Overview

Chronic constipation is defined as having fewer than three bowel movements per week for at least three months, often accompanied by straining, hard stools, or a sensation of incomplete evacuation. Unlike occasional constipation that most people experience, chronic constipation is persistent and can significantly affect daily activities and overall well-being.

The condition results from various factors affecting the normal movement of stool through the colon. When stool moves too slowly, excessive water is absorbed, making it hard and difficult to pass. This can create a cycle where the fear of painful bowel movements leads to withholding, which worsens the constipation.

Chronic constipation affects people of all ages but is more common in women, older adults, and those with sedentary lifestyles. While rarely life-threatening, untreated chronic constipation can lead to complications such as hemorrhoids, anal fissures, fecal impaction, and in severe cases, rectal prolapse. Understanding and addressing this condition is crucial for maintaining digestive health and quality of life.

Symptoms

Chronic constipation presents with various symptoms that can range from mild discomfort to severe pain and complications. The symptoms often develop gradually and may worsen over time if left untreated.

Primary Bowel Symptoms

  • Constipation - Fewer than three bowel movements per week
  • Straining during bowel movements
  • Hard, dry, or lumpy stools
  • Feeling of incomplete evacuation
  • Sensation of blockage in the rectum
  • Need for manual maneuvers to help with defecation

Abdominal Symptoms

Rectal and Anal Symptoms

Associated Symptoms

Causes

Chronic constipation can result from various factors affecting the normal function of the digestive system. Understanding these causes is essential for effective treatment.

Primary Constipation (Functional)

Normal Transit Constipation: The most common type where stool moves at a normal rate through the colon, but patients still experience difficulty with evacuation or hard stools.

Slow Transit Constipation: Characterized by delayed movement of stool through the colon due to reduced colonic motility. More common in young women and can be severe.

Dyssynergic Defecation: Also called pelvic floor dysfunction, where the muscles involved in bowel movements don't work together properly, making it difficult to evacuate stool.

Secondary Causes

Medications:

  • Opioid pain medications
  • Anticholinergics
  • Antidepressants
  • Calcium channel blockers
  • Iron supplements
  • Antacids containing aluminum

Medical Conditions:

Structural Problems:

  • Colorectal cancer
  • Strictures or narrowing of the colon
  • Rectocele
  • Rectal prolapse
  • Hirschsprung's disease

Lifestyle Factors

  • Low fiber diet
  • Inadequate fluid intake
  • Lack of physical activity
  • Ignoring the urge to defecate
  • Changes in routine or travel
  • Stress and anxiety

Risk Factors

Several factors can increase the likelihood of developing chronic constipation:

Demographic Factors

  • Age: More common in adults over 65
  • Gender: Women are affected more often than men
  • Pregnancy: Hormonal changes and pressure on intestines
  • Socioeconomic status: Lower income associated with higher rates

Lifestyle Risk Factors

  • Sedentary lifestyle: Lack of regular physical activity
  • Poor diet: Low in fiber, high in processed foods
  • Dehydration: Inadequate water intake
  • Irregular eating habits: Skipping meals or irregular timing
  • Toilet habits: Ignoring urge to defecate

Medical Risk Factors

  • Neurological disorders
  • Metabolic and endocrine conditions
  • Mental health conditions (depression, anxiety)
  • History of sexual or physical abuse
  • Eating disorders
  • Chronic pain conditions requiring opioids

Environmental Factors

  • Limited access to bathroom facilities
  • Lack of privacy
  • Institutionalization (nursing homes, hospitals)
  • Travel and time zone changes
  • Occupational factors (limited break time)

Diagnosis

Diagnosing chronic constipation involves a comprehensive evaluation to identify the underlying cause and rule out serious conditions.

