Constipation

Constipation is when you have infrequent bowel movements or your stool may be hard, dry and difficult to pass. Constipation could also mean that you have 3 or fewer bowel movements in a week. The American College of Gastroenterology defines constipation based upon symptoms including unsatisfactory defecation with either infrequent stools, difficulty in passing stool or both ¹. But if there is a new change in bowel habits, people should consult with their doctor ². You may also have stomach pain, stomach cramps, bloating, and nausea when you are constipated ³. A bowel movement occurs when the food you eat passes through your digestive system. Your body takes the nutrients it needs from that food. What’s left over is called stool or feces. Your stool can be soft or hard. Bowel movements usually happen on a regular basis.

Constipation is a condition in which you typically have ⁴:

• Fewer than 3 bowel movements a week,
• Bowel movements with stools that are hard, dry, and small, making them painful or difficult to pass.

Symptoms of constipation:

• Feeling like you still need to have a bowel movement, even after you’ve had one.
• Feeling like your intestines or rectum (bottom) are blocked.
• Having hard, dry stool that is difficult to pass.
• Having fewer than 3 bowel movements in a week.
• Straining to have a bowel movement.

More serious symptoms of constipation include:

• Constipation that is new and unusual for you.
• You have been constipated for 3 weeks or more despite dietary changes to help.
• You have abdominal (stomach) pain.
• You lose weight without trying.
• You notice blood or white mucous in your stool.
• You cannot pass the stool on your own.

Some people think they are constipated if they don’t have a bowel movement every day. However, people can have different bowel movement patterns (how often, how consistent, and what time of day it occurs). Some people may have three bowel movements a day. Other people may only have three bowel movements a week ⁵. However, if your bowel movements become less frequent (based on your bowel movement patterns), are hard (and difficult to pass), and you are physically uncomfortable, you may be constipated.

Constipation is the slow movement of feces through your large intestine (bowel or colon) that results in the passage of dry, hard stool. This can result in discomfort or pain ⁶. The longer the transit time of stool in your large intestine, the greater the fluid absorption and the drier and harder the stool becomes.

People of all ages experience constipation occasionally. It is estimated that in the United States, constipation is one of the most common gastrointestinal (GI) problems affecting about 42 million people ⁷. About 33 out of 100 adults ages 60 and older have symptoms of constipation ⁸.

Constipation is common among all ages and populations in the United States, yet certain people are more likely to become constipated, including ⁹:

• 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.
• People with certain health problems, including functional gastrointestinal disorders

You might become constipated because there is not enough fluid in your digestive system or not enough movement in your large intestine (bowel or colon) where stool is formed and pushed through to be passed from the body. Lack of physical activity, changes in food intake, or poor fluid intake add to the problem. And people who take certain kinds of pain medicine, especially opioids, are more at risk of constipation. Certain people with cancer might have an increased risk for constipation if they have a tumor in the belly or pelvis or get certain types of cancer treatment.

Usually, constipation goes away and is not serious. See your doctor if your constipation is chronic or frequent. Also see your doctor if your bowel habits change. It may be a problem with your diet or another health problem.

Most cases of constipation are easy to treat at home with diet and exercise. However, some cases require doctor recommendations, prescription medicine, or a medical procedure.

Home remedies for constipation includes:

• Eating high fiber diet. Eating a healthy diet with fiber and drinking plenty of fluids (water is the most helpful) can usually clear up constipation. High fiber foods include beans, dried fruits, fresh fruits and vegetables, whole-grain foods (choose brown rice or whole wheat bread instead of white), flaxseed meal, bran and powdered products containing psyllium. For example, 3 cups of popped popcorn has a little more than 3 grams of fiber. One cup of oatmeal has 4 grams of fiber. Adding fiber to each meal and snack will help you reach your goal for the day. Fiber supplements are helpful. Processed foods, such as desserts and sugary drinks, only make constipation worse.
  • Men over the age of 50 should get at least 38 grams of fiber per day.
  • Women over the age of 50 should get 25 grams per day.
  • Children ages 1 to 3 should get 19 grams of fiber per day.
  • Children between 4 and 8 years old should get 25 grams per day.
  • Girls between 9 and 18 should get 26 grams of fiber each day. Boys of the same age range should get between 31 and 38 grams of fiber per day.
• Drinking plenty of water. Being dehydrated causes your stool to dry out. This makes having a bowel movement more difficult and painful. 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.
• Don’t ignore the urge to pass stool. When you have the urge to have a bowel movement, don’t hold it in. This causes the stool to build up.
• Exercise. Exercise is helpful in keeping your bowel movements regular. 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.
• Beware of medicines. Certain prescription medicines (especially pain medicines) can slow your digestive system. This causes constipation. Talk to your doctor about how to prepare for this if you need these medicines.
• 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.
• Try to manage stress.
• Bowel training. Teach your children to go to the bathroom when they have to. Holding it can lead to constipation. This also may be necessary for your elderly parents, if you are caring for them.
• Laxatives. This is over-the-counter medicine that helps you have a bowel movement. Laxatives should only be used in rare instances. Do not use them on a regular basis. If you have to use a laxative, bulk-forming laxatives are best (two brands: Metamucil and Benefiber). These work naturally to add bulk and water to your stools so they can pass easily. Bulk-forming laxatives can cause some bloating (when your stomach feels full) and gas.

