*To press or crowd together*

That's "constipation," from the Latin "constipare."

Patients have asked me about constipation a lot this week. That’s not unusual given that at least 20% of us experience this on a regular basis. If you don’t have this problem it’s almost certain you know someone in your family who does. So here are some quick yet expanded ideas that go beyond the typical “eat fiber, drink water, and take some Metamucil” we only have brief time to review before our twenty minutes are up, and the other twenty issues go unattended. I’m guessing most of us have experienced constipation at some point, and know it can be terrible, while sometimes bordering on desperate. But as always, I bet we can find some overlooked ideas here, even in the proverbial toilet. Ever feel like the world is headed there?

Photo by Sincerely Media on Unsplash

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General ways to help relieve constipation

Always best to start with the basics. These are usually the safest approaches to build upon.

1. Increase water intake

• Aim for ~6-8 glasses per day, but this hard number is debatable. A less numerical approach would be to keep a glass/bottle of water handy, and to drink enough water so that we are not thirsty, and so that our urine stays a light, pale yellow color.

• Stay hydrated especially during physical activity and days with low humidity

2. Add more fiber to our diet - but carefully - I’ll expand on this more below!

• Fresh fruits (especially pears, apples, berries)

• Vegetables (leafy greens, broccoli, carrots)

• Whole grains (oats, brown rice, quinoa)

• Legumes (beans, lentils)

• Increase (or start) fiber slowly to avoid gas/bloating

* Consider a fiber supplement like psyllium (once again, see below)

3. Exercise regularly

• Whatever intensity your body allows, most days of the week if possible. I’m not into pushing this to extremes. Most of the benefit of exercise comes from just being active in my opinion, and avoiding prolonged sedentary times.

4. Establish a regular bathroom routine

• Try going around the same time each day. The bowels often develop a circadian rhythm.

• Don't ignore the urge to go. The next peristaltic train might not be leaving the station for hours. Or more.

• Allow sufficient time without rushing. This is the worst if you have a job where the next patient is always 20 minutes away, the next class to teach 45 minutes away, or there are too few toilets and someone keeps knocking impatiently.

5. Natural position adjustments

• Try using a footstool while on the toilet.

• Leaning forward slightly can help many people.

• Reading or scrolling on a cell phone can make things worse if we are constipated. Coordinated voluntary/involuntary nervous system signals and movements can suffer from cognitive multitasking interference. Sorry.

6. Massage

• Gentle clockwise abdominal massage, focusing on the lower left side of abdomen. Evidence for this helping constipation is mixed and not that robust. The randomized controlled studies that have looked into this practice over the past 20 years have generally found some benefit, but are published in fringe journals.

7. Stress reduction

• Regular meditation, deep breathing exercises, etc. stimulate the digestive system, too. Adrenaline can divert blood away from the gut and slow it down, while cortisol can affect motility, the microbiome, and inflammation.

• Good/adequate sleep

8. Evaluate medications

Here are common types of medications that can cause or worsen constipation, but this list is not exhaustive:

Pain medications

• Opioids (like oxycodone, hydrocodone, morphine)

• NSAIDs (less commonly)

Antacids containing calcium or aluminum

• Calcium carbonate (Tums)

• Aluminum hydroxide

Iron supplements

Anticholinergics

• Overactive bladder medications

• Some antihistamines (especially older ones like diphenhydramine)

Psychiatric medications

• Many antidepressants, especially tricyclics

• Some antipsychotics

• Anti-anxiety medications

Blood pressure medications

• Calcium channel blockers

• Diuretics

• Some beta blockers

Anti-epileptics/anticonvulsants

• Often used as mood stabilizers

Anti-Parkinson's medications

Antispasmodics

Important notes about medications:

• Don't stop prescribed medications without consulting your healthcare provider

• Alternative medications may be available if constipation is problematic

• Dosing changes might be possible, as higher doses can result in more problems

• Sometimes changing the timing of medications can reduce side effects

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More about fiber

Dietary fiber is an indigestible carbohydrate found in plant foods. There are two main categories: soluble fiber, which dissolves in water to form a gel-like substance, and insoluble fiber, which adds bulk to stool. While men should aim for 38 grams and women 25 grams daily, most people only consume about half the recommended amount.

