables, beans and whole grains. With your health care provider’s OK, consider a fiber supplement, such as Metamucil.

If you take iron supplements, mention the constipation to your health care provider. Although iron is an important nutrient during pregnancy, too much iron can contribute to pregnancy constipation.

If you haven’t had a bowel movement in three days, ask your health care provider for a recommendation. If your health care provider approves stool softeners or other types of laxatives, use them as directed.

Is it safe to take stool softeners to treat pregnancy constipation ?

Stool softeners are generally considered safe during pregnancy ¹⁵⁾.

Pregnancy constipation can be stubborn and uncomfortable. Stool softeners, such as Colace, moisten the stool and make it easier to pass. These products are unlikely to harm a developing baby because their active ingredient is only minimally absorbed by the body. Check with your health care provider, however, before taking any medication — including stool softeners and other types of laxatives — to treat pregnancy constipation.

Babies and Infant Constipation

Infant constipation isn’t common ¹⁶⁾. However, your baby might have infant constipation if he or she has:

• Hard or pellet-like bowel movements
• Bowel movements that appear difficult to pass, causing your baby to arch his or her back or cry
• Infrequent or less frequent bowel movements

If your newborn seems constipated, contact his or her doctor for advice. But keep in mind that the normal amount of bowel movements an infant passes varies depending on his or her age and what he or she is eating.

Infants also have weak abdominal muscles and often strain during bowel movements. Infant constipation is unlikely if your baby passes a soft bowel movement after a few minutes of straining ¹⁷⁾.

Infant constipation often begins when a baby starts eating solid foods ¹⁸⁾. If your baby seems constipated, consider simple dietary changes:

• Water or fruit juice. Offer your baby a small amount of water or a daily serving of 100 percent apple, prune or pear juice in addition to usual feedings. These juices contain sorbitol, a sweetener that acts like a laxative. Start with 2 to 4 ounces (about 60 to 120 milliliters), and experiment to determine whether your baby needs more or less ¹⁹⁾.

• Baby food. If your baby is eating solid foods, try pureed peas or prunes, which contain more fiber than other fruits and vegetables. Offer whole wheat, barley or multigrain cereals, which contain more fiber than rice cereal.

If your baby is struggling, it’s been a few days since his or her last bowel movement, and dietary changes haven’t been effective, it might help to place an infant glycerin suppository into your baby’s anus. However, glycerin suppositories are only meant for occasional use. Don’t use mineral oil, stimulant laxatives or enemas to treat infant constipation ²⁰⁾.

Rarely, infant constipation is caused by an underlying condition, such as Hirschsprung’s disease, hypothyroidism or cystic fibrosis. If infant constipation persists despite dietary changes or is accompanied by other signs or symptoms — such as vomiting or weakness — contact your baby’s doctor.

Constipation in Children

Constipation in children is a common problem ²¹⁾. A constipated child has infrequent bowel movements or hard, dry stools.

Common causes include early toilet training and changes in diet. Fortunately, most cases of constipation in children are temporary.

Encouraging your child to make simple dietary changes — such as eating more fiber-rich fruits and vegetables and drinking more fluids — can go a long way toward alleviating constipation. If your child’s doctor approves, it may be possible to treat a child’s constipation with laxatives.

Symptoms of Constipation in Children

Signs and symptoms of constipation in children may include:

• Less than three bowel movements a week
• Bowel movements that are hard, dry and difficult to pass
• Large-diameter stools that may obstruct the toilet
• Pain while having a bowel movement
• Abdominal pain
• Traces of liquid or clay-like stool in your child’s underwear — a sign that stool is backed up in the rectum
• Blood on the surface of hard stool.

If your child fears that having a bowel movement will hurt, he or she may try to avoid it. You may notice your child crossing his or her legs, clenching his or her buttocks, twisting his or her body, or making faces when attempting to hold stool.