Doctor recommended treatments for constipation:

• Mineral oil. Do not use this without your doctor’s recommendation. Your doctor may recommend using it if you recently had surgery and should not strain for a bowel movement. Do not use it regularly. It causes your body to lose important vitamins: A, D, E and K.
• Enema. This is a liquid medicine. It is inserted into your anus to help with constipation. It is often used after a surgery or before some medical procedures.
• Prescription medicine. Your doctor will prescribe a medicine based on the reason for your constipation.
• Medical procedures. This is done to help remove stool from the intestine.
• Surgery. This is rare. It might involve removing a damaged intestine for serious reasons.

What is fecal impaction?

A fecal impaction also known as stool 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 ¹⁰. 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 ¹¹. If the fecal impaction is not recognized, the signs and symptoms may progress and resulting in death ¹².

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 ¹³, 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 ¹⁴. 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 ¹⁵.

Fecal impaction is a cause for increased morbidity and a significant cause of a decrease in quality of life among the elderly ¹⁶.

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 blockage 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 ¹⁷.

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 ¹⁸.

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 ¹⁸.

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 ¹⁹.

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 ²⁰.

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 1. Fiber-Rich Foods

Grains
Food and Portion Size	Amount of Fiber
1⁄3-3⁄4 cup high-fiber bran ready-to-eat cereal	9.1–14.3 grams
1-11⁄4 cup of shredded wheat ready-to-eat cereal	5.0–9.0 grams
11⁄2 cup whole wheat spaghetti, cooked	3.2 grams
1 small oat bran muffin	3.0 grams
Fruits
Food and Portion Size	Amount of Fiber
1 medium pear, with skin	5.5 grams
1 medium apple, with skin	4.4 grams
1⁄2 cup of raspberries	4.0 grams
1⁄2 cup of stewed prunes	3.8 grams
Vegetables
Food and Portion Size	Amount of Fiber
1⁄2 cup of green peas, cooked	3.5–4.4 grams
1⁄2 cup of mixed vegetables, cooked from frozen	4.0 grams
1⁄2 cup of collards, cooked	3.8 grams
1 medium sweet potato, baked in skin	3.8 grams
1 medium potato, baked, with skin	3.6 grams
1⁄2 cup of winter squash, cooked	2.9 grams

[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 ²¹ ]

Constipation during pregnancy

Pregnancy triggers many physical changes in your body, some quite aggravating, including constipation. Constipation in pregnancy and after delivery can happen to anyone ²². In fact, constipation is the 2nd most common gastrointestinal complaint in pregnancy. Over 40% of women experience constipation during pregnancy, commonly in the 1st and 2nd trimesters ²³. Women who have had constipation before pregnancy are, unfortunately, likely to experience worsening of symptoms during pregnancy ²². Constipation can start in the first trimester and worsen throughout pregnancy as progesterone levels rise. Other culprits include prenatal vitamins that contain iron, decreasing activity levels as pregnancy advances, low fiber intake, and inadequate water intake. While constipation will often resolve itself as pregnancy progresses and improves after delivery, it may continue to be an issue if you take certain medications for post-partum pain or prenatals while breastfeeding. Some women may have a pre-existing history of chronic constipation, in which they experience certain symptoms for more than 3 months at a time. For these women, constipation and its treatment needs to be navigated before, during, and after pregnancy.

If you have constipation and are planning a pregnancy, try to get into good habits before you become pregnant. Keeping to a healthy diet, drinking plenty of fluids, and doing regular exercise may help you maintain regular bowel motions. It is better to prevent constipation early on rather than wait to treat it later.

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.

While most cases of constipation are not a sign of illness, sometimes there are complications such as hemorrhoids (commonly called piles), fecal impaction or rectal prolapse. Sometimes the constant straining can lead to an anal fissure (a tear in the skin around the anus) or hemorrhoids where the veins in your rectum become swollen and itchy. Untreated constipation and constant straining also put stress on the pelvic floor which may lead to pelvic floor problems in later life ²⁴.

In rare cases, constipation can be caused by more serious conditions such as tumors.

Speak with your doctor if you are concerned, and especially if you notice blood in your stools.

What causes constipation during pregnancy?

Low levels of dietary fiber in your diet can contribute to constipation during pregnancy – as they can at any other time. There are, however, reasons why constipation is more common during pregnancy. An increase in the pregnancy hormone progesterone can cause your gut to work less efficiently and your food to move more slowly through your intestines. This is known as reduced gastric motility.

Another cause of constipation is the medicines and supplements that some women take during pregnancy. Medicines prescribed for nausea and vomiting, antacids for heartburn, and some strong pain medicines can induce constipation in some women. Supplements like iron and calcium, as well as some multivitamins can also trigger constipation.

If you take any of these during your pregnancy and are troubled by constipation, speak with your doctor about whether a change in the formulation of your medicine or supplement can help. Sometimes a simple change of brands or dose can reduce constipation. However, everyone is different and a formulation that causes constipation for one person might work well for another.

