Constipation: treatment options
There are several treatments available for the treatment of constipation. Your doctor will be able to advise you on the most suitable treatment for you, depending on how long you have been constipated, how severe your constipation is and the cause of your constipation.
Controlling your bowel activity through lifestyle measures such as diet and exercise can help prevent and treat constipation.
Sometimes a change of lifestyle is enough, paying special attention to a few dietary factors to ease the problem of constipation and prevent it happening.
Eat more foods containing high levels of dietary fibre
The most common reason for hard or slow bowel motions is a lack of dietary fibre in your diet. Average consumption of dietary fibre in Australia is lower than recommended levels, and simple changes to replace low fibre foods with those with higher levels of dietary fibre is the first (and often the only) change required. Adding extra fibre to your diet should make your stools more bulky and easier to pass, but it may take a few days for you to notice an effect.
Most types of dietary fibre are broken down by 'good' bacteria in the large bowel (the colon). This helps with the health of the colon, although gases are produced as a by-product. Some people are concerned about this, but although it may be a social problem, it is not a medical one. If you increase your intake of dietary fibre gradually, it will help possible embarassment of increased production of gas.
The Australian National Health and Medical Research Council has set an adequate intake of dietary fibre as:
- adult men: 30 grams a day;
- adult women: 25 grams a day.
These are average values and some people may find higher levels of dietary fibre are necessary for them to avoid constipation.
A diet high in dietary fibre may also reduce your risk of obesity, cardiovascular disease, type 2 diabetes and certain cancers.
Dietary fibre occurs only in plant foods and does not necessarily appear fibrous. On the other hand, meat contains no dietary fibre, even though it may appear fibrous. The following are good sources of dietary fibre to include in your diet.
- Wholegrains. Wholegrain cereals (such as oats, wholewheat breakfast cereals, brown rice, quinoa, cracked wheat), wholegrain breads and pasta are good sources of dietary fibre.
- Fruits and vegetables, both raw and cooked, add extra fibre to your diet. All fruits and vegetables contain dietary fibre with top sources including green peas, spinach, broccoli, passionfruit, bananas, raspberries, pears, citrus fruit and apples.
- Resistant starch. This is a form of carbohydrate that is not digested in the small intestine but is broken down by 'good' bacteria in the bowel, acting in a similar way to some types of dietary fibre. Resistant starch is found in pasta cooked to the 'al dente' stage, some especially bred types of corn, potatoes that have bee cooked and cooled and unripe bananas.
- Unprocessed wheat, oat or rice bran can be added to some meals to increase the fibre content.
- Legumes or pulses (such as dried beans, lentils, chick peas) are very good sources of soluble and insoluble fibre, and can be added to soups, salads and stews or made into burgers.
- Nuts and seeds are high in fibre and can be added to salads, vegetable dishes and breakfast cereals, or eaten as a snack.
- Psyllium husks provide soluble fibre and can be added to breakfast cereals, yoghurt and smoothies. Like other foods that contain soluble fibre (oats, some seeds and legumes), they can also help lower cholesterol. Psyllium husks are a component of a few commercial breakfast cereals and are also the main ingredient in some laxatives such as Metamucil. Drink extra water if you eat psyllium.
Increase fibre gradually into your diet or you may feel bloated and have problems with gas.
Drink plenty of fluids
Dehydration can exacerbate constipation. For good health, it's important to have plenty of fluids. Each day about 10 litres of fluid enters the digestive tract. This includes about 2 litres from the diet as well as digestive juices. About 8.5 litres of fluid is absorbed as food passes through the small intestine. Another 1.3-1.4 litres is absorbed in the large intestine and the rest becomes part of the stool. Dietary fibre and this liquid keeps the stools soft and easy to pass.
Aim to drink 8 to 10 glasses of liquids per day. This should be mostly water, but can also include tea (4 cups is fine), coffee (2-3 cups is fine), soup or other fluids. However, it is better to eat fruit than to drink juice as fruit also provides dietary fibre.
Exercise and physical activity help prevent constipation by increasing the muscle activity in your bowel. Being physically active and getting some exercise on most days can help treat constipation.