When to see a doctor

Constipation in children usually isn’t serious. However, chronic constipation may lead to complications or signal an underlying condition. Take your child to a doctor if the constipation lasts longer than two weeks or is accompanied by:

• Fever
• Vomiting
• Blood in the stool
• Abdominal swelling
• Weight loss
• Painful tears in the skin around the anus (anal fissures)
• Intestinal protrusion out of the anus (rectal prolapse)

Causes of Constipation in Children

Constipation most commonly occurs when waste or stool moves too slowly through the digestive tract, causing the stool to become hard and dry.

Many factors can contribute to constipation in children, including:

• Withholding. Your child may ignore the urge to have a bowel movement because he or she is afraid of the toilet or doesn’t want to take a break from play. Some children withhold when they’re away from home because they’re uncomfortable using public toilets.

Painful bowel movements caused by large, hard stools also may lead to withholding. If it hurts to poop, your child may try to avoid a repeat of the distressing experience.

• Toilet training issues. If you begin toilet training too soon, your child may rebel and hold in stool. If toilet training becomes a battle of wills, a voluntary decision to ignore the urge to poop can quickly become an involuntary habit that’s tough to change.

• Changes in diet. Not enough fiber-rich fruits and vegetables or fluid in your child’s diet may cause constipation. One of the more common times for children to become constipated is when they’re switching from an all-liquid diet to one that includes solid foods.

• Changes in routine. Any changes in your child’s routine — such as travel, hot weather or stress — can affect bowel function. Children are also more likely to experience constipation when they first start school outside of the home.

• Medications. Certain antidepressants and various other drugs can contribute to constipation.

• Cow’s milk allergy. An allergy to cow’s milk or consuming too many dairy products (cheese and cow’s milk) sometimes leads to constipation.

• Family history. Children who have family members who have experienced constipation are more likely to develop constipation. This may be due to shared genetic or environmental factors.

• Medical conditions. Rarely, constipation in children indicates an anatomic malformation, a metabolic or digestive system problem, or another underlying condition.

Risk factors for Constipation in Children

Constipation in children is more likely for kids who:

• Are sedentary
• Don’t eat enough fiber
• Don’t drink enough fluids
• Take certain medications, including some antidepressants
• Have a medical condition affecting the anus or rectum
• Have a family history of constipation

Diagnosis of Constipation in Children

Your child’s doctor will:

• Gather a complete medical history. Your child’s doctor will ask you about your child’s past illnesses. He or she will also likely ask you about your child’s diet and physical activity patterns.
• Conduct a physical exam. Your child’s physical exam will likely include placing a gloved finger into your child’s anus to check for abnormalities or the presence of impacted stool. Stool found in the rectum may be tested for blood.

More-extensive testing is usually reserved for only the most severe cases of constipation. If necessary, these tests may include:

• Abdominal X-ray. This standard X-ray test allows your child’s doctor to see if there are any blockages in your child’s abdomen.
• Anorectal manometry or motility test. In this test, a thin tube called a catheter is placed in the rectum to measure the coordination of the muscles your child uses to pass stool.
• Barium enema X-ray. In this test, the lining of the bowel is coated with a contrast dye (barium) so that the rectum, colon and sometimes part of the small intestine can be clearly seen on an X-ray.
• Rectal biopsy. In this test, a small sample of tissue is taken from the lining of the rectum to see if nerve cells are normal.
• Transit study or marker study. In this test, your child will swallow a capsule containing markers that show up on X-rays taken over several days. Your child’s doctor will analyze the way the markers move through your child’s digestive tract.
• Blood tests. Occasionally, blood tests are performed, such as a thyroid panel.

Complications of Constipation in Children

Although constipation in children can be uncomfortable, it usually isn’t serious. If constipation becomes chronic, however, complications may include:

• Painful breaks in the skin around the anus (anal fissures)
• Rectal prolapse, when the rectum comes out of the anus
• Stool withholding
• Avoiding bowel movements because of pain, which causes impacted stool to collect in the colon and rectum and leak out (encopresis).

