Constipation

By: Mike Harlos MD, CCFP(PC), FCFP
 

What is constipation?

Constipation is a condition where stool is slow to move through the large intestine and bowel movements occur less frequently than they normally do.

The slower the movement, the more fluid is absorbed out of the bowel and the drier and harder the stool becomes. Stool that is hard and dry can become difficult or even painful to pass out of the body.

Constipation can have a negative affect on overall quality of life. When you are constipated, you may feel bloating, abdominal discomfort and pain. You may not feel like eating. Or, feelings of uncomfortable fullness and nausea may make eating less enjoyable.

Although everyone’s bowel pattern may be different, you should generally have at least one bowel movement every three days. Left untreated, constipation can lead to more serious digestion problems such as fecal impaction and bowel obstruction. Fecal impaction is a large mass of stool, usually in the large intestine. This build up of stool can eventually prevent bowel movements from occurring or result in a partial or complete blockage of the intestine (otherwise known as a bowel obstruction).

Causes of constipation

Constipation can be caused by many factors, frequently working in combination.

General factors

• a decrease in eating, which results in a decreased amount of stool
• a decrease in drinking, which can cause the stool to become hard and difficult to pass
• a decrease in exercise or activity, which tends to result in the gut being less active
• eating foods that are greasy or low in fibre

Medications

• opioids - used to treat symptoms such as pain and shortness of breath
• diuretics -used to increase the production of urine
• anticonvulsants -used to prevent seizures and to treat many other symptoms including pain
• iron supplements - used to treat anemia
• anti-depressants and anti-anxiety medicines - used to improve mood and to treat many other symptoms including pain
• antacids - used to relieve irritation in the stomach
• laxatives and stool softeners - frequent or long-term use of these medicines can cause the gut to be less active on its own, which can lead to constipation

TIP: Sometimes people feel reluctant to take medication to treat their pain because they worry about having problems with constipation. Concern about constipation is not a reason to undertreat your pain! Constipation that occurs with pain treatment can be managed and prevented.

Social factors

• feeling depressed or anxious
• difficult access to a bathroom (bathroom may be occupied, hard to get to or not very private)
• needing assistance in the bathroom
• needing to use a bedpan or bedside toilet (commode)
• being in unfamiliar surroundings or an atmosphere that creates stress

Medical conditions 

• high levels of calcium in the blood
• low levels of potassium or sodium in the blood
• an irritable bowel
• muscle weakness
• nerve dysfunction, such as in people with diabetes
• conditions of low thyroid function
• tumours in or near the intestine

Sorting out symptoms

To determine possible causes of constipation, the health care team will often ask questions, conduct a physical examination, or order some tests. This will help them to make decisions about how best to manage the constipation.
 

Questions from the health care team

The medical team may ask some of the following questions in order to understand the extent of the patient's constipation and what may be causing it:
 

• How bad is the constipation?
  • Mild, moderate or severe?
  • Rate the constipation on a scale from 0 to 10, where zero means no constipation and 10 means the worst possible constipation.
• How often does a bowel movement normally occur?
  • When was the last bowel movement?
• What was the last bowel movement like?
  • Hard or soft?
  • How much?
  • What colour?
  • Any signs of blood? If so, was it bright or dark?
  • Was the bowel movement painful?
• Has there been an urge to have a bowel movement, but no stool?
• Has there been any nausea or vomiting? What about pains or cramps in the stomach?
• Has there been gas passed? How many times a day?
• Medications – past and present
  • How effective were they? How long did they work for?
  • How often are they taken?
• What has helped with constipation in the past?
• How is the constipation affecting quality of life?
  • What kinds of things does it stop you from doing?
  • Are there feelings of discouragement or depression?

TIP: Keep a written record to help you keep track of your symptoms.

Physical examination

General exam
The health care provider will likely do a general physical examination. This may include pressing on the abdomen, feeling for tenderness or hard spots. Listening to bowel sounds with a stethoscope in different areas of the abdomen is also a routine part of a physical examination.

Digital rectal exam
A digital rectal exam may also be done. The health care provider will insert a gloved finger into the rectum, feeling for stool or hard masses in the rectum. During this examination, you will feel pressure in the rectum, which can be similar to the pressure felt during a bowel movement.

Tests

Abdominal X-ray
An abdominal x-ray may be requested. This is done in an x-ray department and can be done on an out-patient basis. An x-ray can show where there is stool in the bowel.

Blood samples
Blood samples may also be requested to check for levels of calcium, potassium, and thyroid stimulating hormone. Changes to these levels in the blood can contribute to constipation.

What you can do

Prevention is key when you’re dealing with constipation. That’s because managing constipation becomes more difficult the more time that passes between bowel movements. Check with your health care team about making small lifestyle changes or a treatment plan.

Lifestyle Changes

Small lifestyle changes may encourage regular bowel movements.
 

• Visits to the bathroom at the same time each day may be a good idea for some people.
• Try to eat foods that are naturally high in fibre such as dried fruits and fresh vegetables. There are many recipes for natural fruit laxatives which you may find helpful. A sample recipe is found below:
   

• Drink as much fluid as you feel comfortable taking.
• Avoid constipating foods as much as possible, for examples fried foods and hard cheeses.
• Try to increase physical activity if you can.
• Consider taking pain medication before attempting a bowel movement to decrease discomfort if bowel movements are uncomfortable.
• If possible, try to have a bowel movement from a seated position, instead of while lying down.
• Try to have a bowel movement 30 to 60 minutes after meals to take advantage of the movement of the intestines that follows after eating.
• Ensure privacy in the bathroom or create a dignified environment if you need help from someone else.

