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Constipation: A Guide for Patients

Constipation
Constipation is a symptom, not a disease. It is frequently caused by a disturbance of how the colon works. The normal functions of the colon are to:

• Remove water from the waste material that passes from the small intestine into the colon,
• Serve as a storage area for waste material, and
• Help move and expel stool from the body.

Constipation may occur because:

• Too much water is removed by the colon, causing dry or hard stools,
• Stool moves too slowly through the colon, or
• The patient is unable to expel stools.

Normal bowel habits among healthy people vary greatly from three times a day to three times a week. In some individuals, constipation may refer to infrequent bowel movements (less than 3 per week). While troublesome, constipation is usually not serious. It should be treated and corrected to reduce abdominal discomfort and other related symptoms and to prevent the development of complications. Untreated chronic constipation may lead to or aggravate more serious problems such as hemorrhoids or fecal impaction (partial blockage due to hard stool).

Measures to Treat Constipation
The goal of treatment is to reestablish normal bowel habits without the use of laxatives or enemas. The treatment measures listed below are explain in more detail in the following paragraphs.

• Eat a diet high in roughage (fiber).
• Eat regular meals; it is especially important to have breakfast.
• Take bulking agent with meals and follow with a full glass of water. Begin with:
  • 1-2 tablespoons millers bran 3 times a day or
  • 1-2 heaping teaspoons Metamucil 3 times a day
• Do not take harsh (stimulant) laxatives except as directed.
• Establish regular daily bowel habits; DO NOT ignore the urge to have a bowel movement.
• Allow 15 minutes after breakfast to sit on the toilet - do not strain.
• If there has been no bowel movement after 48 hours, take 1 or 2 tablespoons Milk of Magnesia at bedtime. If unsuccessful, the dose may be increased the next evening.
• If no bowel movement occurs after 3 days, use a glycerin suppository or, if necessary, you may take a small tap water enema.
• Exercise daily.
• Whenever possible, avoid medications that contribute to constipation. DO NOT stop taking any prescribed medications unless approved to do so by your physician.

Proper Diet
The first treatment for constipation is to eat a high fiber diet to provide natural bulk in your daily food intake. Dietary fiber, often called roughage, is a portion of food that passes through the intestine and colon almost unchanged. Undigested fiber holds water to keep the stool soft and adds bulk which helps move stool to the rectum. Most Americans eat very little roughage and this is often a major factor in the cause of constipation. An increase in dietary fiber generally results in a softer and bulkier stool which can be passed more easily. Ask to see a dietitian for complete instructions.

Bulk Agents
Bulk agents are very useful in addition to dietary fiber to restore and maintain regularity. These include bran and psyllium.

Bran
Unprocessed bran, known as "millers bran," can be purchased at a health food store as an inexpensive source of fiber. Bran is the outer coating or shell on grain which is removed during processing white flour. It has very little taste. Wheat, oats, and brown rice are common sources of bran. One tablespoon of raw bran contains approximately 2 grams of dietary fiber. This may be used to supplement the fiber content of your diet.

Start with one or two tablespoons of bran in a glass of juice or water and gradually increase to three times a day with meals. If you prefer, it may be sprinkled on cereals or included in bran muffins, hamburgers, etc. Start slowly to allow your digestive system a chance to get used to increased fiber. Gradually increase the amount as necessary to achieve desired results. Bran tablets are also available - one tablet equals approximately 2 grams dietary fiber. Drink a full 8-oz glass of water with the tablets. You will find both fine bran and coarse bran available. Purchase the coarse bran because it holds water better.

With an increase in dietary fiber or the addition of bran to your diet, you may notice a temporary increase in bloating, fullness, abdominal cramps and gas. DO NOT STOP USING THE BRAN! Symptoms will lessen as bowel habits improve and usually disappear within 2-3 weeks. If discomfort is significant, it may be necessary to temporarily reduce your amount of fiber intake, then again gradually increase it as your body usually adjusts to the additional fiber. Do not give up if success is not achieved immediately.

Bran will not have any effect on stool already in the colon. It must mix with food in order to absorb water and increase stool volume. Depending on how long you have had constipation, improvement may take a few days to several months. Sometimes it is helpful to empty the bowel with a laxative before starting the high fiber and bran diet.

Commercial Bulk Agents
Commercial bulk products provide natural or synthetic fiber which softens the stool, increases the bulk and makes the stool easier to pass.

Psyllium is a natural dietary fiber made from ground husks of psyllium seed, which has the ability to hold water and form bulk. Psyllium holds water better than bran, so smaller amounts are needed to be effective. Metamucil, Effer-Syllium, Perdieum Fiber and Fiberall powder or wafers are brands of psyllium.

Synthetic or man-made bulk forming products such as Citrucel or Fiberall Chewable Tablets are similar to psyllium. They work the same way and may cause less gas. Many pharmacies sell generic brands of bulk agents which are less costly.