Treatment of Constipation in Children

Depending on the circumstances, your child’s doctor may recommend:

• Over-the-counter fiber supplements or stool softeners. If your child doesn’t get a lot of fiber in his or her diet, adding an over-the-counter fiber supplement, such as Metamucil or Citrucel, might help. However, your child needs to drink at least 32 ounces (about 1 liter) of water daily for these products to work well. Check with your child’s doctor to find out the right dose for your child’s age and weight.

Glycerin suppositories can be used to soften the stool in children who can’t swallow pills. Talk with your child’s doctor about the right way to use these products.

• A laxative or enema. If an accumulation of fecal material creates a blockage, your child’s doctor may suggest a laxative or enema to help remove the blockage. Examples include polyethylene glycol (Glycolax, MiraLax, others) and mineral oil.

Never give your child a laxative or enema without the doctor’s OK and instructions on the proper dose.

• Hospital enema. Sometimes a child may be so severely constipated that he or she needs to be hospitalized for a short time to be given a stronger enema that will clear the bowels. This is called disimpaction.

Alternative medicine

• In addition to changes in diet and routine, various alternative approaches may help relieve constipation in children:
• Massage. Gently massaging your child’s abdomen may relax the muscles that support the bladder and intestines, helping to promote bowel activity.
  Acupuncture. This traditional Chinese medicine involves the insertion and manipulation of fine needles into various parts of the body. The therapy may help if your child has constipation-related abdominal pain.

What are Complications of Chronic Constipation ?

Complications of chronic constipation include:

• Swollen veins in your anus (hemorrhoids). Straining to have a bowel movement may cause swelling in the veins in and around your anus.
• Torn skin in your anus (anal fissure). A large or hard stool can cause tiny tears in the anus.
• Stool that can’t be expelled (fecal impaction). Chronic constipation may cause an accumulation of hardened stool that gets stuck in your intestines.
• Intestine that protrudes from the anus (rectal prolapse). Straining to have a bowel movement can cause a small amount of the rectum to stretch and protrude from the anus.

What are Symptoms and Signs of Constipation and Chronic Constipation ?

Signs and symptoms of chronic constipation include:

• Passing fewer than three stools a week
• Having lumpy or hard stools
• Straining to have bowel movements
• Feeling as though there’s a blockage in your rectum that prevents bowel movements
• Feeling as though you can’t completely empty the stool from your rectum
• Needing help to empty your rectum, such as using your hands to press on your abdomen and using a finger to remove stool from your rectum

Constipation may be considered chronic if you’ve experienced two or more of these symptoms for the last three months.

• When to see a doctor: Make an appointment with your doctor if you experience unexplained and persistent changes in your bowel habits.
• Call your doctor immediately if you have:
• Bloody stools
• Severe cramps or pain
• Weakness or unusual tiredness
• Dizziness
• Rectal bleeding
• Unexplained changes in bowel patterns
• Constipation that lasts longer than seven days despite laxative use.

What Causes Constipation

Inactivity, immobility, or physical and social impediments (particularly inconvenient bathroom availability) can contribute to constipation. Depression and anxiety caused by cancer treatment or cancer pain can lead to constipation. Perhaps the most common causes of constipation are inadequate fluid intake and medications (e.g. opioid pain medications); however, these causes are manageable.

Constipation most commonly occurs when waste or stool moves too slowly through the digestive tract or cannot be eliminated effectively from the rectum, which may cause the stool to become hard and dry.

Chronic constipation has many possible causes.

Blockages in the colon or rectum

Blockages in the colon or rectum may slow or stop stool movement. Causes include:

• Anal fissure
• Bowel obstruction
• Colon cancer
• Narrowing of the colon (bowel stricture)
• Other abdominal cancer that presses on the colon
• Rectal cancer
• Rectum bulge through the back wall of the vagina (rectocele).

Problems with the nerves around the colon and rectum

Neurological problems can affect the nerves that cause muscles in the colon and rectum to contract and move stool through the intestines. Causes include:

• Autonomic neuropathy
• Multiple sclerosis
• Parkinson’s disease
• Spinal cord injury
• Stroke.