In addition to the suggestions above, the following relaxation strategies may be helpful:
 

• Progressive muscle relaxation
  Relax and tighten muscles throughout the body, starting at the feet and working up to the head.
• Imagery
  Imagining a relaxing scene, such as a quiet beach with waves lapping the shore, can help both the mind and body relax. Imagery is like a deliberate daydream that can reduce stress and anxiety.
• Distraction
  Watching a TV program or listening to music are some ways to try to avoid thinking about the discomfort of constipation.
   

Treatment Plan

You may also want to ask the health care team to help develop an individualized treatment plan that covers things like how much to eat or drink, when to exercise and when to take medication.

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What your health care team can do

Oral laxatives

Sometimes it is necessary to use laxative medications to be sure that the bowels will empty regularly and effectively. People who are on certain medications, such as opioids to manage pain or shortness of breath, will definitely need laxatives to keep their bowels moving. That’s because opioids are almost certain to cause constipation.

Although all opioids are constipating, this should never be a reason to limit their appropriate use. Instead, the health care team needs to take care to prevent constipation before it occurs.
See also: Potential side effects and myths about opioids in Managing Pain

TIP: When pain medications such as opioids (morphine, hydromorphone, etc.) are prescribed, make sure they come with a prescription for laxatives.

Laxatives may also be prescribed if the patient is getting less fluid and physical activity because of the illness. The health care team will pay close attention to what type of bowel movements occur and how often, and will start laxatives if constipation is a concern.

There is little research to guide the choice of laxative given. The most common types of laxatives used in palliative care include these:

• Stool softeners
  These medications soften the stool that is in the intestine and make it easier to pass. The most commonly used stool softener is docusate, which includes medications such as Colace® and Surfak®. This drug works by helping to retain water in the bowels to mix with the stool, which helps keep the stools soft.
• Stimulants
  These medications help stimulate the passage of stool and encourage it to pass through the intestine. This group includes sennosides (Glysennid®, Senokot® and Senokot S®, which also contains docusate for softening stools), cascara, and bisacodyl (Dulcolax®).

TIP: Try using stool softeners (such as docusate sodium or Colace®) in combination with stool stimulants (such as senna or Senokot®). These medications work best when used together.

Osmotic laxatives

• Lactulose
  This medication is a type of sugar that is not absorbed into the body (so it is safe for people who have diabetes). It helps soften stools by drawing water into the bowels, and stimulates the emptying action of the bowels. Some people can feel bloated and gassy from lactulose, and its sweet taste can be nauseating. If lactulose is mixed with juice or ice, it may taste better.
• PEG (polyethylene glycol) laxatives
  There are several different brands in this group, some of them containing electrolytes (salts) and some not. Examples include Miralax®, PEG-3350, and Go-Lytley®. These medications act by drawing fluid into the intestines, thereby softening and loosening the stool. They may have fewer side effects, such as bloating and cramps, than lactulose.

Saline laxatives

This group of medicines includes magnesium-containing laxatives such as Milk of Magnesia®, Magnolax®, and Citro-Mag®.

Saline laxatives work by drawing fluid into the bowel and stimulating bowel activity. Oral Fleet Phospho-Soda® is a powerful saline laxative that, although effective, can have serious effects on fluid and chemical balance in frail people. For people with advanced serious illness, it should not be used without medical supervision.

The following laxatives should be avoided or used with caution in people who are frail or have serious illness:

• Bulk forming laxatives
  These often contain psyillium (Metamucil®) or wheat bran. In the absence of adequate fluid intake and physical activity, they may result in bloating and further slowing of the bowel activity.
• Mineral oil
  People who are weak and spend a lot of time lying down should not use mineral oil. Small amounts of the oil may pass down into the lungs, which may cause inflammation in the lungs.
• Castor oil
  This laxative can cause significant cramping, and long-term use can prevent certain nutrients from being absorbed by the body.

TIP: Avoid using bulk forming laxatives (such as Metamucil®). Bulk forming laxatives work best for people who drink large amounts of fluids and are physically active. When people are unable to tolerate large amounts of fluid or activity, bulk forming laxatives can make constipation worse.

Rectal medications

Generally, a goal for management of bowel activity is no more than three or four days between bowel movements. If medications taken orally (swallowed) are not helping to meet this goal, then rectal suppositories or enemas may be needed. Usually, oral laxatives should be increased when suppositories or enemas are needed.

Rectal suppositories

Rectal suppositories are small capsules of medicine that melt at body temperature when pushed into the rectum with a gloved finger. They are used to stimulate the passage of stool from the lower end of the intestine.

Often a combination of suppositories is used – one to act as a bowel stimulant and push the stool forward and the other to ease the passage of the stool.

Suppositories include:

• Dulcolax® as a bowel stimulant
• glycerin to ease the passage of the stool.

Enemas

Enemas are solutions inserted into the rectum to clean out the large intestine and to stimulate bowel movements. Solutions are placed into small plastic containers with a tube attached. The tube is gently inserted into the rectum and the solution is slowly sent through the tube into the bowel. After several minutes, the contents of the enema can be pushed out of the body while sitting on a toilet or bedpan.

Enemas are also used in cases of fecal impaction, when a large mass of stool in the intestine prevents bowel movements from occurring. It is important to check with a health care provider before using any type of enema.

The symptom or problem will determine the type of enema that is ordered. Types of enemas include:

• Fleet® enemas
• high saline enemas
• oil retention enemas
• soap suds enemas. Using an enema of mild soap and water is not commonly used because of the potential for irritating the lining of the bowel.

Content reviewed May 2019