Derrick Garwood, Freelance Medical Writer and Editor

Scribbled on the lavatory wall of the Earl of Leicester’s Norfolk mansion (seat?) are the following lines:

Fair Cloacina, Goddess of this place, Look on thy suppliant with a smiling face. Soft, yet cohesive, let my offering flow, Not rudely swift nor insolently slow.

They are attributed to Byron – only he, perhaps, would describe the misery of constipation as insolence!

Most people experience constipation at one time or another, with estimates as high as 10% of the adult population at any one time. The proportion increases dramatically with age; up to 26% of men and 34% of women over 65 are sufferers, and more than 75% of elderly patients in US hospitals or nursing homes use laxatives to regulate bowel function. In that country alone, constipation-related complaints account for more than 2.5 million visits to the doctor each year, the population spending more than $400 million dollars on laxatives in the same period. However, the definition of constipation differs dramatically from person to person. Although studies have shown that 95% to 99% of a healthy population defaecate at least three times per week, ‘normal’ can be anything from three times a week to three times daily depending upon the individual. Some people worry entirely unnecessarily if they do not pass a motion every day.

Many clinicians use the ‘Rome criteria’, which define constipation as infrequency of bowel movement (fewer than 2 motions per week) plus the presence of hard stools, straining or incomplete evacuation at least 25% of the time for a period of three months. But as this site describes in detail, constipation is essentially a symptom defined by patient rather than doctor. Given the variance in habitual bowel function, a patient may well perceive constipation or severe discomfort whilst still not conforming to these guidelines, and subjective assessment methods are explored on a different page.It is important to distinguish between occasional constipation in otherwise healthy adults and chronic idiopathic constipation. The former has a number of common causes, usually related to diet or lifestyle, and a good overview can be found here. A lack of dietary fibre, reduced liquid intake, lack of exercise, changes in routine, repeated ignoring of the urge to defaecate, or pregnancy, can all impact on bowel function. Medication can also be to blame: opioids, antacids containing calcium and aluminium, calcium channel blockers used to treat high blood pressure, antiparkinson and antispasmodic drugs, tricyclic antidepressesents, anticonvulsants, diuretics, antihypertensive agents and iron supplements may all be culprits.

Most occasional constipation does not require clinical treatment, and can be addressed by increasing the intake of liquid and dietary fibre. One patient information site, complete with less than fetching animation, can be found here, whilst this site investigates commercially available fibre supplements. The majority of research also indicates that exercise can be beneficial in stimulating bowel movement, although precisely why is uncertain.

In the majority of cases, clinical management of acute constipation is limited to careful use of laxatives andor enemas, followed by long-term advice on diet. An account of different types of laxative treatment is available here. Detailed information on the function and side effects of different agents can be found at here, whilst York University thoughtfully provides clinical evaluation of individual laxatives, and comparisons, in this report. There is widespread concern about the possible consequences of long term stimulative laxative use, particularly by patients self-medicating. Over time, the bowel can becoming dependent on laxatives to function, and prolonged use can damage nerve cells in the colon and interfere with its natural ability to contract.

If constipation is chronic, a number of examination techniques can be used to help determine diagnosis and treatment. Physical examination can be enough to identify diseases such as scleroderma or obstipation. Blood tests can help eliminate endocrinal causes. Large amounts of stool in the colon will show up on a basic radiograph, and a spectacular example can be seen here. Barium enemas, by outlining the anatomy of the colon or rectum, can detect tumours or strictures, and defaecographs enable pelvic floor muscle movement and the process of defaecation itself to be monitored. Likewise, anal and rectal muscle function can be assessed by an ano-rectal motility study. If necessary, a colonoscopy can investigate the function of colonic nerves and muscles. Lastly, colonic transit studies – where capsules containing plastic markers are swallowed and regular scans taken to show their progression through the bowel – are described here, and illustrated here.

For those with irritable bowel syndrome, bouts of constipation may alternate with severe diarrhoea. The Rome II diagnostic criteria for IBS, plus links to detailed relevant information, can be found here. Hormonal determinants – changes due to pregnancy or menstruation, diabetes, hypothyroidism, hypopituarism or other endocrine disorders – can be explored in detail here, along with links to less common physical causes. On rare occasions, constipation results from gastrointestinal defects, and a good overview of such disorders is given here. Should you have recently returned from a fun-packed fortnight in South America, here’s one you might like to think about.

Finally, sufferers may opt to try natural solutions to their problem. Some authorities recommend adopting a squatting position to defaecate, while anyone hell bent on hi-tech assistance might be interested in this device, but if neither of these works, there’s always yoga…

This tour was submitted by Derrick Garwood, a Freelance Medical Writer and Editor.

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