Constipation treatment and digestive problems

The limits of normal are wide: some healthy people have a bowel movement up to three times a day, and others only three times a week. For a doctor, more important than frequency is how easily and comfortably the stool passes.

Doctors speak of chronic constipation when two or more of the following happen regularly over the last 3 months:

• fewer than 3 bowel movements a week;
• frequent heavy straining;
• hard, lumpy stool;
• a feeling of incomplete emptying;
• a feeling of a “plug” or blockage at the exit;
• needing to help stool out with a finger or hand.

• infrequent and difficult bowel movements, long straining;
• hard, dry stool, sometimes in “nut-like” lumps;
• a feeling that the bowel has not emptied completely after going, and going to the toilet again often;
• bloating, a swollen abdomen, heaviness and gas;
• cramping abdominal pain;
• pain, burning or blood on the paper in the anus after a bowel movement: this may already be a sign of an anal fissure or hemorrhoids (piles).

These symptoms can also occur with irritable bowel syndrome, an underactive thyroid and narrowing of the bowel. That is why you should not try to treat long-lasting constipation yourself: the cause needs to be found.

The most common causes are linked to daily habits:

• Too little fiber and water. A diet low in vegetables, fruit and whole grains makes stool dry and hard.
• Inactivity. A sedentary job and little walking slow the bowel.
• Holding in the urge to go. The longer stool stays in the bowel, the more its water is absorbed back, and it dries out and hardens.
• Irregular eating and strict diets. Fast food, white flour products, sweets, long gaps between meals and single-food diets.
• Stress. The bowel is closely linked to the brain through nerve pathways, and tension can disturb the rhythm of digestion.
• Travel. New food, different water and disrupted sleep can cause short-term constipation.
• Pregnancy and the period after childbirth. Hormonal changes slow the bowel in pregnancy, and after childbirth a woman may put off the toilet for fear of pain.
• Medications. Some painkillers, iron supplements, some antidepressants and blood pressure medications can cause constipation. Do not stop a medication on your own; talk to your doctor.
• Some conditions: an underactive thyroid (hypothyroidism), diabetes, diseases of the nervous system.

Constipation is sometimes a result, not a cause. In such cases, simple changes in diet are not enough.

Rectocele: “helping with a finger” on the toilet is not normal

A rectocele is a weakening of the wall between the rectum and the vagina, with the rectum bulging toward the vagina like a pocket. Stool stays in this pocket, and the bowel does not empty completely. Women often say that they go to the toilet often, still feel full afterward and have to press with a finger on the perineum or the wall of the vagina to pass stool. This is the most typical sign of a rectocele.

The main causes are difficult or multiple childbirths, tears during childbirth, years of straining and the weakening of tissues with age. It is rare in men. “Getting by” for years with laxatives or enemas hides the problem, and during that time hemorrhoids and an anal fissure are added. More: rectocele treatment and What is a rectocele?.

Anal fissure, hemorrhoids and pelvic floor problems

Hard stool tears the anal canal, and heavy straining enlarges hemorrhoid nodes. The pain of a fissure makes people avoid the toilet, and constipation gets worse. Passing stool also becomes difficult when the pelvic floor muscles tighten instead of relaxing during a bowel movement. This is called obstructive defecation (a blockage at the exit of the stool). In these cases, the constipation is treated together with the problem causing it.

Warning signs: when is a colonoscopy needed?

• blood in the stool or on toilet paper;
• constipation that has newly started after age 45–50 and continues, or a change in toilet habits;
• unexplained weight loss, loss of appetite, anemia;
• a long-lasting change in the shape of the stool, a feeling of incomplete emptying;
• colon cancer, polyps or inflammatory bowel disease in the family;
• abdominal pain or diarrhea that wakes you at night.

These signs do not mean cancer, but the cause needs to be checked. It has not been proven that constipation itself causes cancer, but newly started constipation can be a sign of narrowing of the bowel. We also recommend a colonoscopy for patients over 40 who complain of constipation and are found to have hemorrhoids, because hemorrhoids should not “cover up” a problem in the upper parts of the bowel. Colon polyps often cause no symptoms, so a screening examination is recommended after age 45–50 even if you have no complaints, and earlier if there is risk in the family.

Bloating (a swollen abdomen and gas) often goes together with constipation. Its causes include constipation itself, fizzy drinks, eating in a hurry, chewing gum and smoking (which make you swallow a lot of air), sugar and sugar substitutes, a sudden large increase in fiber, and some legumes and types of cabbage. Reactions to foods are individual: it helps to keep a record for a while of which food causes bloating for you. Bloating can also occur with diseases of the stomach, the gallbladder and the pancreas: if you have pain under the right ribs, belching and nausea after fatty food, be sure to tell your doctor.

