Finding Effective Relief for Constipation

Constipation is the Rodney Dangerfield of common conditions—it rarely receives the respect it deserves. Just because it’s common and usually treatable with dietary changes or OTC laxatives, many people—patients and clinicians alike—think constipation is simply an annoying inconvenience.

It can, however, have serious health consequences. Straining affects cerebral and coronary circulations, and can cause syncope or transient ischemic attacks when the parasympathetic nervous system causes blood pressure to fall during bowel movements. Epidemiologists report that up to 8% of sudden cardiac deaths occur after patients with an existing circulatory issue strain to eject a stool; these patients may instinctively use the Valsalva maneuver (attempting to forcibly exhale while keeping the mouth and nose closed) to force hard feces from the rectum.^1,2

Every individual has a different definition of constipation, which is not a diagnosis but a symptom constellation, because normal elimination patterns vary. Many people have a bowel movement daily, whereas others go more than once a day and some only a few times a week.³ With little consensus about the best way to manage constipation, treating it pre-sents a malodorous challenge (Table 1^4-6).

At any given time, up to one-fourth of Americans are constipated.⁷ Patients who are older than 65 years, pregnant, or who have the conditions listed in Table 1 are at increased risk.^8-10 Patients harbor all kinds of myths about constipation, and pharmacists can help dispel those myths. For example, patients often believe that constipation causes the body to absorb poisonous substances from stools or causes disease. It does neither. Colonic irrigation, contrary to popular belief, does not remove toxins and can damage the colonic environment.¹¹

Constipated patients often visit the local pharmacy for advice and OTC products to find relief. Pharmacists can help, but should be sure to refer patients to their primary care providers if the patient has¹⁰:

• Abrupt-onset constipation lasting 1 week or more, or intermittent periods of constipation over 2 months
• Anorexia
• Bloody (maroon or tarry) stool
• Nausea, vomiting, or fever
• Severe pain with bowel movements
• Unexplained weight loss

Start with Lifestyle

Pharmacists should begin by instructing patients to find a bathroom whenever the urge to defecate happens. Most people are creatures of habit, and experience a gastrocolic response after breakfast or dinner.^3,5 Ignoring urges may make patients physically uncomfortable, and it also weakens bowel signals over time.

Next, patients should increase dietary fiber to more than 25 g daily. This sounds easy, but many patients have no idea how to determine foods’ fiber content.³ Showing them how to find this information on labels and on the Internet is simple and ensures better adherence. Note that in slow-transit constipation or diverticulosis, fiber may worsen constipation, at least initially.^12-14

Whole fruits and vegetables, beans, bran, and whole-grain products are the best sources, but advise patients to increase fiber slowly to avoid gas and bloating. Prunes are an easy, effective “neutraceutical.” Many patients will be unreceptive to suggestions that prunes can end constipation, but many patients have never tried prunes and base their opinions on hearsay. Calling prunes “dried plums” can remove the stigma, and explaining that they contain natural laxatives—sorbitol and dihydrophenylisatin—may convince patients to try them.^15,16

Drinking 2 to 4 glasses of water or other fluids above normal intake is also considered important. Lack of physical activity can contribute to constipation. Increasing exercise to at least 20 minutes daily may improve regularity and also decrease stress. Note that little evidence supports these 2 recommendations, but they seem to help.^17-19

Medication side effects should be ruled out as causes. If a prescription medication is the cause, referral to or collaboration with the prescriber is in order. OTC calcium and iron can also lead to constipation.

Selecting Products

Many patients will want or need immediate relief. Various enemas (eg, mineral oil, phosphate, water, or saline) and suppositories (eg, bisacodyl, glycerin) can provide that relief, but it’s important to review proper use.¹⁰

Other OTC laxatives work in hours or days, and are intended for short-term use. These fall roughly into 5 categories (Table 2^3,14,20-22).

