Constipation: What It Is And How To Effectively Manage It

Constipation is one of the commonest complaints that patients visit the community pharmacy or health facility with. Constipation affects all age groups. 

It is very subjective and the mere complaint of it needs further probing. Patients who pass hard stools may complain they are constipated. Others who do not pass stools at all for a day or more and those who strain to pass stools would also describe that as constipation. 

All the above descriptions of constipation are not wrong and would always require the intervention of a health professional which could be with the use of medicines (pharmacologic) or not (non-pharmacologic).

What are the signs and symptoms of constipation?

Constipation is defined as less frequent evacuation of the bowels (less than three times in a week) with difficulty in passing a stool. However, it is best defined by the sufferer and would encompass symptoms such as; 

• difficult bowels movements, 
• passing hard stools, 
• incomplete bowel evacuation, 
• infrequent passing of stools, 
• straining to pass stools
• inability to pass flatus or 
• colicky abdominal pain with or without vomiting. 

Signs of constipation include: 

• frequent high pitched bowel signs, 
• absent bowel sounds or 
• general peritonitis.

What are the causes of constipation?

Constipation may be due to behavioral or non-behavioral causes. Behavioral causes include sedentary lifestyle (lack of exercise), taking diet with low or no roughage, failure to visit the toilet despite the urge,  inability to drink a lot of fluids, chronic use of stimulant laxatives and failure to eat.

The non-behavioral causes could be due to an underlying medical condition or various medications which the patient is on. These are; 

• hypothyroidism, 
• hypercalcemia, 
• medications (opioids, tricyclic antidepressants, aluminium and calcium antacids, calcium channel blockers, alpha blockers, statins etc.), 
• depression and anxiety disorders, 
• intestinal obstruction, 
• irritable bowel syndrome, 
• anal fissures, 
• haemorrhoids, 
• carcinoma of the colon or rectum, 
• pregnancy, 
• spinal cord injury (causing damage to spinal nerves), 
• aganglionic and acquired megacolon and foreign body obstruction of the colon.

With the above numerous causes of constipation, it is necessary that one visits their clinician or pharmacist (for primary care and referral when the need be) for thorough assessment.  

How can constipation be prevented?

To prevent constipation; 

• there is the need to increase the amount of roughage/fiber in your diet and sources are fruits (mangoes, oranges, bananas, apples, pears etc), cereals, legumes, whole grain bread and leafy or fruit vegetables 
• There is also the need to drink a lot of fluids
• Do exercises such as walking, jogging and stretching 
• There is also the need to respond to nature’s call when the urge is there and avoid overuse of laxatives to induce defecation 

How is constipation treated?

Treatment of constipation is based on lifestyle modification or use of various drugs or both. The preventive measures above are also the behavioral modifications that must be observed to facilitate defecation when one is constipated.

Pharmacological management of constipation involves the use of various laxatives such as 

• Ispaghula husk 
• Methylcellulose tablets 
• Lactulose 
• Magnesium only antacids 
• Bisacodyl tablets and suppositories 
• Senna 
• Liquid paraffin 
• Docusate sodium 
• Co-danthramer and co-danthrusate
• Sodium picosulphate enema
• Phosphate enema
• Macrogol enemas  
• Glycerine suppositories

Surgical interventions are required when there is intestinal obstruction, carcinoma, spinal cord injury, aganglionic megacolon, foreign body obstruction amongst others.

For patients who are on medications for a particular therapy, discontinuation of the medicines is not required unless advised by a medical doctor. Various laxatives or medications would be used to relieve the constipation whilst you continue your current medical therapy. 

Are there herbal medicines for treating constipation?

As we are in the era of integrative medical practice, there are various alternative medicines (herbal medicines) that also improve bowel movement and they are; 

• psyllium and ispaghula husk (they are bulk forming laxatives; they act by increasing fecal bulk by retaining water which results in movement in the intestines – peristalsis. They are not digested); 
• cascara, Senna, rhubarb, slippery elm and aloe are stimulant laxatives due to the presence of anthraquinones and they stimulate/irritate the colonic nerve to cause peristalsis and consequently bowel movement. 

Taking bulk laxatives like ispaghula, psyllium or methylcellulose requires intake of a lot of fluids to cause bowel movement. Failure to drink enough fluids would result in bowel obstruction and worsening of the constipation. 

To add, patients with obstructed bowel or fecal impaction or colon atony should not take bulk forming laxatives because they would worsen the constipation. 

Furthermore, prolong intake of stimulant laxatives like senna or cascara can cause lazy bowel syndrome which means one would always have difficult or painful bowel movement unless the person takes these laxatives.  

Are there any side effects to these medicines?

Some side effects of these herbal laxatives are 

• fluid and electrolyte disturbances 
• diarrhoea 
• abdominal cramps 
• elevation of liver enzymes or liver failure
• pseudomelanosis coli 
• bloating (often associated with bulk forming laxatives) and nausea amongst others.

Can constipation result in other complications?

Long standing constipation can lead to; 

• rectal bleeding due to anal fissures 
• rectal prolapse
• piles 
• fecal impaction 

All these complications are serious and would require a medical professional’s intervention. 

To conclude, constipation affects all age groups and can be from an underlying medical problem or behavioral issues. 

At all times, it is appropriate to visit your pharmacist or a medical practitioner or clinician to permit early detection of danger signs which signals a serious underlying medical problem to facilitate early intervention. 

It is however still imperative for you to observe the various preventive measures to avoid being constipated.