Constipation in pregnancy treatment

It is always best to try the natural methods of relieving constipation before deciding to take any medication. The first step in treating constipation is to increase the fluids and fiber in your diet. Eating wholegrain foods, fruit and vegetables can often resolve constipation. If your symptoms continue, then fiber supplements or laxatives may offer a short-term solution. However, it is always better to stimulate your bowel with a healthy diet rather than take medications. Taking laxatives can sometimes result in side effects such as abdominal pain and diarrhea.

Here are a few things that you can do to help prevent constipation from occurring or treat it if you are already experiencing it:

• Eat a high fiber diet. Ideally, you will consume 25 to 30 grams per day of dietary fiber from fruits, vegetables, breakfast cereals, whole-grain bread, prunes, and bran. This helps ensure bulkier stools that are easier to poop.
• Drink plenty of water. Drinking plenty of water is important, particularly when increasing fiber intake helps ensure softer stools. Drink 10 to 12 cups of fluids each day. It is the combination of a high fiber diet and plenty of liquids that best help you eliminate your waste. Sweat, hot/humid climates, and exercise may increase your need for additional fluids.
• Exercise regularly. If you are inactive, you have a greater chance of constipation. Walking, swimming and other moderate exercises will help the intestines work by stimulating your bowels. Exercising for 30 minutes on most, or all, days can benefit your health during pregnancy. Exercising for just 20 minutes, 3 or 4 days a week, is still beneficial, as well. The important thing is to be active and get your blood flowing.
• Over-the-counter remedies. There are over-the-counter products such as Metamucil which may help soften your bowel movements and reduce constipation. Always speak to your health care provider before using over-the-counter medications.
• Reduce or eliminate iron supplements. Iron supplements may contribute to constipation. Good nutrition can often meet your iron needs during pregnancy. Taking smaller doses of iron throughout the day rather than taking it all at once can reduce constipation. Talk to your health care provider about checking your iron levels and recommendations to manage iron intake during pregnancy.

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

It is always best to try the natural methods of relieving constipation before deciding to take any medication. Stool softeners (docusate sodium (Colace®) and glycerin) are generally considered safe during pregnancy ²⁵, ²⁶.

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 ²⁶. Check with your health care provider, however, before taking any medication — including stool softeners and other types of laxatives — to treat pregnancy constipation.

Does taking laxatives increase the chance for miscarriage?

It is always best to try the natural methods of relieving constipation before deciding to take any medication. Laxatives are medications used to treat constipation. Laxatives work in different ways, and the effectiveness of each laxative type varies from person to person ²⁷. 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.

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). Since these ingredients generally do not get into the bloodstream, pregnancy exposure is unlikely. Taken with plenty of water or fruit juice, they are usually effective in 24 hours, but may take 2-3 days of regular treatment.
• Stimulants. Stimulants including Correctol, bisacodyl (Ducodyl), Dulcolax and senna-sennosides oral (Senokot) cause your intestines to contract. Stimulants are best taken at bedtime. Stimulant laxatives (senna, bisacodyl, cascara) act locally to stimulate the gut, and should be effective in 6-12 hours. These should not be used on a regular basis but are fine for one-off or occasional use.
• Osmotics. Osmotics are laxatives that work by pulling water into the intestines. Examples include oral magnesium hydroxide (Phillips Milk of Magnesia), magnesium citrate, lactulose (Kristalose), sodium bisphosphate (OsmoPrep®), and sugars, such as lactulose and polyethylene glycol (Miralax®). In addition, polyethylene glycol (PEG) (Golytely, Nulytely) is available by prescription. Osmotic medications are not well absorbed by the intestine, so very little is expected to get into the bloodstream of the person taking the osmotic laxative. This means exposure to the pregnancy is expected to be small. When taken on an empty stomach, they are effective in 2–48 hours.
• Lubricants. Lubricants such as mineral oil enable stool to move through your colon more easily. These products enter the bloodstream in small amounts, so there may be small exposure to the pregnancy.
• Stool softeners. Stool softeners such as docusate sodium (Colace) and docusate calcium (Surfak) moisten the stool by drawing water from the intestines. Stool softener laxatives (docusate) are often ineffective unless combined with an osmotic or stimulant laxative.
• 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.

Stimulants and lubricants may cause stomach cramps, which can be severe.

Miscarriage is common and can occur in any pregnancy for many different reasons. As there can be many causes of miscarriage, it is hard to know if a medication, the medical condition, or other factors are the cause of a miscarriage. Studies have not been done to see if laxatives increase the chance for miscarriage.

Does taking laxatives in the first trimester increase the chance of birth defects?

Every pregnancy starts out with a 3-5% chance of having a birth defect. This is called the background. Only a few studies have looked at laxative use during pregnancy. However, the available studies show that when used in recommended doses, over-the-counter laxatives are not expected to increase the chance of birth defects. Talk with your healthcare provider to discuss information on your specific laxative medication.

Could taking laxatives cause other pregnancy complications?

