Constipation (cont.)

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What is the approach to the evaluation and treatment of constipation?

There are several principles in approaching the evaluation and treatment of constipation.

  • The first principle is to differentiate between acute (recent onset) and chronic (long duration) constipation. Thus, with acute constipation or constipation that is worsening, it is necessary to assess for the cause early so as not to overlook a serious illness that should be treated urgently.
  • The second principle is to start treatment early and use the treatments that have the least potential for harm. This will prevent constipation from worsening, and it also will prevent potential damage to the colon that can be caused by the frequent use of stimulant laxatives.
  • The third principle is to know when it is time to evaluate the cause of chronic constipation. Evaluation for the cause of chronic constipation needs to be done if there is no response to the simple treatments.

The goal of treatment in constipation should not be a bowel movement every day, but a bowel movement every two to three days without difficulty (without straining).

Start with the simple things.

  • Don't suppress urges to defecate. When the urge comes, find a toilet.
  • With the assistance of your physician and pharmacist, determine if there are drugs that you are taking that could be contributing to the constipation. See if the drugs can be discontinued or changed.
  • Increase the fiber in your diet by consuming more fruits, vegetables, and whole grains. (There are other health benefits from this recommendation as well.)
  • It may be difficult to get enough fiber in the diet to effectively treat constipation, so don't hesitate to take fiber supplements if necessary (wheat bran, psyllium, etc.).
  • Use increasing amounts of fiber and/or change the type of fiber consumed until there is a satisfactory result.
  • Don't expect fiber to work overnight. Allow weeks for adequate trials.

What if constipation does not respond to these simple, safe measures? These efforts should not be discontinued but other measures should be added. If the constipation is infrequent, that is, every few weeks (as it can be when due to the menstrual cycle), it probably doesn't matter what other measures are added-emollient, saline, or hyper-osmolar laxatives, enemas, and suppositories. Even stimulant laxatives every four to six weeks are unlikely to damage the colon. Unfortunately, the tendency when using stimulant laxatives is to unconsciously increase the frequency of their use. Before you know it, you're taking them every week, or more often, and permanent damage might result.

If constipation is a continuous rather than an intermittent problem, probably the safest laxatives to take on a regular basis are the hyper-osmolar laxatives. Their use should be supervised by a physician. As with fiber, increasing doses of different hyper-osmolar laxatives should be tried over several weeks until a satisfactory type and dose of laxative is found. Hyper-osmolar laxatives, however, can be expensive. Milk of magnesia is the mildest of the saline laxatives, is inexpensive, and provides a good alternative. Most patients can adjust the dose of milk of magnesia to soften the stool adequately without developing diarrhea or leakage of stool.

Prunes and prune juice have been used for many years to treat mild constipation. There is no evidence that the mild stimulant effects of prunes or prune juice damage the colon.

Stronger stimulant laxatives usually are recommended only as a last resort after non-stimulant treatments have failed.

Many people take herbs to treat their constipation because they feel more comfortable using a "natural" product. Unfortunately, most of these herbal preparations contain stimulant laxatives and their long term use raises the possibility that they also may damage the colon.

Medically Reviewed by a Doctor on 7/15/2014

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