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written by
Harvard Medical School

Chronic
Constipation

www.patientedu.org
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B owel function is not a topic for polite

conversation. Indeed, when your function
is normal, there’s no need to talk about
it. But millions of Americans are troubled by con-
stipation, and they should talk about it—not to
Is your constipation periodic (occasional) or
chronic? Periodic constipation occurs infrequently
and can usually be relieved by diet and exercise.
Chronic constipation is more serious and may
require medical attention. If you suffer from any
their neighbors, but to their doctors. Constipation two of these symptoms for a period of at least 3
is a medical problem, and your doctor can guide months, you may have chronic constipation:
you to a program of diet, exercise, and medication
to bring relief. Hard or lumpy stools Frequent use of
enemas, laxatives,
Fewer than three bowel
or suppositories
movements in a week
What is Constipation? Feeling like your bowel
Difficulty passing stools
is never totally empty
Although estimates vary widely, up to 28% Straining
of adult Americans may suffer from Feeling like there is
constipation. The problem is more Abdominal discomfort something blocking
and bloating your bowel
common in the elderly than
in young adults, and in
women than men. The good news is that chronic constipation can
be treated. Prescription medications and lifestyle
changes can help. Most importantly, talk to your
doctor, and speak openly about your symptoms
of constipation.

Normal Intestinal Function

Food and fluids start their long tour through your
intestinal tract by passing rapidly through your
mouth and food pipe (esophagus) into your stom-
Esophagus ach. The stomach muscles relax to accommodate
your meal, but within about 20 minutes fluids
move into the small intestine and solids follow
Stomach a few minutes later.
Colon
(Large Intestine) Although the process starts in the mouth and
stomach, most of the digestive process occurs in
the small intestine. As nutrients and fluids are
Small Intestine absorbed into the bloodstream, the intestinal

Rectum For more information about chronic constipation from Harvard

Health Publications, go to www.patientedu.org/constipation.

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contents become smaller and denser. The wall of The good news is that chronic
the intestinal tract contains muscles that contract
rhythmically to propel the intestinal contents on- constipation can be treated.
ward to the large intestine, or colon.

The colon absorbs some additional fluid, and the ing out have to relax. At the same time, the mus-
millions of bacteria that live there give the stool its cles of the lower colon have to contract to propel
characteristic color and odor. Involuntary rhyth- the stool outward, and voluntary contractions of
mic muscular contractions propel the intestinal the abdominal muscles (“straining”) increase pres-
contents through the 4 1/2 foot long colon. The sure to aid the process.
time it takes varies enormously; in healthy people
with good diets, 18 to 36 hours is about average.
The Causes of Constipation
The last step is the rectum. The colon can store a
large amount of fecal material. As the rectum fills Most cases of chronic constipation are caused by
up, it signals the need to have a bowel movement. lifestyle factors, particularly inadequate dietary
To accomplish that task, the two rings of muscles fiber and exercise. But in some cases, underlying
that guard the anal canal to keep stools from leak- problems slow bowel function (see Table 1 below).

Table 1: Causes of Constipation

Low-fiber diet You should consume 25 to 30 Medication side effects Constipation can be
grams of fiber every day to soften the stool and a side effect of many different prescription
encourage proper bowel function and non-prescription medications, including
Not enough liquids To help prevent stools from supplements and vitamins
becoming dry and hard, your daily fluid intake Local pain or discomfort Pain around the anus,
should be equivalent to 6 to 8 glasses of water such as an anal fissure or hemorrhoids, can
Lack of exercise Regular exercise is necessary to make bowel movements painful or uncomfort-
strengthen the lower colon muscles and promote able; this may cause you to resist the urge to
normal muscle contractions in the bowel wall have a bowel movement
Ignoring the urge Disregarding the urge to move Pregnancy Hormonal changes or added pressure
the bowel can not only cause constipation, but on the intestines from the uterus can affect bowels
may also cause you to stop feeling the urge to go
Bowel diseases Including tumors, diverticulosis,
Change in routine Changes in diet and the normal irritable bowel syndrome (IBS), inflammatory
time of meals, as well as limited access to rest- bowel disease, and strictures (scarring)
rooms can cause you to become constipated
Other medical conditions Including diabetes, an
Overuse of laxatives Long-term use of over-the- under-active thyroid gland, multiple sclerosis,
counter laxatives can teach your bowel to rely on Parkinson’s disease, spinal cord disorders, depres-
these medicines, and can eventually cause consti- sion, anxiety, low potassium levels, and high
pation rather than relieve it calcium levels