When laxatives are used more than recommended, they can increase the chance of complications. Laxatives can make food go through the intestines faster than usual, which can reduce the amount of nutrients that are absorbed into the body. For this reason, using laxatives too much or too often can increase the chance of nutritional problems. Using laxatives can also affect the way your body absorbs other medications you might be taking.

Using more than the recommended amounts of laxatives can also lower the levels of needed salts in the blood, such as magnesium. A reported case of low magnesium levels in a newborn was linked to the mother using too much docusate sodium (Colace) during pregnancy. The baby’s main symptom was jitteriness, which went away by the second day of life.

Castor oil has been used at the end of pregnancy to try to bring on labor. Castor oil can cause severe diarrhea and cramping of the bowel and uterus, but these contractions are unlikely to bring on labor if the lower part of the uterus (cervix) is not ready for labor. If you are at the end of your pregnancy, your health care provider can discuss other ways to begin labor.

Does using laxatives in pregnancy cause long-term problems in behavior or learning for the baby?

Using laxatives as directed in pregnancy is not expected to have long-term effects on a baby’s learning or behavior.

Can I use laxatives while breastfeeding?

The medications in some laxatives might get into the mother’s bloodstream, but the amount that passes into breast milk is usually low. Mineral oil can get into the bloodstream and breast milk in greater amounts, so it should be used carefully.

There are occasional reports of loose stools in infants exposed to laxatives from breastfeeding. Contact a MotherToBaby specialist to discuss information on your specific laxative medication. Talk to your healthcare provider about all of your breastfeeding questions.

Will constipation in pregnancy affect my baby?

A pregnant woman may feel uncomfortable from constipation, but it is not harmful to her baby. If you’re pregnant, you don’t need to worry that constipation will affect your baby since the discomfort occurs in the mother’s gut and bowels and isn’t passed on to your baby. Most laxatives are not well absorbed into the bloodstream and can be taken during pregnancy and breastfeeding, but always check with your pharmacist before taking a medicine while pregnant.

Is constipation during pregnancy ever serious?

Usually not, but occasionally constipation during pregnancy can be a symptom of another problem. If you have severe constipation that’s accompanied by abdominal pain, alternates with diarrhea, or you pass mucus or blood, see your doctor or midwife immediately.

Also, straining during a bowel movement or passing a hard stool can lead to or worsen hemorrhoids, which are swollen veins in the rectal area. Hemorrhoids can be extremely uncomfortable, though they rarely cause serious problems. In most cases, they go away fairly soon after your baby is born. However, if the pain is severe, or if you have rectal bleeding, see your doctor.

Will constipation in pregnancy continue after I’ve had my baby?

There are several reasons why constipation may continue after birth. Women who have had a cesarean section often experience constipation for a few days their gut motility resumes. Women who have stitches following vaginal births may be fearful of opening their bowels, and hold off going to the toilet, which can cause a build-up of stools in their bowels.

Strong painkillers given after having your baby can also cause constipation.

New mothers are often busier than usual in the first few weeks and months of motherhood. It may seem like taking care of yourself has become less of a priority, but your health is no less important now than it was during your pregnancy. Be sure to have plenty of fiber-rich fruit, vegetables, and wholegrains as well as increase your fluid intake while breastfeeding to encourage healthy bowel movements, even when you are busy. A glass of water at every breastfeed is a good idea.

Babies and infant constipation

Infant constipation isn’t common ²⁸. 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 ²⁸.

Infant constipation often begins when a baby starts eating solid foods ²⁸. 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 ²⁸.

• 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 ²⁸.

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 ²⁹. A constipated child has infrequent bowel movements or hard, dry stools ³⁰.

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.

Constipation causes

You may be constipated for many reasons and constipation may have more than one cause at a time (multifactorial) ³¹, ³², ³³. Constipation can be caused by your diet (too many processed foods and not enough fiber), certain medicines (opioid medicines given for pain and even too many laxatives, which usually help you have a bowel movement), dehydration (especially not enough water), too little physical activity, intestinal problems, immobility, or physical and social impediments (particularly inconvenient bathroom availability) and major life changes, such as pregnancy. Depression and anxiety caused by cancer treatment or cancer pain can lead to constipation. Constipation becomes more common as you age. Certain diseases and disabilities also can cause constipation. These include multiple sclerosis, stroke, diabetes, hypothyroidism (underactive thyroid) and lupus.

Dehydration (not enough fluids) and dietary changes are the most common causes of constipation in babies. For example, changing from breast milk to cow’s milk or from baby food to solids can cause constipation.

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:

• Tiny tears in the skin around the anus (anal fissure)
• A blockage in the intestines (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:

• Damage to the nerves that control bodily functions (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).

