Constipation has many different defining factors including stool weight, frequency, and consistency. A general guideline for the accepted normal range of bowel frequency is anywhere from 3X/day to 3X/week. As many people fall within this “normal” range, they often have symptoms that are associated with a change in their regular patterns, enough to complain about, which then becomes defined as constipation. These symptoms include straining to defecate, abdominal pain, bloating or a feeling of incomplete rectal emptying after going to the bathroom.
Constipation can be caused by many different things. These include but are not limited to:
- Foods or substances that irritate the lining of the bowel causing inflammation or taking supplements like iron and calcium
- Scar tissue adhesions from either within the large or small intestine or from outside such as with hysterectomy, appendectomy or other belly scars
- A simple lack of fluid or fiber to move material through the bowels
- Anorectal factors such as uncoordinated pelvic floor muscle control between the rectum and the anal sphincter (anismus or dysynergia), pudendal nerve pathology or pelvic parasympathetic nerve damage
- Metabolic and hormonal factors such as diabetes, thyroid issues or electrolyte abnormalities (hypercalcemia, hyponatremia, hypokalemia) can cause delayed intestinal transit
- Poor posture that compresses the abdomen
- Systemic diseases and neurological disorders like scleroderma or multiple sclerosis
- Drug therapy and medications, especially opiates
- Psychological factors like anxiety or irritable bowel syndrome
- Excessive alcohol intake affects gut bacteria and is a diuretic
- Not enough exercise and high intra-abdominal pressure
Pharmaceutical use commonly associated with constipation:
Anticholinergics, antidepressants, beta blockers, calcium channel blockers, cholestyramine, diuretics, narcotic analgesics, phenothiazines and sucralfate. Over the counter medications include aluminum containing antacids, kaopectate and loperamide.
Treatment for constipation varies widely from diet changes to pelvic physical therapy to both natural and pharmaceutical remedies. Dietary fiber and plenty of water must be optimized!! Key word is optimized as excessive fiber can aggravate symptoms like bloating and actually cause so much bulk in the stool that it becomes very difficult to pass. A reasonable goal would be 30g of fiber/day. Laxative therapy is sometimes necessary but with episodic dosing, not continuous dosing. The types of laxatives include stimulants (Ex-Lax, Senecot, dulcolax), bulking (fiber, Citrucel, Benefiber, Metamucil, Fibercon), osmotic (Colace or docusate), lubricant (mineral oil, caster oil), and emollient (Fleet, Milk of Magnesia, Miralax, Kristalose).
Stimulants are for instant relief and should not be used regularly as they will decrease your body’s own ability to defecate naturally causing laxative dependency. They can also cause abdominal cramping and diarrhea. Bloating, cramping and flatulence can occur with adding more bulk or fiber to the diet. You must off set this with lots of water and make sure you are using an appropriate bulking fiber for you. Osmotics have a surfactant that helps to “wet” and soften the stool. It might take a week or longer for osmotic laxatives to be effective. Lubricant laxatives make stools slippery. The mineral oil within these products adds a slick layer to the intestinal walls and stops the stool from drying out. These are best used as a short-term cure for constipation. If used for a longer period, mineral oil can absorb fat-soluble vitamins from the intestine, and decrease certain prescription drugs from being fully absorbed into the body. Do not take mineral oil at the same time as other medications or supplements. Emollients are hydrating agents that draw fluids into the intestine from the surrounding tissues. More water in the intestine results in softer stools that are easier to pass.
More natural remedies include dietary additives like prunes or prune juice, rhubarb, and apple cider. Molasses and honey are both mild laxatives but they are high in calories so keep that in mind. Magnesium Citrate is very effective because it actually battles blockages in two ways. Muscle relaxation is one way in that it sooths and relaxes the muscles used in digestion. It is also a water magnet. Start at 300-600 mg and work up or down as needed. Ester-C or buffered vitamin C will also speed up the digestive process. For adults, adding 2,000-5,000mg/day can help with constipation but split up the doses and add slowly to avoid flatulence. Probiotics are essential in keeping the gut flora in balance, which is crucial in regulating fecal processing. A recent large probiotic study completed in France, UK and Germany identified Bifidobacterium lactis BB-12, which is a specific strain of lactobacilli acidophilus, as a very effective natural combatant to constipation. Very importantly, there must be exercise in the equation. Just as exercise keeps your body, heart, muscles, etc moving, so it keeps your gut moving. Sedentation of the body leads to sedentation of the intestinal system. Start with a gentle 30 minutes 4-5X/wk. Use of a “Squatty Potty” which is a modified foot rest for use in the bathroom will promote a better mechanical position of the pelvic musculature for easier defecation.
Here at Hands On, we can use pelvic physical therapy to evaluate and determine if there are contributing factors like dysynergia, high pelvic muscle tone, high intra-abdominal pressure and behavioral issues that can be treated with a manual therapy approach and behavior modification as well as help you work through the many other variables that can contribute to constipation. Just becoming more aware of the tightness or lack of muscular control of the pelvic floor can help with constipation without negative side effects.
Katrina Barton, LPT
 Dorte Eskesen, Lillian Jespersen, Birgit Michelsen, Peter J. Whorwell, Stefan Müller-Lissner and Cathrine M. Morberg. (2015)Effect of the probiotic strain Bifidobacterium animalis subsp. lactis, BB-12®, on defecation frequency in healthy subjects with low defecation frequency and abdominal discomfort: a randomised, double-blind, placebo-controlled, parallel-group trial. British Journal of Nutrition, available on CJO2015.