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Constipation in Adults

Constipation: Time goes slow when you can’t go What is constipation? What are the common signs of constipation?

Am I supposed to go every day? If I go every day, can I still be constipated? What is chronic constipation?

What causes constipation? What causes constipation? What medications cause constipation? Is constipation more common in the elderly? Is it important to treat constipation? What lifestyle changes help with constipation?

Does fibre help with constipation? What is the difference between soluble and insoluble fibre? What foods are high in fibre? How much fibre should I be taking? What other lifestyle changes are there for constipation?

Do probiotics work? What medications can be used for constipation?

What over the counter medications can I use for constipation? Are there prescription medications for constipation? Can I use laxatives if I’m pregnant or breastfeeding?

Can pregnancy cause constipation? Can I use laxatives if I’m pregnant or breastfeeding?

When should I see my doctor? Resources and References Resources References

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Constipation in Adults

Constipation: Time goes slow when you can’t go

What is constipation? Constipation is when you have unsatisfactory bowel movements because of difficulty passing stools, not going as often versus your regular routine, or both.1 What are the common signs of constipation?2

Hard or lumpy stools

Bloating and discomfort

Feeling that you have not completely emptied your bowels

Feeling that something is blocking the passage of stools

Lots of straining or pushing when having a bowel movement

Am I supposed to go every day? No, not necessarily. Some people may normally have 3 bowel movements per day, while others may have 1 bowel movement every 3 days. There is no set number of times that a person should go per day – Everyone is unique and it varies for each person. If I go every day, can I still be constipated? Yes. Remember that not going as often is only part of the picture. You can still have unsatisfactory bowel movements, and difficulty passing stool even if you go every day. What is chronic constipation? Some people may get occasional constipation, where constipation is only short-term and is usually linked to a change in their diet, lifestyle or medications.3 Other people may have long-term constipation (also known as chronic constipation), where you have symptoms of constipation lasting over 3-6 months. If you have been suffering with constipation over several months, it is important that you talk to your healthcare provider.

Did you know?

About 1 in 4 Canadians have symptoms of constipation.3 Not only does it cause discomfort but it can impact a

person socially, emotionally and financially.3

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What causes constipation?

What causes constipation?

Common Causes of Constipation

Short Term3, 4 Long Term4

Changes in diet Illness Lack of exercise Medications Travel

Medications Medical conditions Problems with colon

What medications cause constipation? Some medications that have been linked with constipation include:1

Pain killers like codeine, or morphine

Iron supplements

Medications or vitamins containing aluminum, or calcium (eg. antacids)

Some high blood pressure medications

Antidepressants, anti-Parkinson medications, antipsychotics

The above list is not complete. There are other medications that can cause constipation. If you think that a medication

may be causing your constipation speak to your doctor or pharmacist.

REMINDER:

DO NOT stop or change any of your medications without first talking to your doctor or pharmacist.

Is constipation more common in the elderly? Constipation is seen more commonly in the elderly. The reason is not because of aging itself but because elderly people often have:5

A less active lifestyle

Multiple medical conditions

More medications Having any of the above can increase a person’s risk of getting constipation. Is it important to treat constipation? Yes. If constipation is not treated, it can cause problems such as hemorrhoids, cuts or tears in the skin in the anus, complete blockage, or fecal incontinence.6

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Helpful Tips:

If you think you have constipation, a useful thing to do is to start keeping some daily

notes on:3

Your bowel movements – This is most effective in the form of a stool diary.

What you eat and how much

How much water you drink

How much physical activity you do

There is a mobile application available for smart phones that will help you to keep track of these.

By keeping a record you can see what worked and what didn’t. It will also be helpful for your doctor as it will

provide a good history of you and your condition.

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What lifestyle changes help with constipation?

Does fibre help with constipation? Fibre is recommended for people that have constipation.7 Your body does not absorb fibre, so when you eat fibre it goes in one end and goes out the other.8 It will help you pass stool more quickly and also increase the weight of your stools. What is the difference between soluble fibre and insoluble fibre? Soluble fibre dissolves in water and works to keep water within the colon, while insoluble fibre does not dissolve in water and increases bulk of stools.9 Both types of fibre can help in constipation, however, insoluble fibre works better.10 What foods are high in fibre?4

Food Type Examples

Vegetables and legumes Beans, lentils, chickpeas, green peas

Fruits Raspberries, avocados, prunes

Cereal Fibre1®, Bran Flakes®

Bread Whole-wheat, rye, pumpernickel

Nuts Almonds, walnuts, pistachios

Click here for more dietary fibre options

How much fiber should I be taking? The amount of fibre you should take depends on you. The values range between 21-38 g of fibre per day.4