Certain medicines and dietary supplements

Medicines and dietary supplements that can make constipation worse include:

• Antacids that contain aluminum and calcium
• Anticholinergics and antispasmodics
• Anticonvulsants—used to prevent seizures
• Calcium channel blockers
• Diuretics (fluid tablets)
• Iron supplements
• Medicines used to treat Parkinson’s disease
• Narcotic pain medicines
• Medicines used to treat depression

Life changes or daily routine changes

Constipation can happen when your life or daily routine changes. For example, your bowel movements can change:

• if you become pregnant
• as you get older
• when you travel
• when you ignore the urge to have a bowel movement
• if you change your medicines
• if you change how much and what you eat

Certain health and nutrition problems

Certain health and nutrition problems can cause constipation:

• not eating enough fiber
• not drinking enough liquids, or dehydration
• not getting enough physical activity
• celiac disease
• disorders that affect your brain and spine, such as Parkinson’s disease
• spinal cord or brain injuries
• conditions that affect your metabolism, such as diabetes
• conditions that affect your hormones, such as hypothyroidism
• inflammation linked to diverticular disease or proctitis
• intestinal obstructions, including anorectal blockage and tumors
• anatomic problems of your digestive tract

Risk factors for constipation

Factors that may increase your risk of chronic constipation include ³⁴, ³², ³⁵, ³⁶:

• Being an older adult
• Being a woman
• Being dehydrated
• Eating a diet that’s low in fiber
• Getting little or no physical activity
• Taking certain medications, including sedatives, opioid pain medications, some antidepressants or medications to lower blood pressure
• Having a mental health condition such as depression or an eating disorder
• Stressful life events
• Physical and sexual abuse

Constipation prevention

There are things you can do to reduce constipation. Take these steps to help you avoid developing chronic constipation:

• Add more fiber to your diet. Adults should eat between 20-35 grams of fiber each day. Foods, such as beans, whole grains, bran, fruits, and vegetables are high in fiber. 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 more water. Being dehydrated causes your stool to dry out. This makes having a bowel movement more difficult and painful. 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.
• Don’t ignore the urge to pass stool. When you have the urge to have a bowel movement, don’t hold it in. This causes the stool to build up.
• Exercise. Exercise is helpful in keeping your bowel movements regular. 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.
• Beware of medicines. Certain prescription medicines (especially pain medicines) can slow your digestive system. This causes constipation. Talk to your doctor about how to prepare for this if you need these medicines.
• 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.
• Try to manage stress.
• See your doctor if you are being treated for certain diseases that are related to constipation. He or she may have additional guidance for lowering your risks.

Constipation signs and symptoms

Signs and symptoms of constipation include:

• Passing fewer than three stools a week or not having regular bowel movements within the past 3 days
• Having lumpy or small hard stools (sometimes described as “pellets”)
• 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
• Stomachache or cramps
• Passing a lot of gas or frequent belching
• Belly looks blown up or puffy
• Leakage of soft, liquid stool that looks like diarrhea
• Vomiting or nausea
• 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.

Constipation complications

Complications of chronic constipation include:

• Anal fissure (a tear in the skin around your anus). A large or hard stool can cause tiny tears in the anus.
• Stool impaction or fecal impaction (when your stool becomes too large to pass on your own). Chronic constipation may cause an accumulation of hardened stool that gets stuck in your intestines.
• Hemorrhoids (swollen veins in your anus). Straining to have a bowel movement may cause swelling in the veins in and around your anus.
• Rectal prolapse (when a small piece of your rectum comes out of your anus from straining to have a bowel movement). Straining to have a bowel movement can cause a small amount of the rectum to stretch and protrude from the anus.
• Encopresis (when your bowels are so backed up that only liquid can pass through). Many people mistake this for diarrhea take anti-diarrheal medicine, making constipation even worse.

Complications of constipation can become serious if left untreated. They may require surgery.

Constipation diagnosis

Doctors use your medical and family history, a physical exam, or medical tests to diagnose and find the cause of your constipation. Your doctor will ask you about your symptoms and medical history. This will include asking you about any medicines you take. Your doctor also will ask when you had your last bowel movement and how often you have them. Think about that before you see your doctor. It might be helpful to write it down for yourself or a child before your appointment. During the visit, your doctor may examine your rectum (the end of your large intestine near your anus), this is called digital rectal exam. During the digital rectal exam, your doctor will insert his or her finger (while wearing rubber gloves) into your rectum to feel for blockages.

Depending on your symptoms and health, your doctor may first try a treatment to improve your symptoms before ordering additional tests and procedures.

Your doctor may order additional tests and procedures, including a blood test and X-ray, to diagnose constipation and try to find the cause. A more thorough test is a colonoscopy. This is an invasive procedure done with anesthesia. During this test, your doctor will examine your colon with a long, flexible scope attached to a camera.

• 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 ³⁷.
• 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 ³⁷.
• 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) ³⁷. 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 ³⁷.

Medical and family history

Your doctor will ask you questions about your medical history, such as:

• whether you have ever had surgery to your digestive tract
• if you have recently lost or gained weight
• if you have a history of anemia

Your doctor also is likely to ask questions about your symptoms, such as:

• How often do you have a bowel movement?
• How long have you had symptoms?
• What do your stools look like?
• Do your stools have red streaks in them?
• Are there streaks of blood on your toilet paper when you wipe?

Your doctor is likely to ask questions about your routines, such as:

• What are your eating habits?
• What is your level of physical activity?
• What medicines, including supplements, and complementary and alternative medicines, do you take?

