Constipation – Your Questions Answered

We’ve all probably experienced this at some point in our lives – where the inability to move our bowels can leave us feeling extremely uncomfortable. General surgeon Dr Lim Jit Fong answers some of the frequently asked questions surrounding constipation.

What is Constipation?

Constipation is defined medically as having less than 3 bowel movements per week.

Along with having limited bowel movement, constipation may cause one to feel bloated from a distended abdomen or even experience intermittent abdominal cramping pain. If the constipation is severe, the sufferer may even develop a loss of appetite. Hard stools may be common, but it isn’t always the case. Constipation though, often causes one to strain hard while trying to pass motion, and may lead to secondary problems such as bleeding from haemorrhoids or anal pain from anal fissures.

These symptoms are often confused with a related condition called dys-synergic defaecation. This refers to the need for excessive abdominal straining to defaecate, even when one may have regular, daily bowel movement.

However, many people who move their bowels every 2 – 3 days can still complain of abdominal bloating, cramps and hard stools which are difficult to evacuate. This is quite common and can be treated similarly to constipation.

What are the common causes of constipation?

Most patients with constipation have primary constipation (functional constipation) where no secondary causes can be found. The second group is secondary constipation, where the constipation is caused by use of medication or caused by another medical condition such as hypothyroidism.

There is a third group, congenital constipation. This involves infants who are born with constipation. These infants may have been born with fewer nerves in their bowels which do not allow the colon to function normally. An example of this category is Hirschsprung’s disease.

When should you see a doctor to evaluate the cause of constipation?

If you have infrequent bowel movement but do not have any symptoms from constipation, there is no urgency to seek medical advice.

However, if the constipation is a recent or sudden occurrence, a medical consultation would be needed. Especially if abdominal or anal pain, bloating or anal bleeding is experienced.

How will the doctor assess your constipation?

A detailed history of your diet, daily schedule, lifestyle (including exercise habits) and medication is required. Occasionally, an abdominal x-ray may be performed to determine the severity of your constipation. Blood tests are often used to rule out other medical conditions which may present as constipation. If your doctor suspects a growth or cancer in the colon, they may recommend a colonoscopy. When all secondary causes of constipation have been ruled out, your doctor may request a colonic transit marker study.

What is a colonic transit marker study?

This is a simple outpatient test where patients will be asked to swallow a capsule containing 24 plastic markers. An abdominal x-ray is taken 5 days later and the location (as well as number) of retained markers are recorded. This test helps to identify the most severe cases of constipation which may require surgery.

Is my constipation treatable?

Nobody needs to suffer from constipation as it is very treatable. The aim of treatment is to relieve symptoms that patients might have. Bowel movement does not have to happen daily, as long as symptoms from constipation are not experienced.

Treatment involves modifications to your diet and lifestyle. Medications (such as laxatives) may be helpful to maintain a regular bowel habit.

In some patients, anorectal biofeedback (a form of pelvic floor rehabilitation physiotherapy) can provide dramatic improvement especially for patients with constipation and dys-synergic defaecation simultaneously. Surgery is rarely required except for the most severe cases.

Does constipation lead to cancer?

Constipation is not associated with an increased risk of cancer. However, as the incidence of constipation is high among the average population, it is not uncommon to find a patient with colorectal cancer who has a preceding history of long-standing constipation.

A note of caution must be mentioned for patients with sudden onset constipation. If one develops constipation over a few days to a few weeks, but has had normal bowel habits previously, see a doctor to rule out the possibility of colorectal cancer causing partial bowel obstruction. In patients with partial bowel obstruction, they complain of abdominal distension and cramps that is relieved by passing bowel movement. They also have less stools passing through the narrowed part of the bowel hence fewer bowel movements (constipation).

Does taking laxatives regularly lead to dependence or worsening constipation?

Laxatives used at the prescribed dosages by your doctor are very safe. They are used to help constipated patients contract the bowel wall harder to push the stools toward the rectum and anus. Some laxatives also soften or liquefy hard stools so that it is easier to pass the stools. Please remember that laxatives are prescribed for patients with constipation or dys-synergic defaecation and not for people with normal bowel movements.

The term "laxative abuse" was coined a long time ago and refers to patients with normal bowel habits who take laxatives for reasons other than to regulate their (already) normal bowel habits. Examples of laxative abusers are anorexics and Munchausen Syndrome sufferers (people who fake an illness to get attention).

If you have to take laxatives to improve your constipation (and it works), you do not need to fear that you will develop worsening constipation in the future.