Medical History

Your doctor will ask about:

  • Bowel movement frequency and consistency
  • Duration of symptoms
  • Associated symptoms (pain, bloating, bleeding)
  • Dietary habits and fluid intake
  • Medications and supplements
  • Medical conditions and surgeries
  • Family history of bowel disorders

Physical Examination

  • Abdominal examination: Checking for distension, masses, or tenderness
  • Digital rectal examination: Assessing anal tone, masses, stool presence
  • Perineal examination: Looking for hemorrhoids, fissures, prolapse
  • Neurological assessment: If indicated

Diagnostic Criteria (Rome IV)

Must include two or more of the following for at least 3 months:

  • Straining during >25% of defecations
  • Lumpy or hard stools in >25% of defecations
  • Sensation of incomplete evacuation in >25% of defecations
  • Sensation of anorectal obstruction in >25% of defecations
  • Manual maneuvers to facilitate >25% of defecations
  • Fewer than 3 spontaneous bowel movements per week

Laboratory Tests

  • Blood tests: CBC, thyroid function, electrolytes, calcium
  • Stool tests: Occult blood, if indicated
  • Other tests: Based on suspected underlying conditions

Specialized Tests

If initial treatment fails or red flags are present:

  • Colonoscopy: To rule out structural abnormalities
  • Colonic transit study: Measures how fast stool moves through colon
  • Anorectal manometry: Evaluates pelvic floor function
  • Defecography: X-ray or MRI study of defecation
  • Balloon expulsion test: Tests ability to evacuate

Treatment Options

Treatment for chronic constipation typically follows a stepwise approach, starting with lifestyle modifications and progressing to medications and specialized therapies as needed.

Lifestyle Modifications (First-Line)

Dietary Changes:

  • Increase fiber intake to 25-35 grams daily
  • Add fiber gradually to avoid gas and bloating
  • Include fruits, vegetables, whole grains, and legumes
  • Consider psyllium or other fiber supplements
  • Drink 8-10 glasses of water daily
  • Limit processed foods and dairy if problematic

Physical Activity:

  • Regular exercise (30 minutes daily)
  • Walking, swimming, or yoga
  • Abdominal exercises and stretches
  • Avoid prolonged sitting

Toilet Habits:

  • Establish regular toilet time (after meals)
  • Don't delay urge to defecate
  • Use footstool for proper positioning
  • Allow adequate time without straining
  • Practice relaxation techniques

Over-the-Counter Medications

Bulk-forming Laxatives: (First choice)

  • Psyllium (Metamucil)
  • Methylcellulose (Citrucel)
  • Polycarbophil (FiberCon)

Osmotic Laxatives:

  • Polyethylene glycol (MiraLAX)
  • Lactulose
  • Magnesium hydroxide (Milk of Magnesia)

Stimulant Laxatives: (Short-term use)

  • Bisacodyl (Dulcolax)
  • Senna (Senokot)

Stool Softeners:

  • Docusate sodium (Colace)

Prescription Medications

  • Lubiprostone (Amitiza): Chloride channel activator
  • Linaclotide (Linzess): Guanylate cyclase-C agonist
  • Plecanatide (Trulance): Guanylate cyclase-C agonist
  • Prucalopride (Motegrity): Serotonin receptor agonist
  • Methylnaltrexone (Relistor): For opioid-induced constipation

Specialized Treatments

Biofeedback Therapy:

  • For dyssynergic defecation
  • Teaches proper muscle coordination
  • Success rate of 70-80%
  • Requires specialized physical therapist

Other Interventions:

  • Sacral nerve stimulation
  • Botulinum toxin injections
  • Surgery (rare, for specific conditions)
  • Psychological counseling for associated anxiety

Complementary Approaches

  • Probiotics
  • Acupuncture
  • Abdominal massage
  • Herbal remedies (with caution)
  • Mind-body therapies

Prevention

Many cases of chronic constipation can be prevented through healthy lifestyle habits and proper bowel care:

Dietary Prevention

  • Maintain high-fiber diet consistently
  • Eat regular, balanced meals
  • Include probiotic foods (yogurt, kefir)
  • Limit constipating foods (cheese, processed foods)
  • Stay well-hydrated throughout the day
  • Moderate caffeine and alcohol intake