You may want to track your bowel movements and what your stools look like for several days or weeks before your doctor’s visit. Write down or record the information so you can share it with your doctor.

If you’ve been constipated a long time, your health care professional may ask whether anyone in your family has a history of conditions that may cause long-lasting constipation, such as:

• anatomic problems of the digestive tract
• intestinal obstruction
• diverticular disease
• colon or rectal cancer

Physical exam

During a physical exam, a health care professional may:

• check your blood pressure, temperature, and heart rate
• check for dehydration
• use a stethoscope to listen to sounds in your abdomen
• check your abdomen for:
  • swelling
  • tenderness or pain
  • masses, or lumps
• perform a rectal exam

Lab tests

Your doctor may use one or more of the following lab tests to look for signs of certain diseases and conditions that may be causing your constipation:

• Blood tests can show signs of anemia, hypothyroidism, and celiac disease.
• Stool tests can show the presence of blood and signs of infection and inflammation.
• Urine tests can show signs of diseases such as diabetes.

Endoscopy

Your doctor may perform an endoscopy to look inside your anus, rectum, and colon for signs of problems in your lower digestive tract. Endoscopies for constipation include:

• colonoscopy
• flexible sigmoidoscopy

During these two tests, your doctor may also perform a biopsy. A biopsy is a procedure that involves taking small pieces of tissue and examining them under a microscope. A doctor can use a biopsy to look for signs of cancer or other problems.

Colorectal transit studies

Your doctor may use bowel function tests called colorectal transit studies to see how well your stool moves through your colon.

• Radiopaque markers—an x-ray that tracks radioactive markers while they pass through your digestive system. You swallow capsules with the markers, which take about 3 to 7 days to come out with a bowel movement.
• Scintigraphy—a test that involves eating a meal with a small dose of a radioactive substance. Your doctor tracks the substance using special computers and cameras as the substance passes through your intestines.

Other bowel function tests

Your doctor may also use one or more of the following tests to look for signs of certain diseases and conditions that may be causing your constipation:

• Defecography—an x-ray of the area around the anus and rectum to see how well you can hold and release stool
• Anorectal manometry—a test to check how sensitive your rectum is, how well it works, and how well the anal sphincters work
• Balloon expulsion test—a test that involves pushing a small water balloon from your rectum to see if you have a problem pushing out stool

Imaging tests

To look for other problems that may be causing your constipation, your doctor may perform an imaging test such as:

• Lower gastrointestinal (GI) series
• Magnetic resonance imaging (MRI)
• Computed tomography (CT) scan

Constipation treatment

Treatment for constipation depends in part on the underlying cause. Most cases of constipation are easy to treat at home with high fiber diet, plenty of water and exercise. If these changes don’t help, your doctor may recommend prescription medicine, or a medical procedure and rarely surgery.

Home remedies for constipation

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, adults should get 22 to 34 grams of fiber a day ³⁸. 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.
  • Talk with a dietitian, to plan meals with the right amount of fiber for you. Be sure to add fiber to your diet a little at a time so your body gets used to the change. Good sources of fiber are:
    • whole grains, such as whole wheat bread and pasta, oatmeal, and bran flake cereals
    • legumes, such as lentils, black beans, kidney beans, soybeans, and chickpeas
    • fruits, such as berries, apples with the skin on, oranges, and pears
    • vegetables, such as carrots, broccoli, green peas, and collard greens
    • nuts, such as almonds, peanuts, and pecans
  • To help prevent or relieve constipation, AVOID foods with little to no fiber, such as:
    • chips
    • fast food
    • meat
    • prepared foods, such as some frozen meals and snack foods
    • processed foods, such as hot dogs or some microwavable dinners
• Drink plenty of water and other liquids if you eat more fiber or take a fiber supplement. Water is a good choice. Fruit juice — especially prune juice — also can help.
  • Drinking enough water and other liquids is also a good way to avoid dehydration. Staying hydrated is good for your overall health and can help you avoid getting constipated. Ask a health care professional how much liquid you should drink each day based on your size, health, activity level, and where you live.
• 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.

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 ³⁹.

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 ⁴⁰.

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 22 to 34 grams of fiber per day in your daily diet ³⁸.

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 ⁴¹]

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 ⁴².

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 ⁴³. 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 2. 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 ⁴³ ]

Types of 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). Taken with plenty of water or fruit juice, they are usually effective in 24 hours, but may take 2-3 days of regular treatment.
• Stimulants. Stimulants including Correctol, bisacodyl (Ducodyl), Dulcolax and senna-sennosides oral (Senokot) cause your intestines to contract. Stimulants are best taken at bedtime. Stimulant laxatives (senna, bisacodyl, cascara) act locally to stimulate the gut, and should be effective in 6-12 hours. These should not be used on a regular basis but are fine for one-off or occasional use.
• Osmotics. Osmotics are laxatives that work by pulling water into the intestines. 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. When taken on an empty stomach, they are effective in 2–48 hours.
• 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. Stool softener laxatives (docusate) are often ineffective unless combined with an osmotic or stimulant laxative.
• 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.
• Products such as liquid paraffin, magnesium salts, suppositories and enemas may be used occasionally to treat fecal impaction, but are not for regular use.