Difficulty with the muscles involved in elimination

Problems with the pelvic muscles involved in having a bowel movement may cause chronic constipation. These problems may include:

• Inability to relax the pelvic muscles to allow for a bowel movement (anismus)
• Pelvic muscles don’t coordinate relaxation and contraction correctly (dyssynergia)
• Weakened pelvic muscles

Conditions that affect hormones in the body

Hormones help balance fluids in your body. Diseases and conditions that upset the balance of hormones may lead to constipation, including:

• Diabetes
• Overactive parathyroid gland (hyperparathyroidism)
• Pregnancy
• Underactive thyroid (hypothyroidism).

How Chronic Constipation is Diagnosed

In addition to a general physical exam and a digital rectal exam, doctors use the following tests and procedures ²²⁾ to diagnose chronic constipation and try to find the cause:

• Blood tests. Your doctor will look for a systemic condition such as low thyroid (hypothyroidism).

• Examination of the rectum and lower, or sigmoid, colon (sigmoidoscopy). In this procedure, your doctor inserts a lighted, flexible tube into your anus to examine your rectum and the lower portion of your colon.

• Examination of the rectum and entire colon (colonoscopy). This diagnostic procedure allows your doctor to examine the entire colon with a flexible, camera-equipped tube.

• Evaluation of anal sphincter muscle function (anorectal manometry). In this procedure, your doctor inserts a narrow, flexible tube into your anus and rectum and then inflates a small balloon at the tip of the tube. The device is then pulled back through the sphincter muscle. This procedure allows your doctor to measure the coordination of the muscles you use to move your bowels ²³⁾.

• Evaluation of anal sphincter muscle speed (balloon expulsion test). Often used along with anorectal manometry, this test measures the amount of time it takes for you to push out a balloon that has been filled with water and placed in your rectum ²⁴⁾.

• Evaluation of how well food moves through the colon (colonic transit study). In this procedure, you may swallow a capsule that contains either a radiopaque marker or a wireless recording device. The progress of the capsule through your colon will be recorded over several days and be visible on X-rays.

In some cases, you may eat radiocarbon-activated food and a special camera will record its progress (scintigraphy). Your doctor will look for signs of intestinal muscle dysfunction and how well food moves through your colon.

• An X-ray of the rectum during defecation (defecography) ²⁵⁾. During this procedure, your doctor inserts a soft paste made of barium into your rectum. You then pass the barium paste as you would stool. The barium shows up on X-rays and may reveal a prolapse or problems with muscle function and muscle coordination.

• MRI defecography. During this procedure, as in barium defecography, a doctor will insert contrast gel into your rectum. You then pass the gel. The MRI scanner can visualize and assess the function of the defecation muscles. This test also can diagnose problems that can cause constipation, such as rectocele or rectal prolapse ²⁶⁾.

How to Prevent Constipation

Take these steps to help you avoid developing chronic constipation:

• Eat high-fiber foods, include plenty of high-fiber foods in your diet, including beans, vegetables, fruits, whole grain cereals and bran. Adding bran to foods such as cereals or smoothies is an easy way to get more fiber in your diet. If you have had an intestinal obstruction or intestinal surgery, you should not eat a high-fiber diet. Ask your health care team how many grams of fiber you should have each day.

• Eat fewer foods with low amounts of fiber such as processed foods, and dairy and meat products.

• Drink plenty of liquids. Most people need to drink at least 8 cups of liquid each day. You may need more based on your treatment, medications you are taking, or other health factors. Drinking warm or hot liquids may also help.

• Try to be active every day. Ask your health care team about exercises that you can do. Most people can do light exercise, even in a bed or chair. Other people choose to walk or ride an exercise bike for 15 to 30 minutes each day.

