Constipation, the most common digestive complaint in the U.S.

population,
can make life miserable. Not only does constipation make you feel bloated,
headachy, and irritable, but relieving constipation -- especially long-term
or chronic constipation -- is time consuming and expensive. Each year in the
U.S., chronic constipation leads to around 2.5 million doctor visits -and medication costs of many hundreds of millions of dollars.

Chronic Constipation: What Is It?

The definition of chronic constipation varies among different people. For
some people, chronic constipation means infrequent bowel movements for
weeks at a time. To others, chronic constipation means straining or having
difficulty passing stools. For instance, many describe chronic constipation as
feeling like you need to have a bowel movement, but no matter how long
you sit, it just won't happen. With chronic constipation, you may have hard or
formed stools, small stools, or a combination of infrequent hard, formed or
small stools.
Generally, the definition of chronic constipation is a stool frequency of less
than three per week that lasts several months. Still, experts believe that
many who think they suffer from chronic constipation may actually
underestimate the frequency of their bowel habits, so this definition may not
be accurate.

Chronic Constipation: What's Normal? What's Not?

If you or a loved one has chronic constipation, much of the anxiety and
distress may result from a lack of knowledge about this problem. Not only
are there magnified fears about what might be causing the problem, the
discomfort of chronic constipation itself can be debilitating. Constipation may
slow your performance at work and even cause you to miss recreational
activities. That's why it's important to know the facts about chronic
constipation and talk to your doctor about your personal situation.
If you don't have one bowel movement a day, it's abnormal. Less than 50%
of people have one bowel movement a day. Fewer than five or six bowel
movements a week is considered to be chronic constipation.
The Truth: 95% of adults have bowel movements between three and 21
times per week. The entire range -- even just three bowel movements a week
-- is normal.

Chronic Constipation: What Causes It?

After you eat, food moves through your digestive tract. The intestinestake
water and nutrients from the food. Normally, the process continues until a
stool is formed. Squeezing contractions in the intestine then pass the stool
out of the body. Because constipation is often linked with hard stools, one
theory is that too much water is absorbed from the stool, leaving it dry and
hard. Another theory is that abnormal hormonal responses to the ingested
water may trigger chronic constipation. More research is necessary to better
understand how constipation happens and to unravel the mysterious link
between the gut, hormones, and the brain.

Keys to Relieving Chronic Constipation

Relieving chronic constipation takes a multifaceted, lifestyle approach:
1. Get Regular
Go to the bathroom at the same time each morning. Make this your morning
"habit," as colonic motor activity is highest at this time.
2. Listen to Your Body
Don't ignore the urge to go. Peristalsis of the bowel -- the movements that
trigger a bowel movement -- come and go. If you ignore this urge, you may
lose the opportunity. The longer stool stays in the bowel, the harder it gets as
more water is reabsorbed, and the more difficult it is to expel. The urge to
defecate also increases after mealtime, so take advantage of your body's
signals.
3. Relax
because stress can interfere with relaxation of the whole body, including the
bowels, it's important to use some type of relaxation technique daily. Satish
Rao, MD, PhD, FRCP, professor of medicine and director of
neurogastroenterology and GI motility at the University of Iowa, finds that
many patients cannot push properly because they are too rushed and
stressed. "They have too little time to take care of their bodies," says Rao.
4. Increase Fluids
Drink plenty of liquids. It's recommended that you drink at least eight glasses
of liquid (preferably water) each day. Drink more on hot days and when you
are exercising.

5. Bulk up Your Diet

Dietary fiber and bulk fiber laxatives such as psyllium or methylcellulose -taken with plenty of fluids -- work well for relieving chronic constipation.
Harris H. McIlwain, a Tampa-basedrheumatologist and author of the new
book A Diet for a Pain-Free Life, believes that wheat bran is the most
effective fiber in relieving chronic constipation. "Wheat bran adds bulk to the
stool and increases the rate of movement of the stool through the bowel,"
says McIlwain.

When Chronic Constipation Is a Warning Sign

Changes in your bowel habits may be a warning sign of a viral or bacterial,
obstruction, inflammatory bowel disease (IBD), or colon. If you have one or
more of the following symptoms, call your health care provider:

Constipation that lasts for more than two weeks

Severe diarrhea lasting more than two days
Mild diarrhea lasting a week
Unexplained urges to have a bowel movement
Bloody diarrhea
Black or tarry-colored stools

Treatment
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.

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.

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.

