Date issued: April 2020
For review: April 2022
Ref: A-326/Surgery/AC/Constipation in adult v2
What is Constipation?
Constipation is a common symptom that does not necessarily mean that you have a disease. It is estimated to affect 1 in 7 adults and can affect people of all ages but is more common in young women and the elderly. It is twice as common in women as in men and affects about 40% of pregnant women.
The word constipated can mean different things to different people. Constipation is generally defined by doctors as a person having any of the following features:
- Opening of the bowels fewer than 3 times a week.
- Needing to strain to pass stools.
- Hard and lumpy stools may be large or small in size.
- Finding it difficult or are unable to completely empty your bowels.
- Having to use a finger or hand to help you to pass stool.
You may also experience:
- Stomach aches and cramps.
- Feeling bloated.
- Feeling sick.
- Loss of appetite.
- Diarrhoea alternating with constipation.
- Pain or bleeding from the rectum (back passage) if you are straining.
- Low back pain.
If you have any of the following symptoms for more than 6 weeks, then you need to see your GP
- A continuing change in bowel habit
- Unexplained bleeding from the back passage
- Abdominal (stomach) pain or discomfort
- Weight loss or tiredness
Normal bowel function
Frequency of bowel movements varies widely in the general population. It is actually normal to pass stools between 3 times a day and once every 3 days. Most adults take bowel control for granted and need to give it little thought except for the few minutes a day that are spent emptying the bowel on the toilet. However bowel control is actually a complex process, involving the co-ordination of many different nerves and muscles.
Type 1, 2 or 3 on the Bristol stool chart show some level of constipation, with type 1 the most severe.
The bowel is part of the digestive system and its role is to digest the food that we eat, absorb the goodness and nutrients from the digested food into the blood stream and then to process and expel waste products from the food that the body cannot use. This process starts at the mouth and finishes at the anus (back passage). Figure 1
Figure 1:The bowel
The small bowel (small intestine) is the part of the bowel where the useful parts of the food are absorbed. The small bowel delivers 1-2 pints of waste to the colon per day. The colon (large bowel) is the waste processing part of the system (Figure 2). This waste is the consistency of thick soup when it enters the beginning of the colon. It is the job of the colon to absorb fluid from this waste and, as it moves around the colon, to gradually form it into stools (faeces or bowel motions). Stool consistency can vary between hard lumps to very loose and mushy, often depending on how long the stools have been in the colon and how much water has been absorbed from them. Ideally stools should be formed into soft smooth sausage-shapes which are comfortable to pass.
Figure 2: the Large Bowel
The left side of the colon and the rectum are the ‘storage tank’ at the end of the large bowel. Normally the rectum is relatively empty. Some stool enters the rectum fairly regularly, but most arrives as a result of ‘mass movements’ which happen from time to time, especially before the need to go to the toilet is experienced. These mass movements are major waves of pressure, which can move stools through the whole length of the colon, like toothpaste being squeezed along a tube. (Figure 3). Often a large part of the contents of the colon arrive in the rectum at once.
Figure 3: Mass movements in the colon
These mass movements are often triggered by the gastro-colic response. Food arriving in the stomach when you eat a meal sets off a pressure wave in the colon some minutes later. This can lead to the need to empty the bowel, sometimes urgently, soon after eating. For many people the bowel is relatively quiet at night. The first meal of the day, together with physical activity involved in getting out of bed and washing and dressing, stimulates contractions in the colon and mass movements. This leads to an ‘urge’, the feeling that the bowel needs emptying, shortly after breakfast.
Food usually takes an average of 1-3 days to be processed and up to 90 per cent of that time is spent in the colon.
How often should I empty my bowels?
There is no right or wrong answer to this. There is a wide range of ‘normal’ bowel function between different people. It is by no means essential to have one bowel action per day. Perception of what is normal is based on personal experiences and growing up with other people. Most of us do not discuss bowel habit with our friends, or even our own family. A few people become obsessed with the need for a daily bowel action and spend excessive amounts of time in the toilet or take laxatives to achieve this. Often this is unnecessary.
What causes constipation?
The exact cause of constipation may be difficult to identify, however, there are a number of things that may contribute to the condition, including
Not drinking enough: the body needs around 2 litres of fluid a day to function efficiently. Without sufficient fluids, stools dry out making them harder to move through the bowel.
Diet: dietary fibre provides the bulk that helps to speed the passage of waste food through the bowel. Lack of fibre results in harder, more compacted stools which take longer to pass.
