Constipation is extremely common, particularly in women and older adults, and it is one of the most self treated conditions in the country. Stimulant laxatives and herbal churnas are used daily for years, which addresses the symptom while the underlying pattern persists.
Most chronic constipation responds well to a systematic approach, and the drugs used first should not be the harshest ones.
What Counts as Constipation
Frequency alone does not define it. Normal ranges from three times daily to three times weekly, and there is no medical requirement to pass stool every day.
Constipation is defined by the presence of two or more of these for at least three months.
- Straining during more than a quarter of bowel movements
- Lumpy or hard stools
- A sensation of incomplete evacuation
- A sensation of blockage
- Needing manual assistance
- Fewer than three bowel movements a week
The Bristol stool chart is useful for describing consistency to a doctor. Types 1 and 2, hard lumps or a lumpy sausage, indicate constipation.
Common Causes
Most constipation is functional, but several treatable causes are worth excluding.
- Inadequate fibre and fluid
- Physical inactivity
- Ignoring the urge, common in people without convenient toilet access at work
- Medications: iron, calcium, opioid painkillers, some antidepressants, antacids containing aluminium, and blood pressure drugs
- Hypothyroidism
- Diabetes, through nerve effects on the gut
- Low potassium or high calcium
- Pregnancy
- Pelvic floor dysfunction, where the muscles do not coordinate properly during defecation
- Structural causes including strictures and tumours
Medication review is frequently the highest yield step. Iron and calcium supplements in particular cause constipation in a large proportion of the women prescribed them.
When to Investigate
Longstanding constipation with no change usually needs treatment rather than investigation. These features change that.
- New onset constipation after age fifty
- A recent change in bowel habit
- Blood in the stool
- Unexplained weight loss
- Anaemia
- A family history of bowel cancer or inflammatory bowel disease
- Severe abdominal pain or vomiting
- Constipation not responding to proper treatment
A new change in bowel habit in an older adult is the pattern that most warrants colonoscopy. Longstanding constipation since childhood is a different situation.
Fibre Done Properly
Fibre advice frequently fails because it is given without detail.
- Target 25 to 30 grams daily, which is considerably more than most people eat
- Increase gradually over two to three weeks, since a sudden increase causes bloating and gas and leads people to give up
- Increase fluid at the same time, otherwise fibre worsens the problem
- Soluble fibre such as psyllium, oats and pulses is generally better tolerated than coarse bran
- Good sources in Indian diets: pulses, whole wheat, ragi, oats, guava, papaya, vegetables with skin, and flaxseed
Note that fibre helps functional constipation but can worsen slow transit constipation and pelvic floor problems. If increasing fibre makes you feel considerably worse, that is diagnostic information worth reporting.
Toilet Habits That Retrain the Bowel
These behavioural measures are more effective than most people expect and cost nothing.
- Go at the same time daily, ideally twenty to thirty minutes after breakfast, when the gastrocolic reflex is strongest
- Never ignore the urge, since repeatedly suppressing it dulls the reflex over time
- Use a footstool to raise the knees above the hips, which straightens the anorectal angle
- Lean forward with elbows on knees and relax the abdomen rather than straining
- Allow no more than ten minutes, then get up and try later
- Leave the phone outside, since prolonged sitting contributes to piles
The squatting posture is worth emphasising. The Indian style toilet achieves this naturally, and a simple footstool replicates it on a Western toilet.
Laxatives in the Right Order
Laxatives differ considerably, and the harshest ones are often used first.
- Bulk forming, such as psyllium: safest for long term use, needs adequate fluid
- Osmotic, such as polyethylene glycol or lactulose: draw water into the bowel, safe for prolonged use, and the usual first line drug treatment
- Stool softeners: mild, useful alongside others
- Stimulant, such as bisacodyl or senna: effective for occasional use. Daily long term use is not ideal
- Suppositories and enemas: for impaction or when rapid relief is needed
- Newer prescription agents for constipation resistant to the above
Polyethylene glycol is safe for long term daily use and is under prescribed in India relative to stimulant laxatives and herbal preparations. Many widely used churnas contain senna, which is a stimulant, without this being obvious to the user.
Pelvic Floor Dysfunction
Some patients cannot evacuate despite soft stool, because the pelvic floor muscles contract instead of relaxing during defecation. Laxatives do not help this and often make things worse.
Clues include prolonged straining with soft stool, needing to press around the anus or vagina to evacuate, a persistent sensation of incomplete emptying, and no benefit from increasing fibre.
This is diagnosed with anorectal physiology testing and treated with biofeedback therapy, which retrains the coordination and has good success rates. Our physiotherapy department provides pelvic floor retraining.
Constipation in Specific Groups
Some situations need particular attention.
Older adults: reduced mobility, medications and inadequate fluid intake combine. Faecal impaction can present paradoxically as overflow diarrhoea, which is frequently misdiagnosed and treated with the wrong drugs.
Pregnancy: hormonal slowing plus iron supplements. Bulk forming and osmotic laxatives are generally safe, stimulants are used cautiously.
Children: often behavioural, following a painful stool that leads to withholding. Treatment requires both softening and reversing the withholding habit, and takes months. Our paediatrics department manages this.
Patients on opioids: constipation is near universal and does not improve with time. Laxatives should be started at the same time as the opioid, not once the problem appears.
Chronic constipation responds to a systematic approach: review medications, build fibre and fluid gradually, use the footstool and a regular morning routine, and choose osmotic laxatives over daily stimulants. If soft stool still will not pass, think about the pelvic floor rather than adding more laxative.
Our gastroenterology department at T. Nagar assesses chronic constipation and excludes structural causes.
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