Irritable bowel syndrome (IBS) is a chronic functional disorder of the large intestine. It causes cramping and pain in the abdomen, bloating, constipation, diarrhea or alternating episodes of both. The pain often eases after a bowel movement. It is more common in young women, and stress and sleep problems can make symptoms worse. IBS does not change the bowel tissue and does not increase the risk of colon cancer. Treatment consists of adjusting the diet, managing stress, regular activity and, when needed, medication, often together with a gastroenterologist. Before an IBS diagnosis is made, the warning signs listed above need to be checked.

With these signs, do not wait. Seek care right away:

• gas and stool cannot pass at all, the abdomen swells more and more and vomiting begins: this may be a sign of bowel obstruction;
• sharp abdominal pain that keeps getting worse;
• heavy or non-stop bleeding, or black stools;
• swelling, constant pain and fever around the anus.

At the first visit, most of the time goes to conversation: how long you have had constipation, the shape of your stool, how much water you drink, which medications you take, whether you have given birth, and whether you need to help with a finger on the toilet. Answer these questions without embarrassment; the right diagnosis starts here.

• Examination of the abdomen and the anal area. You lie on your side; the inspection and finger examination take a few minutes.
• Anoscopy: a look into the anal canal with a short, thin instrument. It shows a fissure, hemorrhoids and inflammation.
• In women, a combined examination of the rectum and vagina identifies a rectocele and its grade.
• Additional tests when needed: defecography (an X-ray or MRI study that shows how the rectum empties during a bowel movement), colonoscopy, blood tests (anemia, thyroid), and tests that measure how the pelvic floor muscles work.

The examination is completely confidential, and both the doctor and the team are women. Male patients are seen with the same confidentiality and respect.

Conservative treatment

The main treatment for functional constipation is not medication but proper diet and habits:

• Diet. Fiber is increased gradually to about 25–30 grams a day: vegetables, fruit, legumes, whole grains, oatmeal and buckwheat. White flour products, sweets and fast food are cut back.
• Water. Drink about 1.5–2 liters a day, with most of it plain water. With heart or kidney disease, your doctor sets the amount of fluid.
• Activity. At least 150 minutes of moderate physical activity a week, for example, a brisk 30-minute walk a day.
• Toilet habits. Don't hold in the urge, set aside unhurried time for the toilet after breakfast, sit for no more than 5 minutes and put a small footstool under your feet.
• Medications. If your doctor thinks it necessary, they prescribe medications that soften the stool or increase its bulk. Laxatives can help in the short term, but “getting by” for years on laxatives or enemas that you take on your own hides the cause. Frequent loose stool, on the other hand, can irritate the anal canal and lead to a fissure.
• Probiotics are useful in some cases, but choose them with your doctor according to your complaint.
• For poor coordination of the pelvic floor muscles, special exercises and biofeedback (a method that teaches the muscles to relax correctly) may be recommended.

Surgical treatment

Simple (functional) constipation is not treated with surgery. Surgical treatment comes up only when a specific problem causing the constipation is found:

• Rectocele. When conservative measures do not help, a rectocele is repaired surgically. The operation is usually done through the vagina, with no incision on the abdomen. It has two parts: posterior colporrhaphy (repairing the wall between the rectum and the vagina with stitches) and anterior levatorplasty (bringing the pelvic floor muscles together in front of the rectum). Depending on its extent, it usually takes 30–60 minutes.
• An anal fissure, hemorrhoids and polyps are each treated with their own method.
• Combined (“bouquet”) surgery. If you have several problems, such as a rectocele, hemorrhoids, an anal fissure and urinary incontinence, they can be dealt with in one session under one anesthetic. More: surgical and conservative treatment.

The exact duration is given after the examination.

This section applies to operations that remove the cause of constipation, for example rectocele surgery.

The exact timeline is given after the examination. The most important rule after surgery is not to strain, so the menu is planned to keep the stool soft and regular in the first weeks.

The five main rules that prevent constipation (water, fiber, activity, proper toilet habits and sitting with a footstool) are explained in detail, together with the Bristol stool scale, in the article 5 golden rules against constipation. During treatment and after surgery, following these rules is especially important for keeping the result, because when constipation comes back, so does the risk of hemorrhoids, an anal fissure and a rectocele. These rules are also the main prevention for hemorrhoids and an anal fissure.

Our patient, in her late 30s and a mother of several children, had long complained of constipation and having to help with a finger on the toilet. The examination found a rectocele and a cystocele (a dropped bladder). In one session, anterior and posterior colporrhaphy, anterior levatorplasty and vaginoplasty were performed. The operation took about 1 hour 15 minutes, and she stayed in the clinic for 1 day. Every patient's situation is individual.