Improving constipation

There are three main ways of dealing with constipation:

eat more fibre (see table below)
drink more fluid
take more exercise.

Alarm signals

Constipation is usually just a nuisance. There is no scientific evidence that ‘toxins’ from faeces in the bowel can affect your health. However, very occasionally it is a sign of serious disease such as cancer of the colon (large bowel). So it is very important that you see your doctor if any of the following applies to your symptoms. (If this is difficult for you, have a look at our section on seeing your doctor about an anal problem.)

Your constipation is a new symptom, and there is no obvious reason for it.
It is severe and changing your diet hasn’t helped.
The constipation alternates with diarrhoea.
You have noticed other symptoms, such as bleeding from the back passage (even if you think this is caused by piles), passing slime from the back passage, tummy pain, weight loss, and/or pain in the back passage when you strain to pass faeces.
Anyone in your family has had colon cancer.

You should also see your doctor if you are a woman and find that putting a finger in the vagina helps to pass faeces, because this may mean a weakness in the supporting tissues (known as a ‘rectocele’). This is not dangerous, but can be treated by a gynaecologist.

An underactive thyroid is an often overlooked cause of constipation, so see your doctor if you are also chronically tired, over-sensitive to cold or gaining weight, or if your hair is thinning.

Your diet

The best way to deal with constipation is to eat plenty of fibre. Fibre is not digested and absorbed in the intestines, so the stools are softer and more bulky, and it is easier for the bowel muscles to push them along. You may think you have a high-fibre diet, but in reality you may not be taking enough. In the UK, 100 years ago, we each consumed about 40 grams of fibre a day, but most of us now have less than 15–20 grams a day. Traditional African diets contain 50–150 grams of fibre a day.

Aim for at least 30 grams of fibre a day, which really means eating one fibre-rich food at every meal. If you suddenly increase the amount of fibre you eat, you may notice wind and bloating, so increase the amount slowly, over about 2 weeks, to allow your gut to adjust to the new diet.

In the past, doctors advised drinking lots of water to help constipation. Research has now shown this will not help (Prescriber 2010;21(11):24–9). However, if you are eating a lot of extra fibre it seems sensible to drink some extra water.

A simple way of increasing fibre in your diet is to:

change to wholemeal bread, and eat 2–4 extra slices a day
eat 2–3 extra helpings of fruit and vegetables a day
change to a wholewheat cereal (the packet will tell you)
add some raw bran to your cereal or yoghurt.

**Fibre checklist**
	Fibre content (in grams)
High-fibre foods
Bowl of All Bran	9.8
Bowl of muesli	6.2
Bowl of Bran Flakes	5.2
2 slices of wholemeal bread	4.1
1/2 large can of red kidney beans	12.4
1/2 large can of baked beans	7.6
Medium jacket potato	4.2
4 tablespoons of peas	4.1
5 dried apricots	5.8
5 prunes	4.9
100 g of Quorn	4.8

Medium-fibre foods
2 Weetabix	3.9
Bowl of Fruit’n Fibre	2.8
2 slices of ordinary brown bread	2.5
2 slices of white bread	1.1
3 tablespoons of cooked sprouts	3.1
2 tablespoons of cooked broccoli	2.3
3 tablespoons of cooked carrots	1.9
1/2 avocado	3.4
Apple (with skin)	3.1
Orange	2.7
Banana	2.2
1 tablespoon of peanuts	1.6
1 tablespoon of mixed nuts and raisins	1.1

Source: MeRec Bulletin 1999;10 (No 9).

Increase the amount of fibre gradually. A high-fibre diet is healthy for most people, but if you are elderly and not very mobile it can make the constipation worse. So check with your doctor. Some people find that high-fibre worsens bloating without improving constipation. And if you have a medical condition, such as heart failure, it may not be advisable to take so much fluid. Again, check with your doctor.

Think about your lifestyle

Inactivity can make the bowels sluggish, and doing more exercise can help to relieve constipation, especially if you are elderly. Changing patterns of shift work can upset the rhythm of your bowels. Similarly, it is quite common to be constipated at the beginning of a foreign holiday, especially if you have crossed time zones and are also eating foods that are different from your normal diet.

Toilet training (for adults)

Another reason for constipation is what doctors call ‘poor bowel habit’. This means ignoring the urge to have your bowels open, perhaps because you are too busy or you dislike using a lavatory away from home or near other people.

The problem with ignoring the urge to defecate is that, after a while, you stop feeling the urge. So don’t ignore it when your body tells you that you’re due to have your bowels open. And give yourself enough time for an undisturbed visit to the lavatory, preferably half an hour after breakfast.

Humans are probably meant to have our bowels open in a squatting posture – sitting on a lavatory is not the optimum posture. So, when you sit on the lavatory, prop your feet up on a footstool.

Don’t push and strain to pass faeces. This increases the likelihood of piles or painful anal cracks (anal fissure), and can be dangerous if you have high blood pressure. If nothing has happened after 10 or 15 minutes, go away and do something else, and try again later.

Dealing with painful anal conditions

If you have a painful anal condition, look at our sections on anal pain, piles (haemorrhoids) and anal fissure.

Do you need a laxative?

Laxatives should be a last resort; they are usually not necessary and can be habit-forming. Dozens of laxatives are available from pharmacies without a prescription, so if you have tried changing your diet and it hasn’t worked you may be tempted to try one. Before doing so, see your doctor. This is because constipation in most people is dealt with by increasing the fibre in the diet as above, by increasing the amount of fluid you drink and by taking more exercise. If this has not worked for you, there could be a more serious reason, which your doctor needs to sort out.