• Learn about medicine. Use only medicines and treatments for constipation that are prescribed by your doctor, since some may lead to bleeding, infection, or other harmful side effects in people being treated for cancer. Keep a record of your bowel movements to share with your doctor or nurse.
• Try to manage stress.
• Don’t ignore the urge to pass stool.
• Try to create a regular schedule for bowel movements, especially after a meal.
• Make sure children who begin to eat solid foods get plenty of fiber in their diets.

How to Relieve and Treat Chronic Constipation

Treatment for chronic constipation usually begins with diet and lifestyle changes meant to increase the speed at which stool moves through your intestines. If those changes don’t help, your doctor may recommend medications or surgery ²⁷⁾.

Diet and lifestyle changes

Your doctor may recommend the following changes to relieve your constipation:

• Increase your fiber intake. Adding fiber to your diet increases the weight of your stool and speeds its passage through your intestines. Slowly begin to eat more fresh fruits and vegetables each day. Choose whole-grain breads and cereals.

Your doctor may recommend a specific number of grams of fiber to consume each day. In general, aim for 14 grams of fiber for every 1,000 calories in your daily diet.

A sudden increase in the amount of fiber you eat can cause bloating and gas, so start slowly and work your way up to your goal over a few weeks.

• Exercise most days of the week. Physical activity increases muscle activity in your intestines. Try to fit in exercise most days of the week. If you do not already exercise, talk to your doctor about whether you are healthy enough to start an exercise program.

• Don’t ignore the urge to have a bowel movement. Take your time in the bathroom, allowing yourself enough time to have a bowel movement without distractions and without feeling rushed.

Laxatives

Several types of laxatives exist. Each works somewhat differently to make it easier to have a bowel movement. The following are available over the counter:

• Fiber supplements. Fiber supplements add bulk to your stool. These include psyllium (Metamucil, Konsyl), calcium polycarbophil (FiberCon) and methylcellulose fiber (Citrucel).

• Stimulants. Stimulants including Correctol, bisacodyl (Ducodyl), Dulcolax and senna-sennosides oral (Senokot) cause your intestines to contract.

• Osmotics. Osmotic laxatives help fluids move through the colon. Examples include oral magnesium hydroxide (Phillips Milk of Magnesia), magnesium citrate, lactulose (Kristalose), polyethylene glycol (Miralax). In addition, polyethylene glycol (PEG) (Golytely, Nulytely) is available by prescription.

• Lubricants. Lubricants such as mineral oil enable stool to move through your colon more easily.

• Stool softeners. Stool softeners such as docusate sodium (Colace) and docusate calcium (Surfak) moisten the stool by drawing water from the intestines.

• Enemas and suppositories. Sodium phosphate (Fleet), soapsuds or tap water enemas can be useful to soften stool and produce a bowel movement. Glycerin or bisacodyl suppositories also can soften stool.

How laxatives relieve constipation

Laxatives work in different ways, and the effectiveness of each laxative type varies from person to person ²⁸⁾. In general, bulk-forming laxatives, also referred to as fiber supplements, are the gentlest on your body and safest to use long term. Metamucil and Citrucel fall into this category.

Oral laxatives may interfere with your body’s absorption of some medications and nutrients. Some laxatives can lead to an electrolyte imbalance, especially after prolonged use. Electrolytes — which include calcium, chloride, potassium, magnesium and sodium — regulate a number of body functions. An electrolyte imbalance can cause abnormal heart rhythms, weakness, confusion and seizures.

Here are some examples of types of laxatives. Even though many laxatives are available over-the-counter, it’s best to talk to your doctor about laxative use and which kind may be best for you.