Begin by taking 1 or 2 rounded teaspoonfuls of powder 2 or 3 times a day with meals. These agents are very safe and if you are not getting desired results, you should increase the daily dose. Mix rapidly with water or juice and drink immediately; followed by drinking a large glass of fluid. If preferred, fiber wafers may be used. The wafers should also be eaten with 8 ounces of your favorite beverage and, for best results, followed by another glass of liquid. Start with 2 wafers a day and increase to 2 wafers 3 times a day. Again, it may be a few days to several months before the desired effects are seen. Some of the recommended bulk agents are listed below - note the difference in dosage.

Each dose listed is equal to approximately 3.4 grams of psyllium and may be taken 1-3 times a day.

It is important to be aware that harsh stimulant laxatives are sometimes added to bulking agents. These are harmful to take regularly and should be avoided. You must ask your pharmacist if you are not sure a harsh laxative is included in the product you are using.

Some individuals experience increased difficulty with gas and bloating when they use these products. This becomes less of a problem when bowel habits improve. So as with natural fiber, do not give up if success does not occur immediately. Once the need for bulk agents has been established, use should continue indefinitely unless bulking agents are replaced by equal amounts of natural fiber in the daily diet.

Adequate Fluid Intake
It is especially important to drink fluids with any bulking agent; either bran or the psyllium products. Drink at least eight (8 ounce) glasses each day, including one glass before each meal. However, fluids alone will not promote normal bowel function because the small intestine can absorb all of this fluid. A high fluid intake without a high dietary fiber and bulk intake will only result in increased urination.

Use of Suppositories and Enemas
Avoid all harsh (stimulant) laxatives that contain cascara, senna and castor oil. Some of these products include Ex-Lax, Correctol, Carter's Little Pills, Perdiem, Dulcolax, Peri-Colace, and Feen-A-Mint. Prolonged daily use of these agents can be habit-forming and may damage your bowel.

A glycerin suppository may be used during the retraining period to stimulate the urge to have a bowel movement. Glycerin suppositories inserted into the rectum provide a mild irritant to help pass the stool. You should gradually decrease this practice until you no longer need it.

Sometimes the above measures alone are not effective and a laxative may be required. If a laxative is necessary, it is best to use one such as Milk of Magnesia. Other magnesium products may be recommended by your physician. These are effective, inexpensive and safe. They may be taken as needed or even regularly without fear of becoming dependent on a laxative. When using Milk of Magnesia, start with 2 tablespoons (30 ml) by mouth in the evening. Results from the laxative are likely to occur the following morning. It is very important to measure the dose carefully. Too little may not work, too much may cause watery diarrhea. You will need to experiment to find the right dose. For example, if 2 tablespoons do not work, increase the dose to 3. If 3 tablespoons cause diarrhea, try 2 tablespoons plus 1 teaspoon. It takes time and patience to find the right dose. By trial and error one can find the right amount to take, but it may take several weeks.

If you don't have a bowel movement for 3 days after beginning the retraining program, you may use a single 250 cc (one cup) enema. If an enema is necessary, use either lukewarm tap water or a mixture of one half (1/2) teaspoon salt to one pint of warm water. We recommend that you consult a physician before continuing the use of enemas.

Medications
Some medications slow the movements of the colon and may cause constipation or make it worse. Medicines that you can buy in the drugstore without a prescription that should be avoided include: antacids containing aluminum hydroxide (for example Amphogel, Alternagel) or bismuth (for example, Pepto Bismol), antihistamines (for example, Benadryl, Dristan, Chlor-Trimeton) and iron. When buying medicine off the shelf in the drugstore, ask your pharmacist for help in choosing a drug that does not make constipation worse. It is important to discuss your medications with your physician as there are a number of prescription drugs that may cause constipation. Do not stop taking any prescribed medications without approval from your physician.

Habits
It is extremely important to have regular habits to reestablish normal bowel function. Establish a regular routine based on your own schedule. Try to have a bowel movement at the same time every day. The activity of the colon increases after waking up in the morning and after eating, so the urge to have a bowel movement is usually greatest after breakfast. Get up early enough in the morning to eat breakfast, exercise, and sit on the toilet. This should become a daily routine.

Promptly obey all urges to have a bowel movement - do not delay or postpone a visit to the bathroom as the urge will disappear. Repeated ignoring of an urge will change your normal sensation in the rectum and can lead to constipation.

The squatting position is the best for having a bowel movement. Elevate your feet on a footstool in front of the toilet or bend forward so that your abdomen rests against your thighs.

Avoid excessive straining. If you feel stool in the rectum but can't expel it, you may find it helpful to apply external pressure by pushing with your hand placed in front of the rectum or just behind the rectum.

Whenever possible, plan in advance for changes in your daily routine. Constipation often occurs during travel, vacation or stressful situations. Take bulk agents and glycerin suppositories with you in case you need them.

Regular Exercise
Exercise increases muscle movements of the colon and promotes normal bowel habits.

Produced by the UIHC Office of Public Information, Publications Division
53251:11/94

Last Reviewed 2005

Source: James A. Clifton Center for Digestive Diseases
University of Iowa Hospitals and Clinics

Disclaimer: This content is reviewed periodically and is subject to change as new health information becomes available. The information provided is intended to be informative and educational and is not a replacement for professional medical evaluation, advice, diagnosis or treatment by a healthcare professional.