Lack of exercise: if you don’t exercise regularly, things can slow down, including muscle contractions that move stools through the gut.
Pregnancy: Hormonal changes in pregnancy can slow down the gut movements, and in later pregnancy, the baby pushes the bowel making it more difficult for stools to move. New mothers may find they cannot respond to the urge to open the bowels and they run into problems through a lack of routine.
Some medications: can cause constipation as a side effect. For example, painkillers like co-codamol, codeine and morphine slow down the bowel. Iron tablets and some of the medication used to treat heartburn, high blood pressure, heart problems, depression and Parkinson’s disease.
A decrease in thyroxine levels in the blood, due to a condition called hypothyroidism, can slow down the bowel. Similarly, increased levels of calcium in the blood called hypercalcaemia can slow down the bowel leading to constipation.
Following any major surgery: this is due to a variety of factors such as painkillers. An inability to push due to pain following surgery, decreased food intake and damage to various nerves in the pelvis following some major pelvic operations.
Eating disorders: patients with an eating disorder cannot be expected to have regular bowel actions due to a lack of roughage. They may continue to have constipation even after normalisation of eating behaviour, due to the inability of their bowel to fully recover.
Lifestyle: people sometimes feel unable to open their bowels due to various reasons, for example stress, poor toilet access or their busy life schedule. Consequently, they tend to ignore the sensation of needing to go to the toilet to open their bowels and over the years, their bowel slows down, resulting in constipation.
Psychological disturbances: major events in life such as a bereavement can result in constipation. Constipation is common in people suffering with anxiety and depression.
Sexual or physical abuse: it is not uncommon to see patients suffering from constipation giving a history of physical or sexual abuse in their childhood. This group of patients are often found to have incoordination between the rectum and anal sphincter. During the normal process of bowel evacuation, when the rectum contracts, the anal sphincter relaxes to expel stool, but in this group of patients the normal relaxation of the anal sphincter does not happen, leading to constipation, which in turn slows down the gut.
Pelvic Floor Dysfunction: if you have chronic constipation you may have pelvic floor muscle incoordination (dyssynergia). This is when your pelvic floor muscles may tighten rather than relax when you sit on the toilet. You may want and have the urge to have your bowels open but instead you have a feeling of something stopping you.
Pain in the anal area: for example a fissure (split in the anal lining) or haemorrhoids, constipation then results from the fear of provoking defecation.
Obstruction to the bowels, for example by scarring, inflammation or tumours.
Rectocoele: which means bulging of the rectum, most commonly found in women who have had a baby via vaginal delivery. During defecation, the rectum bulges forward to the vagina and the stool can get trapped in the rectoceoele (Figure 4)
Figure 4: Rectocoele
Injury to the nerves or nerve disease, for example, people with spinal cord injury, multiple sclerosis, Parkinsons disease or from childbirth.
Mega colon or mega rectum, these are rare conditions in which the gut enlarges.
Hirschprungs disease is a very rare condition, usually diagnosed in babies soon after birth. It is due to a lack of nerve supply to the lower part of the bowel.
Unknown Cause: some people have a good diet, drink a lot of fluid, do not have disease or take any medication that can cause constipation, but still become constipated. This is common (up to 1 in 6 people) and mostly occurs in women. This condition starts in childhood or early adulthood and persists throughout life.
Colonoscopy: A test to check inside of your bowel. A long thin flexible tube with a small camera inside is passed into your bottom.
CT scan of the Colon: Virtual colonoscopy uses special x-ray equipment to examine the large intestine. During the examination, a small tube is inserted a short distance into the rectum to allow for inflation with gas while CT images of the colon and rectum are taken.
Anal Physiology investigations: tests to assess the strength of the sphincter muscles and sensitivity of the rectum and ultrasound to specifically look at the sphincter muscles.
Proctogram: an examination of your pelvic floor to see what happens when you empty your bowels and why you may be having problems doing this.
Complications of constipation
A large number of patients with constipation get abdominal bloating and discomfort. Patients often complain of tiredness and fatigue, although there is no clear evidence of anaemia or build-up of supposed gut ‘toxins’. Pain and vomiting are rarer complaints.
It is very uncommon for the young and fit to get serious complications from constipation. However elderly or malnourished people may develop problems including:
Faecal impaction: this is a condition in which a solid ball of stool builds up in the rectum. This can present with diarrhoea as only liquid stool can make its way past the obstructing stool. It is seen most often in people who are unable to move around easily and those taking lots of medications.