When counseling about OTC laxatives, pharmacists need to caution patients to follow package directions and avoid overuse. Using laxatives to cleanse bowels routinely is a dangerous practice; it can alter the gut’s normal physiologic functioning.¹⁰

Summary

Acute constipation occurs frequently, but fortunately most problems can be treated with OTC products. Untreated, it may lead to chronic, complicated constipation. If chronic constipation develops, patients may experience pelvic floor problems involving bladder voiding difficulties, sexual dysfunction, and pain syndromes.⁷

References

1. Hayashi S, Toyoshima H, Tanabe N, et al. Activity immediately before the onset of non-fatal myocardial infarction and sudden cardiac death. Jpn Circ J. 1996;60:947-953.

2. Mikhail MS, Thangathurai D, Viljoen JF, Chandraratna PA. Atrioventricular block secondary to straining. Crit Care Med. 1987;15:705-706.

3. Pare P, Bridges R, Champion MC, et al. Recommendations on chronic constipation (including constipation associated with irritable bowel syndrome) treatment. Can J Gastroenterol. 2007;21(suppl B):3B-22B.

4. Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology. 2006;130:1480-1491.

5. Chatoor D, Emmnauel A. Constipation and evacuation disorders. Best Pract Res Clin Gastroenterol. 2009;23:517-530.

6. Chatoor D, Emmanuel A. Development and assessment of the constipation-related disability scale. Aliment Pharmacol Ther. 2012;35:487-488.

7. Doty JE. Bowel dysfunction in pelvic floor dysfunction. Springer Publishers; 2006:15-23.

8. Bosshard W, Dreher R, Schnegg JF, Büla CJ. The treatment of chronic constipation in elderly people: an update. Drugs Aging. 2004;21:911-930.

9. Bharucha AE, Pemberton JH, Locke GR 3rd. American gastroenterological association technical review on constipation. Gastroenterology. 2013;144:218-238.

10. Curry CE, Butler DM. Constipation. In: Handbook of Nonprescription Drugs. Washington DC: American Pharmacists Association; 2009:263-288.

11. Prasad P, Tantia O, Patle NM, Mukherjee J. Herbal enema: at the cost of colon. J Minim Access Surg. 2012;8:104-106.

12. Foxx-Orenstein AE, McNally MA, Odunsi ST. Update on constipation: one treatment does not fit all. Cleve Clin J Med. 2008;75:813-824.

13. Anti J, Pignataro G, Armuzzi A, et al. Water supplementation enhances the effect of high-fiber diet on stool frequency and laxative consumption in adult patients with functional constipation. Hepatogastroenterology. 1998;45:727-732.

14. Dukas L, Willett WC, Giovannucci EL. Association between physical activity, fiber intake, and other lifestyle variables and constipation in a study of women. Am J Gastroenterol. 2003;98:1790-1796.

15. McRorie JW. Prunes vs. psyllium for chronic idiopathic constipation. Aliment Pharmacol Ther. 2011;34:258-259.

16. Scott SM, Knowles CH. Constipation: dried plums (prunes) for the treatment of constipation. Nat Rev Gastroenterol Hepatol. 2011;8:306-307.

17. Meshkinpour H, Selod S, Movahedi H, Nami N, James N, Wilson A. Effects of regular exercise in management of chronic idopathic constipation. Dig Dis Sci. 1998;43:2379-2383.

18. Young RJ, Beerman LE, Vanderhoff JA. Increasing oral fluids in chronic constipation in children. Gastroenterol Nurs. 1998;21:156-161.

19. Tuteja AK, Talley NJ, Joos SK, Woehl JV, Hickam DH. Is constipation associated with decreased physical activity in normally active subjects? Am J Gastroenterol. 2005;100:124-129.

20. Hamilton JW, Wagner J, Burdick BB, Bass P. Clinical evaluation of methyl-cellulose as a bulk laxative. Dig Dis Sci. 1988;33:993-998.

21. Corazziari E, Badiali D, Habib FI, et al. Small volume isosmotic polyethylene glycol electrolyte balanced solution (PMF—100) in treatment of chronic nonorganic constipation. Dig Dis Sci. 1996;41:1636-1642.

22. Foxx-Orenstein AE, McNally MA, Odunsi ST. Update on constipation: one treatment does not fit all. Cleve Clin J Med. 2008;75:813-824.

About the Author

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance clinical writer.