You may find that a laxative becomes less effective the longer you use it, so if you really need a laxative it is best to find two or three different ones that work for you, and rotate them. Keep the dosage to the minimum that is effective.

If your doctor decides there is nothing seriously wrong, a laxative might be appropriate, particularly if:

you have piles, and they bleed if you strain to pass faeces
you have bad angina, and your doctor has told you to avoid straining to pass faeces
you are elderly, and your tummy and pelvic muscles are weak, so passing faeces is difficult.

Types of laxative

Bulk laxatives (such as psyllium husk from health-food stores, bran, ispaghula husk, methylcellulose, sterculia) provide fibre in a concentrated form. They have to be taken with plenty of water, and it can be several days before they have an effect. They are the best type of laxative for long-term use.

Osmotic laxatives retain fluid in the bowel, which then softens the faeces. They may take several days to work. Examples of this type of laxative are: milk of magnesia, which is magnesium hydroxide; Epsom salts or Andrews Liver salts, which are magnesium sulphate; and laxatives containing polyethylene glycol. If you have kidney or heart failure problems talk to your doctor before taking this type of laxative, as they may not be suitable.

Stimulant laxatives (such as senna, bisacodyl) work by increasing contractions of the bowel, and so they can cause tummy cramps. The effect occurs within a few hours, so they are taken at night to produce a morning bowel action. Some experts think that if you use these regularly for years, the contractions of the large bowel (colon) may eventually become weakened, making the problem much worse than before, so this type of laxative is inadvisable for long-term use. Glycerol suppositories that you insert into the back passage (rectum) act as a stimulant because they are slightly irritant to the bowel.

Lactulose and lactitol are types of sugars that the body cannot digest, so they remain in the bowel where they act partly like fibre and partly like an osmotic laxative. They often cause bloating, wind and tummy cramps and have to be taken regularly for up to 3 days before having an effect.

Faecal softeners, such as sodium ducosate or ‘liquid paraffin’ from a pharmacy, lubricate and soften the faeces. Sodium ducosate encourages water into the faeces, whereas liquid paraffin probably acts by lining the bowel with a film of oil that stops water being absorbed into the body from the faeces. Liquid paraffin is also a mild stimulant. Faecal incontinence (soiling) can occur with this type of laxative. These laxatives are not suitable for long-term use.

If laxatives don't work

If laxatives do not relieve the constipation, your doctor may consider other treatments. Biofeedback is one possibility. Some people, most often young women, have a problem coordinating the muscles of the bowel, anus and pelvic floor. For example, when they are trying to pass faeces, they contract the anus muscle instead of relaxing it. Special feedback training can overcome the problem. This treatment is available in only a few specialist hospitals, and is reserved for people with a severe constipation problem.

Your doctor might suggest a medication called prucalopride. This is not a laxative, and is fairly new. It is used only by people in whom laxatives have not worked, and only in women. It can have side effects – headache (in 11%), nausea (in 95%), tummy pain (in 7%) and diarrhoea (in 6%) (Prescriber 2010;21(11):24–9).

Written by: Dr Margaret Stearn
Edited by: Dr Margaret Stearn
Last updated: Thursday, May 17th 2012

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Comments on this article

Posted by student on 31/01/2012 at 02:17

hi everyone I am the engineering student.I am suffering from constipation over 3 years but no medicine helped me.The main problem is foul smell(very bad) is from me and nobody sits with me....and i have a thyroid problem and i am using a iodine tablets for that and checked reports which are normal....I am very much depressed and i wanted to die....please anyone help me>>>>

Posted by Optional on 14/12/2011 at 07:54

I'm sure this is TMI, but I'm not the most "regular" gal on the block. As a gastric bypass surgery patient, I am prone to constipation. I also take iron and calcium supplements which exacerbate things quite a bit. When I mentioned this to one of my doctor's nurses, she recommended the Fiber Cleanse from Lady Soma products. It was very easy to use; I just take with a glass of water once a day. Most importantly, this stuff works!! I find it's better to take it on a regular basis, rather than waiting to get constipated and then taking it. I feel good taking it every day because I know it is all natural, and it keeps me nice and regular.

Posted by Optional on 14/04/2011 at 09:21

Million thanks for this article, it is a life saver!

Posted by Puri on 30/10/2009 at 06:44

My 2 year child constipated for long time. He passes small amount stool once in 15 days. He has symptoms loose of appetite and his intestines expanded to an extraordinary size We use to bowel him with glycerin suppository.

Posted by Anonymous on 09/10/2009 at 08:40

I had terrible constipation for a year before doing much about it. I was only able to pass a small amount every week and my intestines expanded to an extraordinary size.. Now fortunately my situation is improving with doses of parrafin oil daily. If wind and other IBS symptoms are also present, see a doctor as you may have fructose malabsorption. (I have it) ***beware of fibre supplements. mainly eat a very fibrous diet as fibre supplements merely add to the blockage (they bulk the faeces). eat a lot of vegetables and 2 pieces of fruit.

Posted by palfiova on 14/08/2009 at 07:46

I am constipated for long time. I pass the stool once in three weeks. I have symptoms :passing slime from back passage ,bloated tammy,loose of appetite.