How laxatives relieve constipation

Laxatives work in different ways, and the effectiveness of each laxative type varies from person to person ²⁷. 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 3. 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 ²⁷ ]

Footnotes:

• 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.

Prescription medicines

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

• Medications that draw water into your intestines. A number of prescription medications are available to treat chronic constipation. Lubiprostone (Amitiza), linaclotide (Linzess) and plecanatide (Trulance) work by drawing water into your intestines and speeding up the movement of stool.
• Serotonin 5-hydroxytryptamine 4 receptors. Prucalopride (Motegrity) helps move stool through the colon.
• Peripherally acting mu-opioid receptor antagonists (PAMORAs). If constipation is caused by opioid pain medications, PAMORAs such as naloxegol (Movantik) and methylnaltrexone (Relistor) reverse the effect of opioids on the intestine to keep the bowel moving.
• 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 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.

Constipation prognosis

Most children with constipation are managed with medical therapy, and most of them will improve. However, at least 30% will persist to be symptomatic until adulthood. Factors that are associated with a worse prognosis are female gender, older age of onset, longer time between symptom presentation and starting therapy, and longer colonic transit time ⁴⁴.

In adults constipation has a poor prognosis; it seriously affects the quality of life ⁴⁴. In many cases, treatments do not work and even when they work, the benefits are short-lived.

