1. Am I really constipated?
Just because you’re not moving your bowels every day doesn’t mean that you’re constipated. In fact, doctors consider it normal if you’re moving your bowels anywhere between three times a day and every three days. And in fact many people move their bowels even less frequently than that. If your stools are less than twice a week and you’re having symptoms associated with that infrequency such as gas, bloating and cramps, then you’re considered to be constipated. If your stools are hard and lumpy and you’re straining excessively to get them out, or if you don’t feel that you’re evacuating completely, then you are constipated. But if you have a reasonable bowel movement even once a week and you feel fine in between- then that’s fine. You’re not alone. Keep doing what you’re doing.
2. Do I really need a colonoscopy?
Constipation is one of the most common reasons patients visit doctors in America. The vast majority of these patients have chronic idiopathic constipation which means that we don’t know what causes it. “Lazy muscles” is what we tell patients. Your doctor should be looking at three factors when he’s making a decision on whether or not a patient needs a colonoscopy:
1. Does my patient have any alarming symptoms: bleeding, persistent abdominal pain or weight loss?
2. Is my patient due for a colonoscopy: is it beyond ten years for most patients or 3-5 if there is a personal history of colon polyps or family history of colon cancer?
3. Is there a clear cut change in my patient's bowel habits that has been persisting for more than a few weeks at least?
If the answer to all these questions is ‘no’, then you should press your doctor to give you a thorough explanation on why it might be necessary or helpful to repeat a colonoscopy at this point. You probably don’t need one.
3. Are my medications playing a role?
Open up the package insert for pretty much any medication, read the side effects section, and almost always you will find constipation listed. It’s among the most common symptom caused by pretty much any medication. So if that’s the case, what do you do? I don’t usually suggest changing medications around as a first step, because chances are that the new medication is going to have the same side effects. I think a better approach is to try to overcome the constipation on your own, naturally. If you’re not getting 30 grams of fiber in your diet every day then you certainly should make more of an effort to do so. You should be focusing on insoluble fibers- all your fruits, salads and vegetables. I have found dried fruits to be especially helpful. I’ll even suggest using a gentle over-the-counter laxative on some regimented schedule such as twice a week to see if that helps. If none of that is working then only at that point will I readdress the issue and consider changing medications.
4. Do I have pelvic floor dysernegia?
My old mentor marveled at the rectal muscles. He pointed out that the rectum can release gas in preference to solid material when it wants to. Not even your hand can do that. Indeed, moving your bowels is a more complicated activity than you appreciate. We all have two sets of muscles in the rectum. One of these needs to contract while the other one relaxes for you to have a normal bowel movement. In pelvic floor dysernegia (or defecation dysernegia or pelvic floor dysfunction or various other names) these muscles don’t do what they’re supposed to do and ‘constipation’ is the result. High fiber diets and laxatives are generally not helpful as the problem is not in the stool consistency. About 15% of patients with idiopathic chronic constipation suffer from pelvic floor dysernegia. Diagnosis is quite simple and treatment is conservative with simple retraining of those muscles. Be sure you ask your physician if he’s thought about this diagnosis. You might be able put away your prune juice- which wasn’t helping anyway.
5. Should I worry?
I can’t tell you how many times I say to my patients who have constipation “you know you shouldn’t worry about this, right?” and then watch as relief washes over their face and body. Constipation is almost never a serious problem. A nuisance? Absolutely. Uncomfortable at times? Definitely. But just because you’re constipated doesn’t mean you have colon cancer. In fact you almost certainly don’t. And it doesn’t mean that your colon is about to explode. It’s not. See your doctor, let him or her talk to you, examine you and then make suggestions about what you can do to help the problem. Without those alarming symptoms- persistent abdominal pain, bleeding or weight loss, it’s very unlikely that you have anything serious going on. Be sure your doctor reassures you.