While increasing fiber intake can relieve constipation for many people, particularly those with low fiber consumption, it's not a universal solution. For some individuals, especially those with conditions like chronic idiopathic constipation or irritable bowel syndrome (IBS), additional fiber might actually worsen symptoms.

Good all around sources of fiber include vegetables, fruits, oats, legumes, nuts, dark chocolate, avocados, chia and flax seeds. These also help regulate blood sugar, increase feelings of fullness, and support healthy gut microbiome bacteria. Healthline has a pretty good run down of 22 examples of foods that contain good amounts of fiber.

However, dietary fiber intake should be increased gradually to avoid digestive discomfort, and those with chronic digestive issues should be careful and probably consult their healthcare providers before making significant changes to their fiber consumption. New constipation and changes in bowel habits should also prompt a visit to your doctor.

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Treatments and medications

First-line medication options for constipation include bulk laxatives and osmotic laxatives.

Second-line therapies include stimulant laxatives, stool softeners, and newer agents.

Bulk Laxatives. Psyllium (like Metamucil) contains soluble and insoluble fiber. Other options include polycarbophil (Fibercon/soluble fiber) and methylcellulose powder (Citrucel/insoluble fiber). These absorb water into the stool. Good water intake is necessary for bulk agents to work; otherwise bloating and constipation can worsen. Per American Family Physician:

A 2011 systematic review of patients with chronic constipation compared soluble and insoluble fiber with placebo and found that soluble fiber improved global symptoms (86.5% vs. 47.4%), decreased straining (55.6% vs. 28.6%), decreased pain with defecation, improved stool consistency, and increased the mean number of stools per week (3.8 stools per week compared with a baseline of 2.9 stools per week). The evidence for insoluble fiber was inconsistent.

Osmotic Laxatives. Osmotic laxatives, such as polyethylene glycol (Miralax), lactulose, and magnesium-based products increase water secretion into the gut. Miralax is generally considered to be better than other osmotic laxatives.

In a 2010 Cochrane review, polyethylene glycol was superior to lactulose for improving stool frequency per week, form of stool, abdominal pain, and the need for additional medications. Although generally well tolerated, osmotic laxatives can cause electrolyte disturbances within the colon, leading to hypokalemia, fluid overload, and chronic kidney disease, and patients should be monitored accordingly.

Stimulant Laxatives and Stool Softeners. Bisacodyl (Dulcolax) and sennosides (Senakot), are decent short-term, second-line add-ons to osmotic and bulk laxatives. There are not many quality studies about long-term effectiveness.

In a randomized controlled trial comparing four weeks of oral bisacodyl to placebo, the treatment group experienced an increased number of spontaneous bowel movements from 1.1 per week to 5.2 (compared with 1.9 in the placebo group). However, the long-term effects of prolonged stimulant laxative use were not assessed.

Other Agents. Lubiprostone (Amitiza) and linaclotide (Linzess), plecanatide (Trulance), Prucalopride (Motegrity) are more effective than placebo and should be considered when dietary modifications and osmotic and/or stimulant laxatives are ineffective. These are beyond the scope of this post, and should be discussed with a doc as they are available by prescription only.

Probiotics might help, according to some recent meta-analyses (1, 2). I think the quality of the studies and the variation in probiotics available make this a difficult conclusion to be sure of though. The best probiotic that I have found for other conditions is called Visbiome. They provide a pretty balanced statement about their own product - kind of a maybe?

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In conclusion

Constipation is a common condition affecting at least one-fifth of the population, but there are multiple evidence-based approaches to finding relief. While proper hydration, fiber intake, exercise, and consistent bathroom habits form the foundation of treatment, it's important to recognize that certain medications can contribute to constipation and may need adjustment under medical supervision. Treatment options range from over-the-counter bulk laxatives to prescription medications, with the choice depending on individual circumstances and response to first-line therapies. Though emerging research suggests probiotics may play a role in treatment, more conclusive evidence is needed – emphasizing that managing constipation often requires a personalized approach combining lifestyle modifications with appropriate medical interventions.

Did you know that there is even a kind of prayer called asher yatzar? The purpose of this blessing is to thank God for good health: specifically thanks for having the ability to excrete, for without it existence would be impossible.

That’s true.

Wellness sites often challenge us to cultivate a sense of gratitude along the way to pursuing happiness. I bet very, very few mention gratitude for the overlooked blessings of regularity.