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Harvard Commentaries
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Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Man to Man Man to Man
 

Chronic Constipation: A Strain On Health


September 12, 2013

By Harvey B. Simon M.D.

Harvard Medical School


When the topic of guts comes up in the locker room, most men are talking about courage on the field, not results in the bathroom. Bowel function is not a "guy thing," but chronic constipation surely can be, particularly for older men.

In healthy men, bowel function should be regular, painless and come naturally. If you're one of the many people who suffers from chronic constipation, here's what you need to know to get a sluggish gut moving.

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What Is Constipation?

Constipation usually stems from the slow passage of stool through the large intestine or colon. For most men, constipation means having

  • Bowel movements too infrequently (typically fewer than three times a week)
  • Hard or small, lumpy stools
  • Stools that are hard to pass, straining or painful bowel movements
  • The sensation of incomplete emptying after a bowel movement.

Most cases of chronic constipation are caused by lifestyle factors, particularly too little dietary fiber, not drinking enough fluids and lack of exercise. But in some cases, bowel function slows due to other underlying problems:

  • Medications, such as aluminum-containing antacids, calcium channel-blockers, antihistamines, tricyclic antidepressants, narcotics, non-steroidal anti-inflammatory drugs, anticholinergics, and anti-Parkinson's drugs
  • Supplements, such as iron and calcium
  • Endocrine disorders, such as diabetes and an under-active thyroid gland
  • Metabolic imbalances, such as low potassium and high calcium levels
  • Neurologic disorders, such as multiple sclerosis, Parkinson's disease and spinal cord disorders
  • Depression and anxiety
  • Bowel diseases, such as tumors, diverticulosis, irritable bowel syndrome, inflammatory bowel disease, strictures (scarring) and rectal disorders.

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Finding the Cause

Chronic constipation itself doesn't usually lead to serious medical problems. Nevertheless, the first step to easing elimination is to find out why you are constipated.

Your doctor will review your diet, exercise and bowel habits in detail. Your doctor will also check your general health, medications and supplements you take, and ask about your family history of bowel disease. Abdominal and rectal exams are particularly important.

Although there are no specific lab tests for constipation, your doctor may check for blood in your stool, for anemia, diabetes, thyroid abnormalities, and blood potassium and calcium levels.

More extensive testing, such as a colonoscopy, sigmoidoscopy, or barium x-rays may be needed if you have any of the following additional symptoms:

  • A sudden change in bowel function or new symptoms of constipation
  • Vomiting, abdominal distention or abdominal pain
  • Intestinal bleeding
  • Weight loss
  • Fever
  • Anemia
  • Rectal pain
  • Family history of colon cancer or inflammatory bowel disease.

Even without these symptoms, every man over age 50 should have regular screening tests for colon cancer to detect polyps and tumors long before they cause symptoms.

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The Consequences of Constipation

Straining and hard stools can trigger painful rectal problems:

  • Hemorrhoids – Swollen rectal veins can cause rectal bleeding or, if they become clotted (thrombosed), severe rectal pain.

 

  • Anal fissures – The combination of straining and hard stools can tear rectal tissue, producing anal fissures that are so painful that patients avoid moving their bowels.

 

  • Impacted stools – In older men (and women), hard, dry stools can become trapped in the rectum, preventing normal bowel movements.

 

  • Rectal prolapses – Straining can push rectal tissue out through the anus, which may require surgical repair.

 

  • Diverticulosis and diverticulitis – Low-fiber diets typically associated with chronic constipation are associated with these common colon disorders that can cause bleeding or inflammation with pain and fever.

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Four Changes To Ease Constipation

The discomfort associated with chronic constipation is a good reason to seek treatment even when there are no complications. The goal of treatment is comfort not regularity. That's because "success" is judged by the ease and comfort of bowel function, not by the number of bowel movements you have in a week. Lifestyle changes will help you reach that goal. If they are not enough, your doctor can recommend appropriate laxatives and medications.

Four lifestyle changes can prevent or treat many cases of chronic constipation.

1. Increase dietary fiber. Chronic constipation is rare in "primitive" societies that rely on traditional unrefined foods. But it's extremely common in industrial societies. The missing element is dietary fiber.