Treating Constipation with laxatives

Before heading to the laxative aisle at your local pharmacy to selftreat constipation, its important to be informed. With the many varieties and types
of laxatives and therapies available, choosing the best one for your bodys needs,
while avoiding those that are too aggressive, requires knowledge and
understanding. Also, as with all treatments, proper use will help to avoid unwanted
side effects.
Normally, if youre eating a diet high in insoluble fiber, drinking at least 6-8 cups
(250mL or 8oz) of liquids a day, and exercising daily, this is enough to maintain a
healthy, constipation-free digestive system. Of course, many of us sometimes
deviate from this and find that constipation is a problem. Some people with
conditions such as diabetes or Parkinsons disease are more likely to experience
constipation. Additionally, some drugs cause constipation, for example, the codeine
contained in many combination-type pain medications (e.g., Tylenol #1, 2, or 3).
However, when chronic constipation occurs, its possible that diet and lifestyle
regimes may not be enough to remain symptom free without the assistance of overthe-counter or prescription laxatives.
Whether you need a short-term solution for constipation in an otherwise normal
digestive tract, or you need relief on a regular basis, as prescribed by a healthcare
professional for a specific situation, the following is a list of the different types of
laxatives and treatments available. Its best if your decision is guided by your
healthcare provider so you can make an informed choice that is most suitable for
you.

Bulk-Forming
Your body does not digest bulk-forming laxatives; instead, the fiber they contain
absorbs and retains a large quantity of fluid, thereby forming a soft, bulky stool
(formed feces). The bulky size stimulates the intestinal muscles to naturally contract

(peristalsis), causing digestive contents to move along and leading to an easier

bowel movement. It can take anywhere from about 12 hours to 3 days for bulkforming laxatives to show results, depending on individual digestive system transit
times, so this laxative type will not provide immediate relief of constipation. They
are best to use for ongoing digestive regularity and are helpful for conditions such
as diverticular disease, irritable bowel syndrome, and hemorrhoids. Although bulkforming laxatives are safe for long-term use and are usually well tolerated,
sometimes these products can cause bloating, intestinal gas, cramping, and/or
increased constipation, especially if you dont consume enough water. To help
prevent side effects, start consuming these products slowly, gradually increasing
each dose while making sure to drink plenty of extra water. Examples of bulkforming laxatives are psyllium (Metamucil), inulin (Metamucil Simply Clear),
wheat dextrin (Benefibre), methylcellulose (Citrucel), and polycarbophil
(FiberCon, Prodiem).

Stool Softeners
Stool softeners enable easier incorporation of water into the stool to keep it soft and
easier to pass. By making the stool softer, it reduces or eliminates the need to
strain, so stool softeners may be recommended after childbirth or surgery, or during
a bout of hemorrhoids. Some individuals may form a tolerance to softeners and may
require higher doses over time. Stool softeners do not directly affect the digestive
tract muscles and are safe to use in pregnant women and elderly people. Some
experts do not classify stool softeners as laxatives. An example of a stool softener is
docusate sodium (Colace). Long-term use, if bowel movements remain
comfortable, is acceptable.

Lubricants
Lubricant laxatives simply coat the colon and stool in a waterproof film allowing it to
remain soft and easier to slip through the intestine while retaining its moisture,
usually within 6-8 hours. Dont use these products for longer than a week, as some
have been shown to cause vitamin deficiencies and they might also interact with
some medications by affecting how the body absorbs them. Pregnant women and
persons who have difficulty swallowing should avoid lubricant laxatives. An example
of a lubricant laxative is mineral oil.

Stimulants
Stimulants increase muscle contractions of the digestive system (peristalsis) to
move contents along, facilitating a shorter colonic transit time. Although individuals
often use this type of laxative as a form of self-treatment, they should be reserved
for use in extreme conditions and only under the recommendation or supervision of
a pharmacist or physician. A risky side effect is that they may cause the colon to
stop functioning correctly (cathartic colon), which often occurs with daily use after
which the body becomes dependent on the stimulant laxative for normal peristaltic

activity. Stimulants taken orally often take 6-10 hours to have an effect. For patients
who have chronic constipation caused by irritable bowel syndrome, stimulants may
be the only solution but, even then, should only be used for a short term. This form
of laxative is not recommended for pregnant women. Examples of stimulants are
bisacodyl (Ex-lax, Dulcolax), castor oil, and Senna (Senokot).