Recommended amount of fibre per day.8

Age Women Men

19-50 25 g 38 g

51+ 21 g 30 g

Not sure what 21-38 g looks like? Here are some examples:

21 g of fibre ≈ 4 medium pears11

25 g of fibre ≈ 8 slices of whole wheat bread11

30 g of fibre ≈ 1 ¼ cups of All Bran® cereal12

38 g of fibre ≈ 2 ⅓ cups of cooked split peas13 Fibre Tips:

1) It is important to drink lots of fluid to supplement fibre. Aim to drink around 6-8 glasses (1.5 – 2.0 L) of fluid per

day.14

NOTE: Drinks with caffeine and alcohol have water losing effects in the body.3 It is best to avoid these

drinks or if not possible, then you should drink extra water to counteract the effects of caffeine and

alcohol.

2) Don’t start eating a large amount of fibre tomorrow. If you change how much fibre you eat too quickly you

can get some serious bloating and gas. To prevent this from happening, slowly increase the amount of

fibre you eat over a few weeks.15

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What other lifestyle changes are there for constipation?

1) Go to the bathroom as soon as you feel the urge to go – If you feel the urge to go to the bathroom, don’t resist it!

Delaying it can make it harder to pass in the future.

2) Set aside a specific time to go to the washroom – This should be at the same time every day. After breakfast is a good

time as it is when the activity in the colon is at the highest.4

3) Drink lots of fluid – This is especially important if you are eating or taking a lot of fibre. Aim to drink at least 6-8

glasses of fluid daily (around 1.5 - 2.0 L).14

4) Exercise – People that are not active and moving around are at higher risk of constipation.4 Exercise will not only help

for constipation but is important to keep you healthy! Find physical activity guides here.

Do probiotics work? Some probiotics may help to move stool through the colon. There is not a lot of research to show that they will work to treat constipation.4 Before taking a probiotic, consider talking to your doctor or pharmacist.

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What medications can be used for constipation ?

If you are constipated you should always try to change your lifestyle first. If this does not help with your constipation,

there are laxatives that you are able to buy without a prescription at your local pharmacy.

REMEMBER:

Even if you are taking a laxative for your constipation, you should still do the lifestyle changes. Both will work

together to help with your constipation.

What over the counter medications can I use for constipation? What are the common side effects? There are a couple of non-prescription medications available for constipation. Before selecting a medication, you should speak to a pharmacist or doctor. There are many options to choose from and they can help select the best option for you. Bulking agents – holds water and adds extra bulk to the stool4

Examples: Metamucil® (psyllium), Prodiem® caplets (polycarbophil calcium)

Common side effects: bloating and gassiness.4 To prevent this from happening, start with a small amount and slowly increase

Bulking agents contain fibre, they may take a couple of days to work and they are safe for long term use6 CAUTION:

It is important to drink plenty of fluids if you are taking bulking agents. If you are unable to drink a lot of fluids, this option may not be the best for you. Speak to your pharmacist or doctor for more information.

Osmotic Laxatives – Pulls water into the colon3

Examples: Lax-A-Day® (polyethylene glycol 3350 or PEG-3350), lactulose, Milk of Magnesia®(magnesium hydroxide)

Common side effects: bloating, gassiness, cramps, nausea6

If fibre or fibre supplements don’t work or do not work fast enough, these laxatives may be an option for you

PEG-3350 has been shown to be effective for long-term use in chronic constipation7 CAUTION:

Some osmotic laxatives such as Milk of Magnesia® and Citro-Mag® should be avoided if you have kidney problems because they can be high in salt and magnesium which can either cause you to swell or cause your magnesium levels to go high in the body.

Stimulants – Stimulates movement in the intestines4

Examples: Senokot® (senna), Dulcolax®(bisacodyl)

Common side effects: cramping, diarrhea6

Can be used for occasional constipation or rescue therapy in chronic constipation.7, 14 Stool Softeners – Makes stool softer by allowing more water to enter and mix with stool more readily3

Examples: Colace® (docusate sodium), docusate calcium

Stool softeners have very little side effects

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They don’t work well on their own to help with constipation, but it can soften the stool which can help with straining4

Reduced straining can be helpful, especially if you have certain conditions such as hemorrhoids or angina4 Suppositories and enemas work quicker compared to pills and liquids.6 Usually these options are only used short term. There are different suppositories and enemas available. Speak to your pharmacist for more information. REMEMBER:

Before choosing a medication, speak to a pharmacist or doctor to make sure it is the best medication for you.