Table 1. Laxatives for Chronic Constipation

Type of laxative (brand examples)	How they work	Side effects
Oral osmotics (Phillips’ Milk of Magnesia, Miralax)	Draw water into the colon to allow easier passage of stool	Bloating, cramping, diarrhea, nausea, gas, increased thirst
Oral bulk formers (Benefiber, Citrucel, FiberCon, Metamucil)	Absorb water to form soft, bulky stool, prompting normal contraction of intestinal muscles	Bloating, gas, cramping or increased constipation if not taken with enough water
Oral stool softeners (Colace, Surfak)	Add moisture to stool to allow strain-free bowel movements	Electrolyte imbalance with prolonged use
Oral stimulants (Dulcolax, Senokot)	Trigger rhythmic contractions of intestinal muscles to eliminate stool	Belching, cramping, diarrhea, nausea, urine discoloration with senna and cascara derivatives
Rectal suppositories (Dulcolax, Pedia-Lax)	Trigger rhythmic contractions of intestinal muscles and soften stool	Rectal irritation, diarrhea, cramping

[Source ²⁹⁾ ]

• Precautions for pregnant women and children. Don’t give children under age 6 laxatives without a doctor’s recommendation. If you’re pregnant, ask your doctor before using laxatives. Bulk-forming laxatives and stool softeners are generally safe to use during pregnancy, but stimulant laxatives may be harmful.

• If you’ve recently given birth, consult your doctor before using laxatives. Although they’re usually safe to use during breast-feeding, some ingredients may pass into breast milk and cause diarrhea in nursing infants.

Other medications

If over-the-counter medications don’t help your chronic constipation, your doctor may recommend a prescription medication, especially if you have irritable bowel syndrome.

• Medications that draw water into your intestines. A number of prescription medications are available to treat chronic constipation. Lubiprostone (Amitiza) and linaclotide (Linzess), work by drawing water into your intestines and speeding up the movement of stool.

• Other types of medications. Misoprostol (Cytotec), colchicine/probenecid (Col-Probenecid) and onabotulinumtoxinA (also called botulinum toxin type A or Botox) all work in different ways and may be used to treat chronic constipation.

Training your pelvic muscles

Biofeedback training involves working with a therapist who uses devices to help you learn to relax and tighten the muscles in your pelvis. Relaxing your pelvic floor muscles at the right time during defecation can help you pass stool more easily.

During a biofeedback session, a special tube (catheter) to measure muscle tension is inserted into your rectum. The therapist guides you through exercises to alternately relax and tighten your pelvic muscles. A machine will gauge your muscle tension and use sounds or lights to help you understand when you’ve relaxed your muscles.

Surgery

Surgery may be an option if you have tried other treatments and your chronic constipation is caused by a blockage, rectocele, anal fissure or stricture.

For people who have tried other treatments without success and who have abnormally slow movement of stool through the colon, surgical removal of part of the colon may be an option. Surgery to remove the entire colon is rarely necessary.

Alternative medicine

Many people use alternative and complementary medicine to treat constipation, but these approaches have not been well-studied. Using a probiotic such as bifidobacterium or lactobacillus may be helpful, but more studies are needed. Fructooligosaccharide, a sugar that occurs naturally in many fruits and vegetables, may be helpful as well. Researchers currently are evaluating the usefulness of acupuncture.

Home Remedies for Constipation

Increase your dietary fiber intake

Today more than 80 percent of the U.S. population eats less than the recommended amount of vegetables, about 70 percent of the population eats more saturated fat, sodium and added sugar than is recommended. That is because the top three sources of calories in the U.S. are burgers, sandwiches and tacos; followed by desserts, sweet snacks and sugar-sweetened beverages, according to the most recent data from the National Health and Nutrition Examination Survey ³⁰⁾.

Adding fiber to your diet increases the weight of your stool and speeds its passage through your intestines. Slowly begin to eat more fresh fruits and vegetables each day. Choose whole-grain breads and cereals.

Adding fiber to the diet can have some side effects, such as abdominal bloating and/or gas, so start slowly and work your way up to your goal over a few weeks, until stools become softer and more frequent ³¹⁾.

However, many people, including those with irritable bowel syndrome, cannot tolerate fiber supplements and do better by not increasing fiber in their diet

Your doctor may recommend a specific number of grams of fiber to consume each day. In general, aim for 30-35 grams of fiber per day in your daily diet.

What is Dietary Fiber ?

