Constipation is a common and often overlooked problem, particularly among the elderly. It is not a disease, and is defined as having a bowel movement fewer than three times a week. It is often accompanied by straining, pain, hard, lumpy stools, feelings of incomplete emptying, and, in the elderly, urinary retention. Using fingers to extract stools, enemas, or laxatives is often tried by sufferers. Prolonged, untreated constipation can lead to piles, anal fissures, faecal impaction, and rectal prolapse. Several medical conditions can mimic constipation. It usually results from low fibre intake, dehydration, lack of activity, ignoring bowel urges, or underlying medical conditions. Management involves a high fibre diet, drinking more water, an active lifestyle, regular exercise, and establishing a regular toilet routine to avoid ignoring urges, though it can become a complex, chronic issue requiring personalised care. Eubiosis, or restoring the balance for beneficial gut bacteria to thrive and outnumber harmful ones through probiotics, prebiotics, and beneficial compounds like theaflavins, is essential for health, supporting digestion, immune function, and gut barrier integrity. 95% of constipation in children is functional, often linked to lifestyle, and should be managed by a paediatrician.
COMMON CAUSES OF CONSTIPATION:
Low intake of fibre (fruits, vegetables, sprouts, whole grains) and high consumption of processed foods, including white rice and white pasta, baked foods (bread, cookies, cakes), dairy, eggs, or meat, as animal sources do not have fibre. High consumption of tannin-rich foods can reduce digestive efficiency, inhibit bowel movement, and cause constipation. Foods high in fat and protein take longer to digest, slowing down bowel transit time.
Lack of adequate water intake causes the large intestine (colon) to absorb more water, making stool hard and difficult to pass. Alcohol and caffeine act as diuretics, leading to dehydration and hard stools.
A sedentary lifestyle or lack of regular physical exercise.
Frequently delaying or ignoring the urge to have a bowel movement, often due to stress or lack of a clean toilet. Bacteria in the gut then break down the fibre in the stools, leading to bloating, flatulence, and hard stools.
Change in routines during travel, or in diet or eating habits, or in sleeping patterns.
Commonly used medications include pain relievers (opioids), antacids containing aluminium or calcium, iron supplements, calcium channel blockers (for hypertension, angina, and certain arrhythmias), some anti-nausea drugs, antihistamines, anticholinergic antispasmodic drugs used for overactive bladder and spasmodic pain, diuretics, AI-generated image Parkinson’s disease medications, anticonvulsants, antipsychotics, and antidepressants. These drugs often slow down bowel transit time.
Pregnancy or medical conditions like hypothyroidism, diabetes, irritable bowel syndrome (IBS), multiple sclerosis, Parkinson’s disease, pelvic floor dyssynergia, and other neurological disorders.
Pain during bowel movements due to anal fissures, etc., can cause voluntary holding, leading to constipation.
CONSTIPATION REQUIRING MEDICAL INTERVENTION:
Prolonged constipation or associated symptoms should not be ignored.
Duration of more than three weeks.
Rectal bleeding or blood in the stool.
Severe, constant abdominal or rectal pain.
Unexplained weight loss, fever, or vomiting.
Inability to pass gas, as it may indicate a bowel obstruction or ileus (lack of bowel movement) secondary to sepsis or an intra-abdominal catastrophe.
Faecal impaction – dried, hard stool that cannot be passed, causing severe abdominal cramping pain, bloating, leakage of liquid stool around it, which is mistaken for diarrhoea (“pseudo-diarrhoea”).
Any of the complications listed below.
COMPLICATIONS OF CHRONIC CONSTIPATION:
Prolonged constipation can lead to:
Piles (Haemorrhoids) and bleeding – swollen blood vessels in the anus caused by straining.
Anal Fissures – small tears in the anus caused by passing hard stool.
nHernia an internal body
organ that pushes through the wall of muscle that surrounds it, due to prolonged, frequent straining.
Rectal Prolapse – the weakening of muscles causing part of the rectum to emerge from the anus.
STOOLS:
Faeces, stools, or poop are solid or semi-solid undigested remains of food, also containing water (about 75%), bacteria, mucus, and dead cells. It is typically brown in colour, with a soft consistency. White colour occurs in jaundice, red colour may indicate lower intestinal bleeding, and black suggests upper gastrointestinal issues. Frequency varies, generally ranging from three times a day to three times a week. It is important to observe it before flushing it, as it is a critical indicator of digestive health. It is classified into 7 types on the Bristol Stool Chart below (The choice of adjectives is not mine). Types of mucus flecks are suggestive of Cholera.