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Evaluation Consequences
Your doctor will review your general health, your of Constipation
medications and supplements, and your family
history, with an emphasis on bowel disease. A Chronic constipation itself
physical exam may reveal clues; abdominal and does not lead to serious
rectal exams are particularly important. But in medical conditions. But
most cases, a detailed review of your diet, exercise, straining can trigger painful
and bowel habits will provide the most important rectal problems. Hemorrhoids
information. are the most common; they are
swollen rectal veins that can cause
Although there are no specific lab tests for consti- rectal bleeding or, if they become clotted
pation, your doctor may check for blood in your (thrombosed), severe rectal pain. The combination
stool and for anemia, diabetes, thyroid abnormali- of straining and hard stools can tear rectal tissue,
ties, and blood potassium and calcium levels. producing anal fissures that are so painful that
patients avoid moving their bowels. In elderly
Warning symptoms should prompt more inten-
people, hard, dry stools can become impacted
sive testing. Table 2 lists some red flags.
(trapped) in the rectum, preventing normal bowel
Patients with constipation warning signs may movements. Straining can also push rectal tissue
benefit from additional tests, such as colonoscopy, out through the anus; these rectal prolapses may
sigmoidoscopy, or barium x-rays. And even with- require surgical repair. And the low-fiber diets
out warning symptoms, everyone over 50 should typically associated with chronic constipation are
have regular screening tests for colon cancer to linked with diverticulosis and diverticulitis, common
detect polyps and tumors long before they cause colon disorders that can cause bleeding or inflam-
constipation. mation with pain and fever.

Even without any complications, the discomfort

Table 2: Constipation Warning Signs associated with chronic constipation provides
good reason to seek treatment.
• New constipation • Fever
or sudden change
in bowel function • Anemia
Treating Constipation: Goals
• Vomiting, abdomi- • Rectal pain
nal distention, The goal of treatment is not regularity but comfort.
abdominal pain • Family history Success is not judged by the number of bowel
of colon cancer movements you have in a week, but by the ease
• Intestinal bleeding or inflammatory and comfort of bowel function. To reach that
• Weight loss bowel disease goal, every patient with chronic constipation
should make lifestyle changes to help. And if
more help is needed, your doctor can help you
find appropriate medications.