When you feel the urge to go, make sure you go. Ignoring the urge to go can result in constipation by stretching the lower bowel. Commonly, the urge to open your bowels occurs after a meal (this is called the gastro-colic reflex) and upon waking in the morning.
Laxatives are medicines used to treat constipation by making it easier to have a bowel movement. There are several different types of laxative, and they are available in different preparations, including tablets, powders, granules, syrups, solutions, suppositories and enemas.
You should only use laxatives if your constipation has not improved with diet and lifestyle measures. As different laxatives work in different ways, your doctor can advise you on which laxative may be suitable for you.
Laxatives are not usually needed long-term. However, some people may need to use regular laxatives to maintain bowel function. Overuse or inappropriate use of laxatives may cause electrolyte imbalances, which can be dangerous. In addition, people who have abused laxatives may have trouble maintaining a regular bowel habit after stopping the laxative use.
Bulk forming laxatives (fibre supplements)
Bulk forming laxatives (fibre supplements) are generally the first choice treatment for mild constipation that has not improved with lifestyle measures. They can also be used to help prevent constipation in people at risk of constipation.
Bulk-forming laxatives work by absorbing fluid in the bowel, increasing faecal bulk and moisture, which stimulates bowel movement. It is very important to drink plenty of water with these laxatives — inadequate fluid intake can result in worsening constipation. Results may be seen in 24 hours, but sometimes the full effect is not noticed for several days.
Bulk forming laxatives include:
- psyllium/ispaghula, which can be taken as husks or powder supplements (e.g. Metamucil, Fybogel); and
- sterculia (e.g. Normafibe).
Side effects can include flatulence and bloating.
Osmotic laxatives are often used in people who need regular, long-term laxatives to stay regular. Osmotic laxatives work by drawing fluid into the bowel, which softens and expands the faeces. These laxatives should be taken with plenty of fluids. Effects should be within 2 to 48 hours.
Osmotic laxatives include:
- lactulose (e.g. Actilax, Duphalac and Lac-Dol);
- sorbitol (e.g. Sorbilax);
- magnesium sulphate (e.g. Gold Cross Epsom Salts); and
- macrogol 3350 (e.g. OsmoLax).
Side effects can include flatulence, bloating, abdominal discomfort, abdominal cramps, nausea and diarrhoea.
Laxatives that contain magnesium are best avoided in pregnancy.
Stimulant laxatives may be required when constipation is severe. Stimulant laxatives work by stimulating the bowel to contract. The onset of action is about 6 to 12 hours.
Stimulant laxatives include:
- bisacodyl (e.g. Dulcolax, Bisalax);
- senna (e.g. Sennetabs);
- sodium picosulfate (e.g. Dulcolax SP Drops); and
- glycerol suppositories (which act as a stimulant in the rectum due to the irritant action of glycerol).
Stimulant laxatives should not be used during pregnancy.
Side effects can include abdominal cramps, abdominal pain and discomfort, nausea and vomiting. Excessive use can cause diarrhoea and salt imbalances.
Stimulant laxatives may be used in combination with stool softeners such as docusate (e.g.Coloxyl with Senna, Sennesoft). Stool softeners are generally not effective laxatives when used alone.
Suppositories or enemas
Suppositories and enemas can be used to stimulate a bowel movement in people who are very constipated, but there is no evidence that they have any long-term effect on constipation.
Suppositories and enemas are best used under the guidance of a health professional.
There is a prescription medicine available called prucalopride (brand name Resotrans) that can be used to treat people who have chronic (ongoing) functional constipation — constipation that is not secondary to another illness or medicine side effect. This medicine can only be prescribed if several laxatives have not been effective in treating constipation over a period of time.
Possible side effects include headache, abdominal pain, nausea and diarrhoea.
Biofeedback pelvic floor muscle retraining
Biofeedback training can be used to treat constipation when abdominal muscles and pelvic floor muscles are not working in coordination. This specialised treatment, which involves learning to relax and contract your pelvic floor muscles, is available in a number of centres in Australia.
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