Stool perforation: this is an exceptionally rare condition where a hard stool sits in the colon for so long that it wears through the wall and surgery becomes necessary.
Rectal prolapse: this means the rectum comes down out of the back passage. This may be a complication of constipation or of generally weak pelvic floor muscles, either due to advanced years or malnutrition.
There are many that believe that haemorrhoids (piles) are a complication of constipation. However, haemorrhoids are more common in young men than young women and constipation is less common in men. It is true however that sitting on the toilet for long periods of time can aggravate haemorrhoids.
How can I reduce constipation?
Improve your diet
- Eat regular meals to get your bowels working.
- Do not skip meals especially breakfast, as it can make your bowel sluggish or irregular.
- Avoid hurrying your meals and chew your food properly.
- Avoid processed foods and foods with a high fat content.
- Eat a diet with a healthy amount of both soluble (vegetables and fruit) and insoluble fibre (cereals / wholegrains) between 30g each day.
- Try to eat at least 5-8 portions of fruit and / or vegetables a day.
- Become a Healthier You, advice for eating, managing stress and eating well.
What is Fibre?
Dietary fibre or roughage is only found in foods that come from plants. Foods rich in fibre should be included as part of a healthy balanced diet. Fibre adds bulk to the stools helping to prevent constipation. There are 2 types of fibre and it should be increased gradually over a period of several weeks. This will prevent unwanted side effects such as bloating and excessive wind:
Insoluble fibre: This is the fibre that our digestive system cannot break down and digest. It passes through the gut helping other food and waste products move through the gut more easily. Good sources of insoluble fibre include wholegrain breakfast cereals, wholemeal / granary bread and fruit and vegetables.
Soluble fibre: This fibre can be partially digested and may help to lower cholesterol levels and slow down the absorption of sugars. Good sources of soluble fibre include oats, pulses, fruits and vegetables.
If you feel that your diet is short of fibre, try to eat more fruit and vegetables, but add them gradually to avoid unpleasant symptoms such as bloating and wind.
Note: Sometimes bran and wholemeal may cause more bloating and cramps and worsen constipation in people with IBS
Easy ways to boost your fibre intake
Have a high fibre cereal for breakfast – 40g branflakes = 5.5g fibre, 100g uncooked oats = 7.8g, 2 slices wholemeal bread = 5.6g fibre
Add fruit to your breakfast – 1 banana = 1.4g fibre, 100g raspberries = 3.3g
Have fresh fruit as a snack – 1 pear = 3.8g fibre, 1 orange = 1.9g fibre, 7 strawberries = 3.2g fibre
Add extra vegetables to sauces such as chilli, curry and Bolognese – 1 extra carrot = 3g fibre, 80g broccoli = 3g fibre
Add pulses such as baked beans to dishes – 80g baked beans = 4g fibre, 200g pot reduced sugar and salt baked beans = 9.8g fibre, 80g canned lentils = 6.3g fibre, 100g red kidney beans = 8.3g
Use frozen vegetables – 80g frozen sweetcorn = 2,5g fibre, 80g frozen peas = 4.4g fibre
Having wholemeal pasta – 100g = 4.2g
Adding 2 tablespoons of Chia seeds a day = 11g fibre
Snack on nuts – 30g skin on almonds = 4g fibre
Easy switches to increase fibre in your diet
- Switch white bread for wholemeal bread
- Switch white pasta and rice for wholemeal
- Make homemade vegetable or lentil soup
- Add extra vegetables to mince, casseroles, soups stews, curry or chilli.
- Add beans and pulses to mince, casseroles, soups, stews, curry or chilli
- Oatcakes or vegetable sticks with hummous
- Snack on vegetable or fruit sticks
- Dried fruit is packed with fibre
- Keep the skins on fruit and vegetables when possible, jacket potatoes
- Popcorn instead of crisps
- Swap refined cereals such as Rice Krispies® or Cornflakes for wholegrain versions such as porridge, bran flakes, Weetabix®, Shredded wheat®.
- Add milled Linseeds of Flaxseeds or nuts and berries to your breakfast
- Try some almonds, pecans and walnuts or sesame and sunflower seeds.
- Fill your plate with vegetables; try as many different coloured vegetables.