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Preventing and Treating It’s best to ease into a high-fiber diet. Increase
your daily intake by about 5 grams per week until
Constipation: Lifestyle you reach your goal, and be sure to have plenty of
fluids as well. For most people, a high-fiber cereal
Lifestyle changes can prevent or treat many cases
is the place to start, but if breakfast isn’t your
of chronic constipation. Four things are important:
thing, you can have it any time during the day.
Dietary Fiber. Dietary fiber is Exercise. Exercise speeds the
a mix of complex carbohydrates transportation of waste through
found in the bran of whole grains, the intestinal tract. It’s one of the
the leaves and stems of plants, and reasons people who exercise regu-
1. in nuts, seeds, fruits and vegeta- larly enjoy substantial protection
bles—but not in any animal foods.
By making the stools bulkier, softer, and easier 2. against colon cancer. And like
dietary fiber, exercise has many
to pass, fiber protects against constipation and benefits beyond constipation. It reduces the risk
other intestinal disorders. By producing a sensa- of heart disease, stroke, high blood pressure, dia-
tion of fullness and by lowering blood sugar and betes, obesity, and many other problems.
cholesterol levels, fiber also helps improve general
health (Table 3). For the sake of your heart and your health, as
well as your bowel function, you should exercise
Table 3: nearly every day. A 30-minute walk is a great
Dietary Fiber Can Benefit These Conditions way to start.
Intestinal Disorders Other Disorders
Fluids. Doctors no longer believe
• Constipation • Heart disease that everyone needs 8 glasses of
• Hemorrhoids • Obesity water a day. But everyone with
• Diverticulosis • Diabetes 3. chronic constipation should have
6 to 8 glasses of fluids a day.
• IBS • Gallstones
• Colon cancer*
Establish a good routine.
Always try to “heed the call” and
The Institute of Medicine recommends 38 grams head for the bathroom whenever
of fiber a day for men younger than 50 and 30 you feel the urge to move your
grams a day for older men; for women, the rec- bowels. Holding back gives your
ommended amount is 30 grams a day before age
50 and 21 grams a day thereafter. Most Americans
4. gut the wrong message. In addi-
tion, set aside some time to sit on
get much, much less. See page 10 for a listing of the toilet every day. Eating stimulates the colon,
the fiber content of some foods and supplements. so a few minutes after a meal may be best. Since
coffee also stimulates the colon, many people find
* The role of dietary fiber in colon after breakfast best—particularly if they’ve been
cancer is not yet well understood smart enough to start the day with bran cereal.

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Table 4: Examples of High-Fiber Foods

Food Serving Size Fiber Content* Treating Constipation:
Cereals
1/2
Medications
All Bran Extra Fiber cup 13
Fiber One 1/2 cup 13 Although it may be difficult to talk to your doctor
1/2 cup
All Bran 9 about constipation, it is important since you may
Shredded Wheat 1 cup 6 need a prescription medication to provide relief.
Oatmeal 1 cup (cooked) 4
Grains When combined with lifestyle changes, medica-
Barley 1 cup (cooked) 6 tions prescribed by your doctor can help stools
Brown rice 1 cup (cooked) 4 move more easily through your intestines. Some
Baked Goods prescription medicines draw fluids into the intes-
Rye Krisp 1 square 5 tine, making the stool softer and easier to pass,
Bran muffins 1 2 while other medications help speed up slowed
Whole wheat bread 1 slice 2 muscle contractions in your intestines.
Legumes
If you are experiencing symptoms of chronic con-
Baked beans 1 cup (canned) 10
Kidney beans 1/2 cup (cooked) 7 stipation, be sure to talk with your doctor about
Lima beans 1/2 cup (cooked) 5 what medications may be right for you.
Greens
Spinach
Vegetables
1 cup (cooked) 4
Conquering Constipation
Brussels sprouts 1/2cup 4 In healthy people, bowel function should be
Broccoli 1/2cup 3 regular, painless, and natural. Many people
Carrot 1 medium 2 in industrialized societies suffer from chronic
Tomato 1 medium 2 constipation and its complications because
1/2 cup
String beans 2
they have gotten away from the natural life-
Fruit
style. Getting back to basics with a high-fiber
Apple (with skin) 1 medium 4 diet and regular exercise can restore natural
Pear (with skin) 1 medium 4
bowel function for many patients—and when
Banana 1 medium 3
more help is needed, doctors can choose a pre-
Dried Fruits
scription medication to help relieve chronic
Prunes 6 8
Raisins 1/4 cup 3
constipation.
Nuts and Seeds
Peanuts 10 nuts 1
Popcorn 1 cup 1
Supplements
Psyllium 1 tsp or 1 wafer 3-4
Wheat bran 1 oz 3
Wheat germ 1 oz 2
Methyl cellulose 1 tbsp 2
*to nearest gram

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To learn more about chronic

constipation, visit the Pri-Med
Patient Education Center at
www.patientedu.org/
constipation.

Brought to you by:

HARVARD
MEDICAL SCHOOL

Pri-Med Patient Education Center

2127 2nd Ave North
Fort Dodge, IA 50501
service@patientedu.org

About This Brochure: This brochure was written by practicing physicians

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Pri-Med Patient Education Center and distributed in conjunction with
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