Dietary fiber, also known as roughage or bulk, includes the parts of plant foods your body can’t digest or absorb. Generally speaking, dietary fiber is a type of carbohydrate that your body can’t digest and dietary fiber is the edible parts of plants that are resistant to digestion and absorption in the small intestine. Though most carbohydrates are broken down into sugar molecules, fiber cannot be broken down into sugar molecules, and instead it passes through the body undigested. Fiber helps regulate the body’s use of sugars, helping to keep hunger and blood sugar in check ³²⁾.

Dietary fiber can be separated into many different fractions. Recent research has begun to isolate these components and determine if increasing their levels in a diet is beneficial to human health. These fractions include arabinoxylan, inulin, pectin, bran, cellulose, β-glucan and resistant starch. The study of these components may give us a better understanding of how and why dietary fiber may decrease the risk for certain diseases ³³⁾.

Children and adults need at least 20 to 30 grams of fiber per day for good health, but most Americans get only about 15 grams a day. The amount of fiber in a food is listed on the food’s nutrition facts label. Some fiber-rich foods are listed in the table below. Great sources are whole fruits and vegetables, whole grains, and beans.

Table 2. Fiber-Rich Foods

[Source: U.S. Department of Agriculture and U.S. Department of Health and Human Services. 2015–2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at ³⁴⁾ ]

Exercise

Exercise most days of the week. Physical activity increases muscle activity in your intestines. Try to fit in exercise most days of the week. If you do not already exercise, talk to your doctor about whether you are healthy enough to start an exercise program.

Don’t ignore the urge to have a bowel movement

Take your time in the bathroom, allowing yourself enough time to have a bowel movement without distractions and without feeling rushed.

Stress Management

Stress is a normal psychological and physical reaction to the demands of life. A small amount of stress can be good, motivating you to perform well. But multiple challenges daily, such as sitting in traffic, meeting deadlines and paying bills, can push you beyond your ability to cope.

Stress has a way of becoming chronic as the worries of everyday living weigh us down. Or perhaps you’ve become accustomed to stress in your life, and you allow whatever is currently the most stressful problem to dictate what you will do each day. Everyone needs pleasure, productivity and creativity in their lives and chronic stress robs us of these.

[Source ³⁵⁾]

Where do you put yourself on this stress chart ?

To monitor your stress, first identify your triggers. What makes you feel angry, tense, worried or irritable ? Do you often get headaches or an upset stomach with no medical cause ?

Relaxation techniques are an essential part of stress management. Because of your busy life, relaxation might be low on your priority list. Don’t shortchange yourself. Everyone needs to relax and recharge to repair the toll stress takes on your mind and body.

Almost everyone can benefit from relaxation techniques, which can help slow your breathing and focus your attention. Common relaxation techniques include meditation, progressive muscle relaxation, tai chi and yoga. More-active ways of achieving relaxation include walking outdoors or participating in sports ³⁶⁾.

It doesn’t matter which relaxation technique you choose. Select a technique that works for you and practice it regularly.

Positive thinking helps with stress management also and can even improve your health ³⁷⁾. Practice overcoming negative self-talk with examples provided.

Some studies show that personality traits such as optimism and pessimism can affect many areas of your health and well-being. The positive thinking that usually comes with optimism is a key part of effective stress management. And effective stress management is associated with many health benefits. If you tend to be pessimistic, don’t despair — you can learn positive thinking skills.

Positive thinking doesn’t mean that you keep your head in the sand and ignore life’s less pleasant situations. Positive thinking just means that you approach unpleasantness in a more positive and productive way. You think the best is going to happen, not the worst.

Positive thinking often starts with self-talk. Self-talk is the endless stream of unspoken thoughts that run through your head. These automatic thoughts can be positive or negative. Some of your self-talk comes from logic and reason. Other self-talk may arise from misconceptions that you create because of lack of information.

If the thoughts that run through your head are mostly negative, your outlook on life is more likely pessimistic. If your thoughts are mostly positive, you’re likely an optimist — someone who practices positive thinking.

