Constipation

The diagnosis of constipation is made when two of the following are present
 > Two or less bowel motions per week
 > Straining more than 25% of the time
 > Lumpy or hard stool more than 25% of the time
 > Feeling like the bowel does not completely empty more than 25% of the time

Constipation occurs in up to 30% of the population under 65 years and up to 50% of those over 65 years.

There are three different types of constipation.

> the first is functional constipation where the bowel is essentially normal. The most common cause of functional constipation is lack of dietary fibre. The second most common cause is lack of physical activity. However, there are medical conditions which cause functional constipation including thyroid and kidney disease. Several medications also cause constipation including iron supplements, pain killers, anti-inflammatory drugs and some blood pressure and Parkinson’s Disease medications.
> the second type of constipation is called slow transit constipation. This is an abnormality of the nerve supply in the bowel which results in abnormal bowel contractions, which slows the stool in its passage through the bowel. This is an uncommon condition.
> the third type of constipation is called pelvic floor dyssynergia. Basically, this is due to a lack of co-ordination between the abdominal muscles used in pushing the stool out and the muscles in the pelvis holding the stool in. In many patients this is an acquired abnormality.

Investigations
Your doctor may request a number of different tests depending upon the history you provide. You may be requested to keep a stool diary to help with the history.
Firstly you will be examined, including a rectal examination. You may then be requested to undergo a telescope investigation of the bowel, an xray examination or special tests of the function of the muscles in the pelvis.

Management

Diet: Fibre supplementation ; You need at least 25g of dietary fibre daily. Foods high in dietary fibre include dried fruits such as dates and apricots, nuts, and cereals such as bran. [Table 1]
Gradually increasing your dietary fibre content will reduce the side effects of bloating and flatulence.

Lifestyle: Regular physical exercise is advised. It is also important to avoid ignoring the urge spend long periods on the toilet. Spending five minutes on the toilet immediately following meals can also help retrain the bowel.

Laxatives: Psyllium and raw bran are the best laxatives to begin with but need to be combined with drinking 6-8 glasses of water per day. Metamucil and fybogel are equivalent. If this is not effective your doctor may suggest oil based laxative. These treatments are safe to continue using for long periods. There are stronger laxatives which your doctor can discuss with you, and which you should only take under medical supervision. These include the “natural or herbal” laxatives.

Biofeedback: Re-training the bowel to respond to the need to pass a motion and to co-ordinate with the abdominal muscles may help some patients with constipation.

Surgery: There are a few patients who have a problem with their bowel that requires surgery. There are a number of different operations, but usually for very specific problems, and your doctor will discuss these with you further if they are relevant to you.

Table 1: Fibre Content of Various Foodstuffs