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Keep Yourself Moving, A Guide to Constipation
Keep Yourself Moving, A Guide to Constipation The fact is that constipation has always been a huge problem in our population, and given our predilection for fast food and our distaste for regular exercise, it likely isnít going away any time soon.

I remember sitting around the dinner table as a kid and listening to my parents complain about the fact that they had to watch television commercials about laxatives and stool softener products during the evening news hour. To this day, there never fails to be at least one uncomfortable commercial about such intestinal relief products during TV viewing with my own kids. The fact is that constipation has always been a huge problem in our population, and given our predilection for fast food and our distaste for regular exercise, it likely isnít going away any time soon. If you are one of the four million Americans who suffer from chronic lack of ability to comfortably and reliably move your bowels, you might be willing to put up with any commercial that promises relief.The clinical definition of constipation actually involves more than simply the lack of a bowel movement at least three times a week. There are also the factors of stool hardness, sensation of incomplete emptying or feeling blocked, and the need to strain to move oneís bowels to consider. When healthcare providers interview a patient and ask about constipation, they are really inquiring about all of those issues, and patients would do well to relate their problem in very specific terms in order to get the help they need. Even if you have a bowel movement every one or two days, if it is very hard and requires a great deal of straining to pass, you meet the criteria for constipation.

Women and adults over age 65 are more likely to become constipated in our population, and the causes can usually be narrowed to insufficient fiber in the diet, lack of physical activity, and/or the chronic use of certain medications. However, there are many other potential contributing factors including travel or other change of routine, consistently ignoring the urge to go, dehydration, abuse of laxatives, and specific disease processes like stroke, diabetes, and under-active thyroid among others.

The American Dietetic Association recommends that we all take in 20-35 grams of fiber on a daily basis, but reality is that we sometimes get only about five grams because of the highly processed nature of foods that we select. Fruits, vegetables, and grains contain two types of fiber - soluble and insoluble. The insoluble component is that material which the body cannot fully digest, and the residual of undigested matter adds bulk to the stool. Soluble fiber is that portion which can dissolve in water and forms a gel-like character that adds softness to the stool; however, pre-prepared and fast food products are typically very low in such fibers.

Another key factor for maintaining stool bulk and softness is getting enough fluid in the diet. Many people simply do not drink adequate water or juice. Substituting water intake with caffeinated beverages or alcohol can have the opposite effect on stool: rather than adding liquid, these products can cause excessive loss of water from the body through a diuretic effect.

The relationship between regular exercise and good bowel habits is elusive, but it is clear that physically moving in the gym or on a treadmill at home on a routine of moderate exercise can contribute greatly to moving regularly in the bathroom. Lack of adequate physical activity is likely a big factor in the disproportionate number of elderly Americans with constipation problems. Immobility after a major surgery can also be a factor especially since those people are often also taking narcotic pain relievers. Women with disorders of pelvic organ support can have significant constipation symptoms related to prolapse of the vaginal walls especially if the recto-vaginal wall-support is lacking (this condition is known as a rectocoele).

There is literally a laundry list of commonly used medications that directly or indirectly cause constipation. As mentioned above, narcotics are notorious for slowing down the intestinal activity, but you may not know that commonly prescribed medications for bladder control, high blood pressure, thyroid disease, Parkinsonís disease, seizure disorders and depression have the same effect. Also, over-the-counter medications for sinus/allergy relief, iron supplementation, and acid stomach can all be significantly constipating. It is important to read the warning label on these products where common side effects will be mentioned.

The American Dietetic Association recommends that we all take in 20-35 grams of fiber on a daily basis, but reality is that we sometimes get only about five grams.
Obsession with having a daily bowel movement can lead some people to abuse over-the-counter laxatives. And while this over-use does not cause colon cancer, it can certainly cause the bowel to cease responding to such medications. Laxative abusers frequently have to escalate their use of the product in order to get the desired effect.

Another problem occurs when people consistently ignore their bodyís signals that it is time to have a bowel movement. This is known as the urge to defecate, and it is quite powerful. It can be counted on to kick in about 30 minutes after eating the first meal of the day, and busy working people may put off their visit to the bathroom because of time constraints in the morning. They may feel inhibited about using the bathroom in the work environment, and over years, this has a profound suppressant effect on the sensation to eliminate. It is possible to retrain your brain to respond to those colonic signals by developing morning habits that allow enough time for the process. Routinely skipping breakfast is not recommended because the stimulation of food in the stomach is what triggers the colon to contract.

Because constipation can be a sign of serious bowel problem, it is important to be seen by a healthcare provider if the problem is severe, unrelenting, or is associated with nausea/vomiting or bleeding from the anus or rectum. However, most of the time, the patient, and healthcare provider discuss constipation issues in the context of a routine physical exam or in relation to another problem. The provider will take a history and perform a basic physical examination, which will likely include a digital rectal examination to rule out the presence of blood or an obvious rectal obstruction. More in-depth testing will depend upon the severity of the problem and the patientís age and other health problems. Colonoscopy is routinely recommended regardless of having any bowel symptoms at age 45-50 as a baseline, and recommendations for more colonoscopies beyond that will vary on an individual basis.

Treatment Options
Treatment options for constipation will depend upon the underlying cause, and many people will get significant relief by following some of the advice that has been outlined here regarding water intake, exercise, and other behavioral changes. When gradually incorporated into your routine, over-the-counter stool bulking agents such as Metamucil and Citrucel may be all that is necessary. Another option is an osmotic-type laxative that draws water into the bowel such as Miralax, which can be used daily if needed. Stimulating agents like Dulcolax and Senokot can be used occasionally but may lead to significant cramping as they irritate the bowel into action. Stool softeners have no stimulating effect and merely add to the water content of the stool. Your doctor may prescribe a medication known as Lubiprostone (Amitiza is the brand name) that acts to stimulate the chloride channels in the intestinal wall such that water is retained in the bowel lumen. All of these choices have potential drawbacks, but the key to relief is to discuss your particular needs with a healthcare provider and consider turning off your television during dinner.

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"Keep Yourself Moving, A Guide to Constipation"
   authored by:
Dr. Jacqueline Thompson is a Board Certified Obstetrician and Gynecologist and Fellow of the American College of Obstetricians and Gynecologists. Formerly an active duty Army doctor, she is now a full time civil service staff physician at Womack Army...

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