Researchers continue to explore the effects of positive thinking and optimism on health. Health benefits that positive thinking may provide include:

• Increased life span
• Lower rates of depression
• Lower levels of distress
• Greater resistance to the common cold
• Better psychological and physical well-being
• Better cardiovascular health and reduced risk of death from cardiovascular disease
• Better coping skills during hardships and times of stress.

It’s unclear why people who engage in positive thinking experience these health benefits. One theory is that having a positive outlook enables you to cope better with stressful situations, which reduces the harmful health effects of stress on your body.

It’s also thought that positive and optimistic people tend to live healthier lifestyles — they get more physical activity, follow a healthier diet, and don’t smoke or drink alcohol in excess.

Not sure if your self-talk is positive or negative ? Some common forms of negative self-talk include:

• Filtering. You magnify the negative aspects of a situation and filter out all of the positive ones. For example, you had a great day at work. You completed your tasks ahead of time and were complimented for doing a speedy and thorough job. That evening, you focus only on your plan to do even more tasks and forget about the compliments you received.

• Personalizing. When something bad occurs, you automatically blame yourself. For example, you hear that an evening out with friends is canceled, and you assume that the change in plans is because no one wanted to be around you.

• Catastrophizing. You automatically anticipate the worst. The drive-through coffee shop gets your order wrong and you automatically think that the rest of your day will be a disaster.

• Polarizing. You see things only as either good or bad. There is no middle ground. You feel that you have to be perfect or you’re a total failure.

You can learn to turn negative thinking into positive thinking. The process is simple, but it does take time and practice — you’re creating a new habit, after all. Here are some ways to think and behave in a more positive and optimistic way:

• Identify areas to change. If you want to become more optimistic and engage in more positive thinking, first identify areas of your life that you usually think negatively about, whether it’s work, your daily commute or a relationship. You can start small by focusing on one area to approach in a more positive way.

• Check yourself. Periodically during the day, stop and evaluate what you’re thinking. If you find that your thoughts are mainly negative, try to find a way to put a positive spin on them.

• Be open to humor. Give yourself permission to smile or laugh, especially during difficult times. Seek humor in everyday happenings. When you can laugh at life, you feel less stressed.

• Follow a healthy lifestyle. Aim to exercise for about 30 minutes on most days of the week. You can also break it up into 10-minute chunks of time during the day. Exercise can positively affect mood and reduce stress. Follow a healthy diet to fuel your mind and body. And learn techniques to manage stress.

• Surround yourself with positive people. Make sure those in your life are positive, supportive people you can depend on to give helpful advice and feedback. Negative people may increase your stress level and make you doubt your ability to manage stress in healthy ways.

• Practice positive self-talk. Start by following one simple rule: Don’t say anything to yourself that you wouldn’t say to anyone else. Be gentle and encouraging with yourself. If a negative thought enters your mind, evaluate it rationally and respond with affirmations of what is good about you. Think about things you’re thankful for in your life.

Here are some examples of negative self-talk and how you can apply a positive thinking twist to them:

If you tend to have a negative outlook, don’t expect to become an optimist overnight. But with practice, eventually your self-talk will contain less self-criticism and more self-acceptance. You may also become less critical of the world around you.

When your state of mind is generally optimistic, you’re better able to handle everyday stress in a more constructive way. That ability may contribute to the widely observed health benefits of positive thinking.

Table 3. Putting positive thinking into practice

Negative self-talk	Positive thinking
I’ve never done it before.	It’s an opportunity to learn something new.
It’s too complicated.	I’ll tackle it from a different angle.
I don’t have the resources.	Necessity is the mother of invention.
I’m too lazy to get this done.	I wasn’t able to fit it into my schedule, but I can re-examine some priorities.
There’s no way it will work.	I can try to make it work.
It’s too radical a change.	Let’s take a chance.
No one bothers to communicate with me.	I’ll see if I can open the channels of communication.
I’m not going to get any better at this.	I’ll give it another try.

[Source ³⁸⁾ ]