Lifestyle Habits

  • Exercise regularly
  • Maintain healthy weight
  • Manage stress effectively
  • Get adequate sleep
  • Establish regular bowel routine
  • Never ignore urge to defecate

Medication Management

  • Review medications with healthcare provider
  • Use preventive measures when starting constipating medications
  • Consider alternatives to opioids when possible
  • Take iron supplements with stool softeners if needed

Special Considerations

  • During pregnancy: Increase fiber and fluids early
  • For elderly: Maintain mobility and hydration
  • Post-surgery: Early mobilization and preventive laxatives
  • Travel: Maintain routines and pack fiber supplements

When to See a Doctor

While occasional constipation is common, certain symptoms warrant medical evaluation:

See Your Doctor If You Experience:

  • Constipation lasting more than 3 weeks
  • Sudden change in bowel habits
  • Severe abdominal pain
  • Blood in stool or on toilet paper
  • Unexplained weight loss
  • Persistent nausea or vomiting
  • Inability to pass gas
  • Family history of colorectal cancer

Seek Emergency Care For:

  • Severe abdominal pain with fever
  • Vomiting blood or material that looks like coffee grounds
  • Signs of bowel obstruction (severe pain, distension, vomiting)
  • Rectal bleeding with dizziness or weakness
  • Severe dehydration

Red Flag Symptoms

These symptoms may indicate serious underlying conditions:

  • New onset after age 50
  • Anemia or iron deficiency
  • Positive fecal occult blood test
  • Family history of colon cancer or IBD
  • Persistent symptoms despite treatment

Related Conditions

Chronic constipation may be associated with or lead to various other conditions:

Frequently Asked Questions

How long can you safely go without a bowel movement?

While normal frequency varies from three times daily to three times weekly, going more than three days without a bowel movement is generally considered too long. After three days, stool becomes harder and more difficult to pass. However, if you're comfortable and not experiencing symptoms, less frequent bowel movements may be normal for you.

Can long-term laxative use be harmful?

Most laxatives are safe for long-term use when used appropriately. Bulk-forming and osmotic laxatives are generally safest. Stimulant laxatives were once thought to cause dependency, but recent research shows they're safer than previously believed. However, it's best to work with your doctor to find the right long-term solution.

Is constipation a sign of colon cancer?

While chronic constipation alone is rarely a sign of colon cancer, a sudden change in bowel habits, especially after age 50 or with other symptoms like blood in stool or weight loss, should be evaluated. Most constipation is functional and not related to cancer.

Why does constipation get worse with age?

Several factors contribute: decreased physical activity, slower metabolism, medications for other conditions, reduced fluid intake, and changes in the digestive system. The colon may become less responsive to normal stimuli, and pelvic floor muscles may weaken.

Can probiotics help with chronic constipation?

Some studies suggest certain probiotic strains, particularly Bifidobacterium and Lactobacillus, may help improve bowel frequency and stool consistency. However, results vary by individual, and probiotics work best as part of a comprehensive treatment approach.

Should I take fiber supplements if I'm already constipated?

Fiber can help, but it must be introduced gradually with plenty of water. Starting with too much fiber too quickly can worsen bloating and discomfort. If you have slow-transit constipation or pelvic floor dysfunction, fiber alone may not help and could worsen symptoms.

References

  1. Bharucha AE, Lacy BE. (2023). Mechanisms, Evaluation, and Management of Chronic Constipation. Gastroenterology.
  2. Serra J, et al. (2022). European society of neurogastroenterology and motility guidelines on functional constipation in adults. Neurogastroenterology & Motility.
  3. American Gastroenterological Association. (2023). Clinical Practice Update on Management of Chronic Constipation.
  4. Mearin F, et al. (2016). Bowel Disorders. Rome IV Functional Gastrointestinal Disorders. Gastroenterology.
  5. National Institute of Diabetes and Digestive and Kidney Diseases. (2023). Constipation in Adults.