Are there prescription medications for constipation? There are prescription medications available for chronic constipation. Lifestyle changes and laxatives you can buy from the pharmacy should be tried before prescription medications. If you find that the non-prescription laxatives are not giving you constipation relief, speak to your doctor.

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Can I use laxatives if I’m pregnant or breastfeeding?

Can pregnancy cause constipation? Constipation during pregnancy is common. Changes in hormones and increased pressure on the colon by the baby during pregnancy are some of the reasons why constipation may be more common when a woman is pregnant.4 Can I use laxatives if I’m pregnant or breastfeeding? The safest and first option is to make some lifestyle changes to your daily routine. There are some laxatives that can be used during pregnancy. If the lifestyle changes are not providing enough relief, speak to your doctor or pharmacist to find the best option for you. REMINDER:

It may take a couple of days before any changes in diet or lifestyle are able to help with your constipation

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When should I see my doctor?

You should see your doctor if you have constipation plus any of the following:9

No bowel movement for more than a week

Constipation for more than 2 weeks even with the use of laxatives

Fever, nausea, vomiting and/or extreme thirst

Rectal bleeding or blood in the stool

Extreme discomfort and/or pain around the rectum or abdomen

Unintended weight loss

Episodes of diarrhea and constipation

Anemia (watch out for symptoms of anemia eg. tiredness, lack of energy)

Family history of colon cancer

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Resources and References:

Resources:

Canadian Digestive Health Foundation

Constipationinfo.ca

Gastrointestinal Society and Canadian Society of Intestinal Research

References:

1) Andrews CN et al. The pathophysiology of chronic constipation. Canadian Journal of Gastroenterology. 2011;25(Suppl

B):16B-21B.

2) American Gastroenterological Association et al. American Gastroenterological Association medical position statement

on constipation. Gastroenterology. 2013;144(1):211-217.

3) Canadian Digestive Health Foundation. Understanding the Prevalence and Impact of Constipation in Canada. Online

resource at http://www.cdhf.ca/bank/document_en/76understanding-the-prevalence-and-impact-of-constipation-in-

canada.pdf, accessed November 2014 .

4) Bowles-Jordan J. Chapter 31: Constipation. In: Patient Self-Care. 2nd edition. Ottawa: Canadian Pharmacists

Association; 2010:262-280.

5) Spinzi G et al. Constipation in the elderly: management strategies. Drugs Aging. 2009;26(6):469-474.

6) Chaun H. Gastrointestinal disorders: constipation in adults. In: Therapeutic Choices. Canadian Pharmacists Association.

Online resource at http://www.e-therapeutics.ca/, accessed November 2014 (subscription required).

7) Paré P et al. Recommendations on chronic constipation (including constipation associated with irritable bowel

syndrome treatment). Canadian Journal of Gastroenterology. 2007;21(Suppl B):3B-22B.

8) EatRight Ontario. Focus on Fibre. Online resource at http://www.eatrightontario.ca/en/Articles/Fibre/Focus-on-

Fibre.aspx#.VIDWr9LF_Sn, accessed December 2014.

9) Canadian Digestive Health Foundation. Understanding Constipation. Online resource at

http://www.cdhf.ca/bank/document_en/5constipation-.pdf, accessed December 2014.

10) Fernandez-Banares F. Nutritional care of the patient with constipation. Best Practice & Research. Clinical

Gastroenterology. 2006;20(3):575-587.

11) Dieticians of Canada. Healthy Eating Guidelines for Increasing Your Fibre Intake. Online resource at

http://www.dietitians.ca/Nutrition-Resources-A-Z/Factsheets/Fibre/Increasing-Your-Fibre-Intake.aspx, accessed

December 2014.

12) Cigner, P. Fibre Q&A. Gastrointestinal Society. Online resource at http://www.badgut.org/information-centre/health-

nutrition/fibre-qa/, accessed on December 2014.

13) Mayo Foundation for Medical Education and Research. Nutrition and Healthy Eating. Online resource at

http://www.mayoclinic.org/healthy-living/nutrition-and-healthy-eating/in-depth/high-fiber-foods/art-20050948,

accessed December 2014.

14) Lindberg G et al. World gastroenterology organisation global guideline: constipation – a global perspective. Journal of

Clinical Gastroenterology. 2011;45(6):483-487.

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15) Liu LWC. Chronic constipation: current treatment options. Canadian Journal of Gastroenterology. 2011;25(Suppl

B):22B-28B.