Hyperosmotics
Osmotic laxatives encourage bowel movements by drawing water into the bowel
from the nearby tissue (intestinal lumen) thereby softening the stool. Some of these
laxatives can cause electrolyte imbalances as they draw out nutrients and other
contents with the water, which increases thirst and dehydration. There are four
main types of hyperosmotic: saline, lactulose, polymer, and glycerin.
Saline laxatives are essentially salts in liquid; they rapidly empty all the contents of
the bowel and are not intended for long-term use or for pregnant women. These
generally work within 30 minutes to 3 hours. Examples of saline laxatives are citrate
salts (Royvac), magnesium preparations (Phillips Milk of Magnesia), sulfate
salts, and sodium phosphate.
Lactulose laxatives are a sugar-like agent that work similarly to the saline laxatives
but at a much slower rate and are sometimes used to treat chronic constipation.
Often they will have an effect in 6 hours, but can take up to 2 days. Lactulose
comes in a liquid form taken orally and several manufacturers make it.
Polymer laxatives consist of large molecules that cause the stool to hold and retain
water. They are usually non-gritty, tasteless and are well-tolerated for occasional
constipation. Results can be expected within 6 hours, but it can take longer
depending on the dose. An example of a polymer laxative is polyethylene glycol
(Lax-A-Day, PegaLAX, RestoraLax).
Glycerin is available as a suppository and mainly has a hyperosmotic effect but it
may also have a stimulant effect from the sodium stearate used in the preparation.
Glycerin is available as a laxative through several manufacturers.

Enema
An enema may be preferred occasionally to relieve severe constipation or to empty
the bowel prior to surgery. This method involves insertion of liquid, usually water or
hyperosmolar salt solution, described above, which acts as a mechanical stimulant
and osmotic, into the rectum via the anus. You can purchase prepared enemas, an
enema bulb, or fountain syringe at your local pharmacy to use for this sole purpose.
Typically, after holding the liquid in place for a few minutes, there is an intense
urgency to move the bowels. An enema may cause uncomfortable bloating and
cramping; however, it usually leads to urgent elimination of the contents of the
rectum and colon, doing away with constipation.

Colonic Irrigation
It is important to note that although many holistic advertising campaigns
recommend colonic irrigation to re-program the bowels motility and assist in the
reduction of constipation, there is no medical evidence that colonic irrigation or
colon cleansing is effective in either of those claims, or the myriad of other cure-alls
promoted on late-night television shows. Physicians and other healthcare providers
associated with the GI Society do not recommend the use of colonic irrigation. In
fact, these procedures could negatively affect the natural pH balance of the colon,
because electrolyte imbalances, upset the natural bacterial and yeast milieu
necessary for good digestion, and could even cause permanent physical damage to
the bowel. This approach may worsen existing digestive conditions.

Pregnancy and Childbirth

A common complication of pregnancy is constipation. If making the appropriate
dietary and lifestyle adjustments to reduce constipation for a pregnant or nursing
woman do not work, then her primary physician may recommend either stool
softeners or bulk-forming laxatives, depending on the frequency and duration of
constipation. It is very important that she drink plenty of water while taking a
laxative, as some can be high in salt and might dehydrate the expectant or nursing
mother. Others require sufficient fluid intake to work properly, as with bulk-forming
laxatives. Always consult a pharmacist or physician before taking medications while
pregnant or nursing, as some formulas of over-the-counter or prescription laxatives
can negatively affect the infant. By preventing straining during a bowel movement,
dietary fiber and bulk-forming laxatives can also assist in the prevention of
hemorrhoids, a common pregnancy and delivery concern.

Proper Use of Laxatives

It is important for individuals to follow the instructions given by a healthcare
provider and those supplied by the product manufacturer when taking an over-thecounter laxative. Unless otherwise directed by a medical professional, remember
that over-the-counter and prescription laxatives are only intended for short-term use
and you should not exceed the dosage on the label.
With all types of laxatives, it is important to consume at least 6-8 cups (250mL or
8oz) of liquids (preferably water) every day plus an additional glass with every
laxative dose taken, unless otherwise advised by your healthcare provider. As
described above, laxatives often draw fluid into the digestive system to soften the
stool and/or pass it out with the bowel movement. Ensure plenty of fluid intake to
prevent dehydration.
Laxative abuse can lead to serious dysfunction of bowel motility such as intestinal
paralysis, cathartic colon, lazy or laxative gut, irritable bowel
syndrome, pancreatitis, and other problems. Using laxatives regularly, except for

bulk-forming agents and stool softeners, can lead to these problems. Therefore, it is
important to use laxatives in moderation and under the supervision of a physician
or other regulated healthcare provider. If you have chronic constipation, where it is
a daily issue or occurs more than once a week, then seek the care of a medical
professional before self-treating with over-the-counter laxatives.

Other medications
Prescription medications used to treat chronic constipation include:

Medications that draw water into your intestines. The

prescription medications lubiprostone (Amitiza) and linaclotide (Linzess)
work in different ways to draw water into your intestines and speed up the
movement of stool. Your doctor may recommend these medications if
over-the-counter laxatives haven't helped you.

Medications in clinical trials. Several new medications for treating

chronic constipation are being studied in clinical trials. Talk with your
doctor about whether any of these drugs may benefit you.

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 treatment and your chronic
constipation is caused by 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 colon is rarely necessary.