Dietary fiber is a mix of complex carbohydrates found in the bran of whole grains, the leaves and stems of plants, and in nuts, seeds, fruits and vegetables. It is not found in any animal foods. Because dietary fiber cannot be digested by the human intestinal tract, it has very little caloric value. But it still has plenty of health value. Fiber makes the stools bulkier, softer, and easier to pass, which helps protect against constipation and other intestinal disorders. Another benefit of fiber is that it creates a feeling of fullness and lowers blood sugar and cholesterol levels.

The Institute of Medicine recommends 38 grams of fiber a day for men before age 50 and 30 grams a day after 50. (The recommended amount for women is 30 grams a day before age 50 and 21 grams a day thereafter.) Most Americans get much, much less. It's best to ease into a high-fiber diet to avoid feeling bloated and gassy. Many people feel bloated and gassy when they start a high-fiber diet, but these side effects usually diminish within a month or so. Increase your daily intake by about 5 grams per week until you reach your goal. Be sure to drink plenty of fluids as well. For most people, adding a high-fiber cereal to the diet is a good place to start. But if breakfast isn't your thing, you can have it any time during the day. Fiber supplements, such as psyllium (Metamucil) or methylcellulose (Citrucel) are anther way to add bulk to your diet.

By eating a variety of fiber-rich foods you can easily get the 30 to 38 grams a day you need.

2. Exercise. Exercise speeds the passage of stool through the intestinal tract. That's why people who exercise regularly enjoy substantial protection against colon cancer. Like dietary fiber, exercise has many benefits beyond relieving constipation. It reduces the risk of heart disease, stroke, high blood pressure, diabetes, obesity, erectile dysfunction, and many other problems. You should exercise nearly every day for heart health and good bowel function. A 30-minute walk is a great way to start exercising.

3. Get plenty of fluids. Doctors no longer believe that everyone needs eight glasses of water a day. But people with chronic constipation should have 6 to 8 glasses of fluids a day.

4. Establish a good routine. Always try to "heed the call" and head for the bathroom whenever you feel the urge to move your bowels. Holding back gives your gut the wrong message. In addition, set aside some time to sit on the toilet every day. Since eating stimulates the colon, the best time may be a few minutes after a meal. Since coffee also stimulates the colon, many people find the best time to be after breakfast, especially if they've been smart enough to start the day with bran cereal.

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When Medications Can Help

Use medication only when you've given diet and exercise a chance to work but still need more help.

Your doctor can help you decide what type of medication is best. In many cases today, the first choice will be an osmotic agent. Polyethylene glycol, sorbitol and lactulose are prescription liquid formulations that contain non-absorbable carbohydrates. They draw water into the intestines, making stool softer and easier to pass. Osmotic agents appear safe for long-term use, even in the elderly. Some people develop bloating and flatulence. Polyethylene glycol is less likely to produce these side effects because it cannot be digested by bacteria in the colon. But it's more expensive.

Saline laxatives, such as magnesium hydroxide and magnesium citrate, also draw fluids into the intestinal tract. Like the osmotic laxatives, they are generally effective and safe, but over-use can produce chemical imbalances, particularly in patients with kidney disease or congestive heart failure. These old standbys are available without prescription.

Bowel stimulants such as senna, bisacodyl, cascara, and castor oil trigger contractions of the intestinal muscles. Although experts no longer believe that long-term use can harm the intestines or make people dependent on them, they still recommend saving these over-the-counter drugs for occasional use.

Stool softeners such as docusate can provide comfort for people with rectal problems, but they do not relieve chronic constipation. Mineral oil is no longer recommended because of possible lung complications.

Suppositories and enemas can provide rapid relief but should be used only when other measures fail.

Lubiprostone (Amitiza) is a prescription medication approved for chronic constipation.

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Conquer Chronic Constipation

Many people in industrialized societies suffer from chronic constipation and its complications because of their lifestyle. Getting back to basics with a high-fiber diet and regular exercise can restore natural bowel function for most people. When more help is needed, your doctor can help you choose among a variety of options.

Harvey B. Simon, M.D. is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.

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