What to do if you are suffering with bloating
Everyone suffers with bloating from time to time, but for some it can cause severe pain as well. There’s a high chance that it may be related to something that you are eating. Keeping a food diary is the best way to pinpoint foods that may be causing you to bloat. You may want to look at some of the following which can be culprits of bloating
Brassica vegetables: cabbage, cauliflower and brussel sprouts.
Starchy carbs: pasta, potatoes and bread, in particular if they are eaten reheated or chilled.
Rye and wheat
Leeks, onions and garlic
Legumes: beans and pulses
Sugar free chewing gum and mints
Apples and pears
Drinks: sparkling water, fizzy drinks, apple juice, alcohol
If you find it difficult to know what to cook or thinking of different healthy meals, you may wish to refer to resources such as
- BBC Good Food website
- Smart Recipes App
- Food Smart App
- Supermarket websites often have a recipes section
If you feel or it has been suggested that you need to lose some weight, there are many different options available to you.
- The Practice Nurse at your surgery can offer support and education and monitor your weight
- For some patients who are significantly overweight, they wish to be referred to a Weight Management programme
- Check with your GP surgery whether they run a weight management group locally
- Consider organisations such as Slimming World and Weight Watchers if you are someone who feels that ‘group’ support would benefit you.
Drink enough fluid
- Try to drink at least 1.5 -2 litres of fluid (5-8 mugs) every day
- Do not drink more than 2 litres per day as this can make you feel bloated
- Avoid drinking too much caffeine (coffee, tea, cola) as this can make you dehydrated
- Avoid fizzy drinks as they can bloat you.
Exercise regularly to encourage bowel function and peristalsis (wave like contractions which moves the waste through the bowel).
- Try to do 20-30 minutes of exercise every day.
- If you do a desk job, try to walk to or from work, or take a walk during your lunch time.
- Try to use the stairs as an alternative to using the lift.
- Look and see whether your employer runs any fitness activities. If not consider setting up your own lunchtime group such as a walking club.
- Use your mobile phone to record the number of steps you do each day or consider a phone App
Try to establish a regular bowel habit
Establishing a regular bowel habit can help with constipation.
Many patients have good results with the programme described below.
Take your time
- Set aside about 10 minutes to sit on the toilet at the same time each day. As a rule, it is best going to the toilet first thing in the morning after breakfast and a hot drink or about 20-30 minutes after a meal. This is because the movement of stools through the lower bowel is greatest in the mornings and after meals.
- Try to find a toilet you feel comfortable using, where you have enough privacy.
- Do not ignore the feeling of needing the toilet. It may result in a backlog of stools which is difficult to pass later.
Sit in the correct position
- Make sure you are comfortable on the toilet
- Keep your feet about 45-60 cm apart and place your feet on a stool/box so that your knees are higher than your hips.
- Lean forward and put your elbows on your knees
- Keep your back straight and bulge your tummy (abdomen) out.
Brace or pump technique
- While keeping the bulge of your abdomen, relax your back passage and push from your waist back and down into the passage at an angle. This allows the anus to open and expel the stools.
- Avoid excessive straining.
- Relax and breathe normally, do not hold your breath.
- When practicing the brace/pump exercise, open your mouth and slowly breathe out while maintaining the swelling effect.
- With practice you will be able to keep the bulge of the your abdomen while taking a new breath and preparing for the next effort to expel stools
- Another way to attempt this is to breathe in and as your breathe out make the ‘S’ sound. You should feel the anus opening
- Repeat the brace / pump technique a few times to empty your bowels completely.
- Before wiping, squeeze and lift your pelvic floor muscles firmly when you have finished.
- Try to avoid straining
- If you do not have your bowels open, do not panic. Try again later, following the steps above.
Do not spend endless time on the toilet straining. If the bowels do not open, do not panic; try again at the same time the next day. It may take a few weeks or even months to retrain your bowel habit, so do not give up.
If there is thought to be a discoordination of the pelvic floor muscles, physiotherapy using bowel retraining and techniques such as relaxation exercises of the pelvic floor can often help. This is bowel retraining and you will be shown how the muscles can be retrained in order to improve bowel emptying
If you are taking any medications ask your pharmacist or doctor if they could be adding to your constipation. If possible, try to remove constipating medications.
If you have ever had a headache after a stressful day, felt anxiety before a job interview, or blushed when you have been embarrassed, these are all demonstrate the close connection between your body and your mind, and how your thoughts and emotions can manifest themselves physically.