References

1. Bharucha AE, Dorn SD, Lembo A, Pressman A. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013. January;144(1): 211–7. 10.1053/j.gastro.2012.10.029
2. Constipation and Defecation Problems. https://gi.org/topics/constipation-and-defection-problems/
3. National Cancer Institute at the National Institutes of Health. Constipation. https://www.cancer.gov/about-cancer/treatment/side-effects/constipation
4. Pare P, Ferrazzi S, Thompson WG, Irvine EJ, Rance L. An epidemiological survey of constipation in canada: definitions, rates, demographics, and predictors of health care seeking. Am J Gastroenterol. 2001 Nov;96(11):3130-7. doi: 10.1111/j.1572-0241.2001.05259.x
5. The National Institute of Diabetes and Digestive and Kidney Diseases Health Information Center. Definition & Facts for Constipation. https://www.niddk.nih.gov/health-information/digestive-diseases/constipation/definition-facts
6. Culhane B: Constipation. In: Yasko J, ed.: Guidelines for Cancer Care: Symptom Management. Reston, Va: Reston Publishing Company, Inc., 1983, pp 184-7.
7. Higgins PD, Johanson JF. Epidemiology of constipation in North America: a systematic review. American Journal of Gastroenterology. 2004;99:750–759
8. American Gastroenterological Association; Bharucha AE, Dorn SD, Lembo A, Pressman A. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013 Jan;144(1):211-7. doi: 10.1053/j.gastro.2012.10.029
9. Rose S, ed. Constipation: A Practical Approach to Diagnosis and Treatment. New York, NY: Springer Science and Business Media; 2014.
10. Report of an unusual case with severe fecal impaction responding to medication therapy. Zhao W, Ke M. J Neurogastroenterol Motil. 2010 Apr; 16(2):199-202.
11. Serrano Falcón B, Barceló López M, Mateos Muñoz B, Álvarez Sánchez A, Rey E. Fecal impaction: a systematic review of its medical complications. BMC Geriatr. 2016;16:4. Published 2016 Jan 11. doi:10.1186/s12877-015-0162-5 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4709889/
12. Wright BA, Staats DO: The geriatric implications of fecal impaction. Nurse Pract 11 (10): 53-8, 60, 64-6, 1986. https://www.ncbi.nlm.nih.gov/pubmed/3785769?dopt=Abstract
13. Management and prevention of fecal impaction. Wald A. Curr Gastroenterol Rep. 2008 Oct; 10(5):499-501.
14. Mathew G, Cagir B. Fecal Impaction. [Updated 2018 Nov 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448094
15. Serrano Falcón B, Álvarez Sánchez Á, Diaz-Rubio M, Rey E. Prevalence and factors associated with faecal impaction in the Spanish old population. Age Ageing. 2017 Jan 12;46(1):119-124.
16. García Cabrera AM, Jiménez Rodríguez RM, Reyes Díaz ML, Vázquez Monchul JM, Ramos Fernández M, Díaz Pavón JM, Palacios González C, Padillo Ruiz FJ, de la Portilla de Juan F. Fecal incontinence in older patients. A narrative review. Cir Esp. 2018 Mar;96(3):131-137.
17. Hampton BG, Bryant RA, eds.: Ostomies and Continent Diversions: Nursing Management. St. Louis, Mo: Mosby Year Book, Inc., 1992.
18. Mayo Foundation for Medical Education and Research. Constipation. http://www.mayoclinic.org/diseases-conditions/constipation/home/ovc-20252671
19. Harvard University, Harvard School of Public Health. Fiber. https://www.hsph.harvard.edu/nutritionsource/carbohydrates/fiber/
20. Lattimer JM, Haub MD. Effects of Dietary Fiber and Its Components on Metabolic Health. Nutrients. 2010;2(12):1266-1289. doi:10.3390/nu2121266. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3257631/
21. U.S. Department of Agriculture and U.S. Department of Health and Human Services. 2015–2020 Dietary Guidelines for Americans. https://health.gov/dietaryguidelines/
22. Cullen G, O’Donoghue D. Constipation and pregnancy. Best Pract Res Clin Gastroenterol. 2007;21(5):807-18. doi: 10.1016/j.bpg.2007.05.005
23. GARTLAND, D., BROWN, S., DONATH, S. and PERLEN, S. (2010), Women’s health in early pregnancy: Findings from an Australian nulliparous cohort study. Australian and New Zealand Journal of Obstetrics and Gynaecology, 50: 413-418. https://doi.org/10.1111/j.1479-828X.2010.01204.x
24. Amselem, C., Puigdollers, A., Azpiroz, F., Sala, C., Videla, S., Fernández-fraga, X., Whorwell, P. and Malagelada, J.-.-r. (2010), Constipation: a potential cause of pelvic floor damage?. Neurogastroenterology & Motility, 22: 150-e48. https://doi.org/10.1111/j.1365-2982.2009.01409.x
25. Mayo Foundation for Medical Education and Research. Pregnancy week by week. http://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/expert-answers/pregnancy-constipation/faq-20058550
26. Docusate Sodium. https://mothertobaby.org/fact-sheets/docusate-sodium-pregnancy/pdf/
27. Mayo Foundation for Medical Education and Research. Over-the-counter laxatives for constipation: Use with caution. http://www.mayoclinic.org/diseases-conditions/constipation/in-depth/laxatives/art-20045906
28. Mayo Foundation for Medical Education and Research. Infant and toddler health. http://www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/expert-answers/infant-constipation/faq-20058519
29. Mayo Foundation for Medical Education and Research. Constipation in children. http://www.mayoclinic.org/diseases-conditions/constipation-in-children/home/ovc-20235976
30. Benninga M, Candy DC, Catto-Smith AG, Clayden G, Loening-Baucke V, Di Lorenzo C, Nurko S, Staiano A. The Paris Consensus on Childhood Constipation Terminology (PACCT) Group. J Pediatr Gastroenterol Nutr. 2005 Mar;40(3):273-5. doi: 10.1097/01.mpg.0000158071.24327.88
31. Forootan M, Bagheri N, Darvishi M. Chronic constipation: A review of literature. Medicine (Baltimore). 2018 May;97(20):e10631. doi: 10.1097/MD.0000000000010631
32. Bharucha AE, Wald A. Chronic Constipation. Mayo Clin Proc. 2019 Nov;94(11):2340-2357. doi: 10.1016/j.mayocp.2019.01.031
33. Bharucha AE, Lacy BE. Mechanisms, Evaluation, and Management of Chronic Constipation. Gastroenterology. 2020 Apr;158(5):1232-1249.e3. doi: 10.1053/j.gastro.2019.12.034
34. Werth BL, Christopher SA. Potential risk factors for constipation in the community. World J Gastroenterol. 2021 Jun 7;27(21):2795-2817. doi: 10.3748/wjg.v27.i21.2795
35. Bharucha AE, Pemberton JH, Locke GR 3rd. American Gastroenterological Association technical review on constipation. Gastroenterology. 2013 Jan;144(1):218-38. doi: 10.1053/j.gastro.2012.10.028
36. van Dijk KN, de Vries CS, van den Berg PB, Dijkema AM, Brouwers JR, de Jong-van den Berg LT. Constipation as an adverse effect of drug use in nursing home patients: an overestimated risk. Br J Clin Pharmacol. 1998 Sep;46(3):255-61. doi: 10.1046/j.1365-2125.1998.00777.x
37. Mayo Foundation for Medical Education and Research. Constipation Diagnosis. http://www.mayoclinic.org/diseases-conditions/constipation/diagnosis-treatment/diagnosis/dxc-20252753
38. Dietary Guidelines for Americans. https://www.dietaryguidelines.gov
39. American Heart Association Scientific Statement October 27, 2016 – Statement provides blueprint for healthcare providers to translate nutrition recommendations into practical food choices – http://newsroom.heart.org/news/statement-provides-blueprint-for-healthcare-providers-to-translate-nutrition-recommendations-into-practical-food-choices
40. UpToDate. Patient education: High-fiber diet (Beyond the Basics). https://www.uptodate.com/contents/high-fiber-diet-beyond-the-basics
41. The American Heart Association. What Is Stress Management ? http://www.heart.org/HEARTORG/HealthyLiving/StressManagement/FightStressWithHealthyHabits/What-Is-Stress-Management_UCM_321076_Article.jsp#.V6Ot_2dTEqw
42. Mayo Foundation for Medical Education and Research. Relaxation techniques. http://www.mayoclinic.org/healthy-lifestyle/stress-management/basics/relaxation-techniques/hlv-20049495
43. Mayo Foundation for Medical Education and Research. Stress management. http://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/positive-thinking/art-20043950?p=1
44. Diaz S, Bittar K, Mendez MD. Constipation. [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513291