What Is Chronic Constipation?
Chronic constipation is a common digestive condition characterized by infrequent bowel movements, difficulty passing stool, or a sensation of incomplete evacuation that persists for three months or longer. While the normal frequency of bowel movements varies widely among individuals, having fewer than three bowel movements per week is generally considered constipation.
Chronic constipation affects approximately 16% of adults in the United States, with prevalence increasing with age. It is more common in women and significantly impacts quality of life, productivity, and healthcare costs. Importantly, chronic constipation is not simply an inconvenience; it can indicate underlying conditions that require medical evaluation.
Common Symptoms
Chronic constipation is defined by the presence of two or more of the following symptoms for at least three months:
- Fewer than three spontaneous bowel movements per week
- Hard, lumpy, or pellet-like stools
- Excessive straining: Needing to push hard during bowel movements
- Sensation of incomplete evacuation: Feeling as though you cannot fully empty the rectum
- Sensation of blockage: Feeling an obstruction in the rectum or anus
- Manual maneuvers: Needing to use fingers to assist with stool removal or support the pelvic floor
- Abdominal bloating and discomfort
- Decreased appetite and nausea
Causes and Risk Factors
Chronic constipation can be broadly categorized into primary (functional) and secondary causes:
Primary (Functional) Constipation
- Normal-transit constipation: The most common type, where stool moves through the colon at a normal rate but patients still experience difficulty with evacuation or hard stools
- Slow-transit constipation: Reduced colonic motility causes stool to move through the colon abnormally slowly
- Dyssynergic defecation (pelvic floor dysfunction): Inability to coordinate the abdominal, rectal, and pelvic floor muscles necessary for normal defecation
Secondary Causes
- Medications: Opioids, iron supplements, calcium channel blockers, anticholinergics, antidepressants, and antacids containing aluminum
- Metabolic and endocrine conditions: Hypothyroidism, diabetes, hypercalcemia, and hyperparathyroidism
- Neurological disorders: Parkinson's disease, multiple sclerosis, spinal cord injuries, and stroke
- Structural abnormalities: Colorectal strictures, rectocele, or obstructing tumors
- Lifestyle factors: Low-fiber diet, inadequate fluid intake, sedentary lifestyle, and ignoring the urge to defecate
- Psychological factors: Depression, anxiety, and eating disorders
Diagnosis
Dr. Khan takes a thorough and systematic approach to diagnosing chronic constipation, which may include:
- Detailed medical history: Including bowel habits, dietary patterns, medications, and symptom timeline
- Physical examination: Including a digital rectal exam to assess sphincter tone, rectal masses, and pelvic floor function
- Blood tests: To screen for thyroid dysfunction, diabetes, calcium levels, and other metabolic causes
- Colonoscopy: Recommended to rule out structural causes such as polyps, strictures, or colorectal cancer, especially in patients over 45 or those with alarm symptoms
- Anorectal manometry: A test measuring the pressures and coordination of the muscles used during defecation
- Balloon expulsion test: A simple bedside test to evaluate the ability to evacuate a water-filled balloon from the rectum
- Colonic transit study: Swallowing a capsule containing radiopaque markers followed by abdominal X-rays to determine how quickly stool moves through the colon
- Defecography (MR or fluoroscopic): Imaging of the pelvic floor during simulated defecation to identify anatomical or functional abnormalities
Treatment Options
Treatment is tailored to the underlying cause and severity of constipation. Dr. Khan employs a stepwise approach:
Lifestyle and Dietary Modifications
- Gradually increase dietary fiber intake to 25 to 30 grams per day through fruits, vegetables, whole grains, and legumes
- Drink adequate fluids, aiming for at least 6 to 8 glasses of water daily
- Engage in regular physical activity, which stimulates colonic motility
- Establish a consistent bowel routine, such as attempting a bowel movement at the same time each day, ideally after meals
- Respond promptly to the urge to defecate rather than postponing
Over-the-Counter Options
- Fiber supplements: Psyllium (Metamucil), methylcellulose (Citrucel), or wheat dextrin
- Osmotic laxatives: Polyethylene glycol (MiraLAX), lactulose, or magnesium hydroxide (Milk of Magnesia)
- Stool softeners: Docusate sodium for mild cases
- Stimulant laxatives: Bisacodyl or senna for occasional use when other agents are insufficient
Prescription Medications
- Linaclotide (Linzess): A guanylate cyclase-C agonist that increases intestinal fluid secretion and accelerates transit
- Plecanatide (Trulance): Works similarly to linaclotide with potentially fewer side effects
- Lubiprostone (Amitiza): A chloride channel activator that increases fluid secretion in the intestines
- Prucalopride (Motegrity): A selective serotonin receptor agonist that stimulates colonic motility
- Naloxegol or methylnaltrexone: Specifically for opioid-induced constipation
Pelvic Floor Biofeedback Therapy
For patients diagnosed with dyssynergic defecation, biofeedback therapy is the treatment of choice. This specialized physical therapy retrains the muscles involved in defecation and has demonstrated success rates of 70 to 80% in well-selected patients.
Surgical Options
Surgery is rarely needed but may be considered in severe cases of slow-transit constipation that have failed all medical therapies. Options include subtotal colectomy with ileorectal anastomosis.
When to See a Doctor
You should consult a gastroenterologist if you experience:
- Constipation lasting more than three weeks despite lifestyle modifications
- A significant change in bowel habits, especially after age 45
- Blood in the stool or on toilet paper
- Unexplained weight loss
- Severe abdominal pain or bloating
- Pencil-thin stools or progressively worsening symptoms
- A family history of colorectal cancer or inflammatory bowel disease
- Dependence on laxatives for regular bowel movements
Dr. Amber Khan at GastroCares provides thorough evaluation and individualized treatment for chronic constipation, helping patients restore comfortable, regular bowel function and improve their daily quality of life.