Research has shown that mood disorders and emotional distress changes the nerve pathway that helps to control gut function, and therefore psychological factors directly influence your digestive system. As a result, if you suffer from depression or anxiety you are more likely to suffer from a digestive disorder, such as constipation.
This is because negative emotions (e.g. worry or anger) activate your stress hormones, which then act in two ways:
- They shut down certain parts of your immune system, increasing inflammation within the body and weakening your overall health.
- They affect your digestion by slowing down or stopping your digestive juices within the stomach which are needed to breakdown food. This then causes any food consumed to just sit there in the gut.
Both of these responses are part of our in-built 'fight or flight' survival mechanism, where the body requires all of its energy to fuel our heart, brain and muscles in response to the increased stress. As a result, any food we eat doesn't move and leads to constipation.
If you recognise that anxiety, depression or a mental health issue is a concern for you, then you may wish to refer to the following individuals / organisations for support.
- Your GP to discuss the options available.
- Consider Mindfullness techniques such as yoga, medication, tai-chi. There are numerous mindfull apps available.
- See whether your employer has an Occupational Health team and Well-Being team, do they offer any individual support or group activities.
- Become a Healthier You, advice for eating, managing stress and eating well. They also offer a free NHS Health check. One You Plymouth
- 1:1 counselling organised privately
If really necessary try using a fibre supplements such as Fybogel and possibly suppositories or mini-enemas to help regularise the bowels. It is best to only use these as an aid to getting into a regular routine, rather than relying on them long term. Some people will find that Fybogel makes their situation worse and if this does happen, switch to an alternative such as Movicol or Laxido. Your local pharmacist will be able to advise you.
It is best to avoid taking laxatives long term. You should use laxatives if:
- You have an occasional episode of constipation
- You need to counteract the effects of medication that causes constipation
- You need to avoid straining, after pelvic or abdominal (stomach) surgery
- You have a problem with your anus, such as a fissure and it needs time to heal.
There are a number of laxatives available:
- Fybogel® or Regulan® which bulk the stool
- Movicol® or lactulose® which soften your stools by drawing fluid into the bowel
- Senna® or Dulcolax® which stimulate the muscle of the bowel
- Prokinetic agents which promote intestinal motility
These are inserted into the anus. They work by softening the stool and causing the muscles of the rectum to contract, making stool easier to pass.
They are different to oral laxatives because:
- They provide fewer side effects and will work directly on the bowel wall
- They can act more quickly than oral laxatives and are less likely to cause diarrhoea
- They can be used to help establish a more regular bowel pattern
- You can buy Glycerine, Bisocodyl and Lecicarbon suppositories over the counter at a chemist
Irrigation is usually recommended for people with chronic constipation who have tried all other measures without success. Small volume systems can be used to aid rectal emptying and a larger volume system may be considered for chronic constipation where the aim is to help empty the left side of the large bowel. Your medical team will decide if you need to try irrigation.
Irrigation uses water to empty stool from the bowel. Water is gently pumped into the lower part of the bowel through the anus using either a catheter or cone. The rectum and some of the bowel above is flushed out and the water and stool are passed out into the toilet.
Most people who irrigate use this method daily or every other day. It aims to improve the function of the bowel by giving you a regular and predictable bowel habit.
Small Volume Irrigation
Qufora Irresido Cone Sysyem www.macgregorhealthcar.com
Larger Volume Irrigation
Peristeen, Coloplast www.coloplast.co.uk
A few people may need surgery to correct a functional problem that makes it difficult to pass stool, such as a repair of a rectocoele but more often conservative measures will improve the difficulty to pass stools.
An operation may involve a repair of:
- A rectocoele: when the bowel bulges forward into the vagina and can trap stool
- A rectal prolapse: when the bowel slides out through the anus
- An intussusception: when the back passage folds in on itself and acts like a trap door.
The results of removal of all or part of the colon to improve bowel function are often poor. About a tenth of patients return to their previous levels of constipation. Approximately 1 in 10 who have their colon removed will end up with a stoma (bowel bought out to the skin to discharge bowel contents into a bag) either because of severe symptoms that cannot be controlled, or as a result of the failure of previous surgery.
Useful sources of information:
British Nutrition Foundation
Food standards agency
British Dietetic Association
One You Plymouth
Patient Information Leaflet: St Marks Hospital
Constipation Information for Patients: Kings College
Patient Information Leaflet Constipation: Rotheram Clinical Commissioning Group