Constipation

Digestive system organs

Alternative names

Irregularity; Lack of regular bowel movements

Definition

Constipation refers to infrequent or hard stools, or difficulty passing stools. More specifically, constipation may involve pain or crying during the passage of a bowel movement, the inability to pass a bowel movement after straining or pushing for more than 10 minutes, or no bowel movements after more than 3 days.

Considerations

Constipation is a relative term. There is wide variability in what is considered normal patterns of bowel elimination. While some healthy people may have consistently soft or near runny stools, others may have consistently hard firm stools, but no difficulty in passing them.

When the stool is hard, infrequent, and requires significant effort to pass, the person has constipation. Constipation may cause discomfort with passage of stools, and passage of large, wide stools may tear the mucosal membrane of the anus, especially in children, causing bleeding and the possibility of an anal fissure.

Constipation can be caused by changes in diet, decrease in physical activity, lack of toilet facilities, behavior and psychological problems, dehydration, diseases of the bowel, neurological diseases, congenital diseases, medications, and many other causes.

Constipation in children is commonly caused when they hold back bowel movements due to fear of painful bowel movements or unreadiness for toilet training.

Common causes

• meconium plug (as seen in infants and children with cystic fibrosis)
• cow?s milk ingestion (infants and children)
• congenital megacolon (Hirschsprung?s disease)
• functional ileus
• meningomyelocele
• mental retardation
• cerebral palsy
• neurological disorders
• depression
• painful defecation (anal fissure, skin irritation, hemorrhoids)
• dietary changes
• medications especially narcotics including methadone
• dehydration
• low-fiber diet
• infrequent physical exercise
• immobility (elderly or bedridden patients)
• endocrine disorders such as hypothyroidism
• endometriosis
• pelvic tumors
• stool withholding
• toilet training difficulties

Home care 

DIET
Dietary measures such as increasing fiber intake from whole-wheat grains, fresh fruits, vegetables and bran may help add bulk to the stool and promote normal bowel movements. Special efforts should be made to increase daily intake of fluids. See also diet for constipation.

Infants less than 2 months old who are constipated should be examined by their physician. 

Infants 2 to 4 months old who are constipated may be given one ounce fruit juice (grape, pear, apple, cherry, or prune) per month of age twice a day.

Infants older than 4 months old who have begun solid foods and are constipated may also be given baby foods with high-fiber content (peas, beans, apricots, prunes, peaches, pears, plums, spinach) twice a day.

Children older than 1 year will benefit from the same dietary changes as adults (i.e., more fruits, vegetables, and whole grain foods which are high in fiber). In addition, increase intake of fruit juices such as apple, pear, cherry, grape, or prune.

BEHAVIOR
If a child is holding back bowel movements in order to resist toilet training, some changes in training may be necessary. Call your health care provider for further assistance dealing with this problem.

EXERCISE
Regular exercise is also very important in establishing regular bowel movements. People who are confined to a wheelchair or bed should be taught to change position frequently and perform abdominal contraction exercises and leg raises. A physical therapist can recommend a program of exercises appropriate for your physical abilities.

MEDICATIONS
Stool softners such as Docusate Sodium may be recommended to aid in the passage of soft, formed stools. Additionally, bulk laxatives such as Psyllium may be used to add fluid and bulk to the stool. Suppositories or gentle laxatives, such as mineral oil or milk of magnesia, may be used in conjunction with a bowel retraining program to establish a pattern of regular bowel movements. Enemas or laxatives should be reserved for severe cases only.  In additionl laxatives should not be used over a long period of time because they can lead to dependence.

Call your health care provider if

• There is constipation in an infant younger than 2 months.
• There is sudden constipation with abdominal cramps, and an inability to pass gas or stool. (In this case, do not take any laxatives. Call your health care provider immediately!)
• There are very thin, pencil-like stools.
• There is also abdominal pain and bloating.
• There is also unexplained weight loss.
• There is blood in the stool.
• Homecare is not working.

What to expect

Medical history will be obtained and a physical examination performed.

Medical history questions documenting constipation in detail may include:

• TIME PATTERN:
  • How long have you had constipation?
  • Has it been persistent? How long (for at least how many months)?
  • How many days between two spontaneous bowel movements?
• AGGRAVATING FACTORS:
  • Is it worse when you are stressed?
• CHARACTERISTICS:
  • What is the frequency of stools?
  • What is the color, shape, and consistency of the stools?
  • Is there any bleeding with the passage of stools?
  • Are you experiencing any abdominal pain?
• ASSOCIATED FACTORS:
  • What surgeries have you had?
  • What injuries have you had?
  • What medications do you take?
  • Do you drink coffee? How much?
  • Do you drink alcohol? How much? How often?
  • Do you smoke? How much each day?
• OTHER:
  • What other symptoms are also present?

The physical examination will include exam of the abdomen and a rectal exam.

Diagnostic tests that may be performed include:

• barium enema
• blood tests such as a CBC, PT, or PTT
• proctosigmoidoscopy (an examination of the lower bowel)
• stool studies
• upper GI series
• X-rays of the abdomen

After seeing your health care provider:
If a diagnosis was made by your health care provider related to constipation, you may want to note that diagnosis in your personal medical record.