TENESMUS: It is not constipation. It is the constant, painful urge to defecate even when the bowels are empty. It is primarily caused by inflammation, infection, or motility issues in the rectum and colon, including inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), rectal infections, chronic constipation, mucosal prolapse-piles, pelvic floor disorders, damage to the rectal lining following radiation therapy for cancer (radiation proctitis), and colorectal cancer. Persistent, worsening symptoms, especially when accompanied by bleeding, severe pain, or unexplained weight loss, warrant immediate medical evaluation.
3 and 4 are healthy, easy-to-pass stool, while Types 1-2 suggest constipation and 5-7 indicate diarrhoea or loose stool.
Type 1: Separate hard lumps, like nuts or pebbles (hard to pass; indicates constipation).
Type 2: Sausage-shaped but lumpy (indicates constipation).
Type 3: Like a sausage but with cracks on the surface (normal/healthy).
Type 4: Like a sausage or snake, smooth and soft (ideal/healthy).
Type 5: Soft blobs with clear-cut edges (lacking fibre or quick transit).
Type 6: Fluffy pieces with ragged edges, a mushy stool (indicates mild diarrhoea or inflammation).
Type 7: Watery, no solid pieces (entirely liquid; diarrhoea).
DIAGNOSTIC STOOLS:
Some types of stools are typical of an infection or other cause.
Black, sticky, and foul-smelling stool (melena) often indicates bleeding in the upper gastrointestinal tract, such as from a stomach ulcer or severe gastritis.
Bright red blood (Haematochezia) indicates lower GI bleeding (Piles, fissures, IBD, etc).
Greasy stool (Steatorrhea) indicates malabsorption syndrome or pancreatic issues.
Pea-soup stool is associated with typhoid fever (Salmonella Typhi).
Bloody, mucoid diarrhoea suggests shigellosis, invasive E. coli, or Entamoeba histolytica.
Greenish, watery stool is common in many acute viral or bacterial gastroenteritis cases.
Rice-water stool – pale, cloudy, white liquid with
CONDITIONS OFTEN MISTAKEN FOR CONSTIPATION:
- Irritable Bowel Syndrome (IBS), Crohn’s disease, or ulcerative colitis can cause rectal inflammation (proctitis), resulting in a constant urge to defecate (tenesmus).
- Pelvic Floor Dysfunction (Outlet Dysfunction), due to (Dyssynergic defecation or Anismus), when the pelvic floor muscles contract instead of relaxing when you try to pass stool, causing straining or the sensation that stool is stuck, even if the stool is soft.
- A rectocele is common in women, where the rectum bulges into the vagina, allowing stool to become trapped.
- Rectal Prolapse, where part of the rectum protrudes out of the anus, leading to the sensation of something still being inside, which is often mistaken for “being constipated”.
- Piles and Anal Fissures can create a false sensation of needing to pass more stool, often leading to excessive straining.
- A growth (colorectal cancer or polyps) in the rectum can give a sensation of incomplete evacuation.
A loss of sensation in the rectum, sometimes caused by nerve damage, can lead to the feeling that you may not have finished. - In obstructed defecation syndrome, the person feels an inability to defecate when desired, or inadequate quantity or frequency of defecation. This can be for a variety of reasons, both mechanical (solitary rectal ulcer syndrome or causes listed above) and psychological (anxiety, depression, phobias, OCD (obsessive-compulsive disorder), and eating disorders). They spend a lot of time on the toilet, waiting or straining to defecate. Eventually, anxiety and excessive straining and passage of hard stools deteriorate the muscles and nerves involved, adding to the problem.
- Intestinal obstruction caused by hernia, scar tissue (adhesions), tumour, etc., prevents the passage of stool.
Constipation is usually a lifestyle issue involving junk food, inadequate hydration, a sedentary lifestyle, stress, and certain medications, and can be resolved with changes in diet and lifestyle.
Sometimes it can be complex enough for detailed investigations, including digital rectal exam, defecography, anorectal manometry, and personalised management, including biofeedback therapy, psychotherapy, and surgery.
