Secrets to staying “regular”…

With so much attention being focused these days on irritable bowel syndrome, colitis, diverticular disease and other gastrointestinal (GI) problems, many people forget about the granddaddy of them all—constipation.

It’s hands down one of the most common GI challenges, and 15% of American adults regularly suffer from the condition. And if you believe TV and magazine advertisements, more fiber (often from a supplement) is the solution.

What you’re not being told: While fiber is helpful, it’s not always the answer. In fact, constipation isn’t as straightforward as most people imagine. There are many common mistakes that prevent some people from getting relief from constipation—and cause others to worry unnecessarily.

Among the most common…

MISTAKE #1: Assuming that “normal” means daily. Constipation is usually defined as having fewer than three bowel movements a week. But there’s a wide range of “normal”—some people routinely have three bowel movements a week…others go three times every day.

Doctors usually do not worry about a few missed bowel movements. There is almost always a simple explanation—travel, a new medication (see below), changes in diet or simply a busy schedule that causes people to delay using the toilet.

When to be concerned: When constipation is persistent—especially when it occurs along with other symptoms, such as lumpy, hard stools, straining to have a bowel movement and/or feeling as though you can’t completely empty the stool from your rectum. It’s also cause for concern when someone’s normal bowel habits suddenly change for no obvious reason. This could indicate irritable bowel syndrome, a thyroid condition or even colon cancer.

MISTAKE #2: Not taking medication into account. Many prescription and over-the-counter drugs as well as supplements can cause constipation as a side effect. People who aren’t aware of this may resort to treatments, such as enemas, that they don’t really need—or book unnecessary visits with their doctors.

Psychiatric medications, including tricyclic antidepressants, such as imipramine (Tofranil) and amitriptyline (Elavil), are notorious for causing constipation. Other offenders: Blood pressure drugs, including calcium channel blockers and beta-blockers…narcotic painkillers…antihistamines such as Benadryl…and iron supplements.

My advice: If a new medication is causing constipation, ask your doctor if you can get by with a lower dose—or switch to a different drug. If that’s not possible, you might need to be more aggressive with lifestyle changes—such as drinking more water and getting more exercise. Both help keep stools soft and intestinal muscles active.

MISTAKE #3: Depending only on fiber. Getting more fiber from plant foods (especially pears, apples and sweet potatoes—all with skins on—and cooked greens) will usually increase the frequency and comfort of bowel movements…but not for everyone.

A form of constipation known as slow-transit constipation (STC) occurs when the intestinal muscles contract less often and with less force than normal. Some patients with STC improve when they get more fiber, but others will still need laxatives or other treatments.

My advice: If you have constipation that hasn’t responded to dietary changes, ask your doctor whether you might have STC. You may need a colonic transit study, which involves swallowing a capsule containing a small amount of material that can be traced with X-rays to show its movement over a period of several days. This test will help your radiologist and gastroenterologist determine how quickly stool moves through your colon.

MISTAKE #4: Rejecting laxatives. Many people have the mistaken notion that laxatives should always be avoided. Admittedly, some of the laxatives used in the past were harsh—people who took them were nervous about being more than a few steps away from a bathroom. But newer laxatives are much gentler.  

I usually recommend one of the osmotic laxatives, such as polyethylene glycol 3350 (MiraLAX) or good old Milk of Magnesia. They help stool retain fluid, which softens stools and stimulates bowel movements. It’s obviously preferable to have “natural” bowel movements, but these laxatives are gentle enough for long-term use (under a doctor’s supervision) and can be a good choice for those with health problems (such as Parkinson’s) that often cause constipation. Note: People with heart or kidney failure should avoid these laxatives—they can cause dehydration and/or a mineral imbalance.

MISTAKE #5: Not checking the bowl. Some people would rather not see what comes out (others closely examine their stools). I advise patients to take at least a quick look before they flush. The appearance of stools can provide important information about your GI health.

Color is a big one. Stools that are extremely dark could be a sign of intestinal bleeding. Bright red can indicate a recent meal of beets, a bleeding hemorrhoid or even colon cancer. Gray can mean that something’s obstructing the flow of bile to the intestine.

Texture/shape is also important. Stools that are hard and pelletlike can indicate more severe constipation, which could have many underlying causes, including chronic conditions such as thyroid problems, diabetes or Parkinson’s disease. “Floaters” are usually normal (they’re caused by gas in the stools) but can also be a sign of conditions that impair fat absorption, such as pancreatitis. (For more on different types of stool, see below.)

MISTAKE #6: Avoiding enemas. Simple fixes might not help when you haven’t had a bowel movement for a week or two. Stools that stay that long in the intestine can become almost rocklike and painful to pass. Enemas are also the best treatment for fecal impaction, a hard-stool blockage that’s usually caused by lengthy constipation.

An enema, available as an over-the-counter saline laxative, increases the flow of water into the intestine. It softens hard stools and usually promotes a bowel movement within a few minutes. Follow package instructions. Fecal impaction that is not relieved by an enema may require a health-care provider to manually remove stool.

MISTAKE #7: Not eating enough prunes. Your grandparents were right—prunes (and prune juice) are an effective treatment for constipation. Prunes are high in fiber, but the main benefit comes from sorbitol, a sugar that draws water into the intestine. Two servings of prunes (about 10 fruits) contain 12 g of sorbitol…and eight ounces of juice has about 15 g. Note: Drinking warm prune juice seems to be more effective at relieving constipation in some people. If you don’t like prunes, consider trying rhubarb, artichokes and/or peaches—all of which promote regular bowel movements.

Important: If you’re prone to constipation, limit your intake of processed foods, cheese and meat—these foods can slow down your digestive system.

How to Talk About Bowel Movements

If you’ve been constipated or your doctor simply asks about your bowel movements, how do you describe them? You might feel awkward or at a loss for words, but help is available.

The Bristol Stool Form Scale is a detailed guide to the usual textures and shapes. Check it for descriptions of the different types of bowel movements.