What is constipation?
Constipation is a common digestive symptom that impacts approximately 15% of the global population. It can appear in isolation as a single digestive symptom or as part of the symptoms seen in IBS.
For example, constipation can occur but the symptoms such as pain are present in a different way. Specifically, for an IBS diagnosis, the pain should improve following a bowel movement. Often with constipation or chronic constipation, the pain does not resolve or there is the sensation of an incomplete evacuation/incomplete bowel movement. [Source: PubMed]
The ROME criteria for functional constipation state that for a diagnosis of constipation, the patient must experience two or more of the following symptoms.
- Straining during more than ¼ (25%) of defecations.
- Lumpy or hard stools (Bristol Stool Form Scale 1-2) more than ¼ (25%) of defecations.
- The sensation of incomplete evacuation of more than ¼ (25%) of defecations.
- The sensation of anorectal obstruction/blockage of more than ¼ (25%) of defecations.
- Manual manoeuvres to facilitate more than ¼ (25%) of defecations (e.g., digital evacuation, support of the pelvic floor).
- Fewer than three natural bowel movements per week.
- Loose stools are rarely present without the use of laxatives.
- Insufficient criteria for irritable bowel syndrome. [Source: The Rome Foundation]
IBS-C
It is also possible for a patient to experience constipation-predominant IBS (irritable bowel syndrome). This is often referred to as IBS-C. The diagnosis of IBS with constipation is defined in a different manner.
This diagnosis made by a doctor requires abdominal pain to be a gut symptom. In addition to this, 2 of the following 3 symptoms are required of IBS-C:
- altered stool form
- altered stool frequency
- relief of abdominal pain with defecation
In reality, constipation and IBS-C are closely related, and it can be challenging to distinguish between the 2 conditions. In approximately 30% of those with these symptoms, the diagnosis can shift back and forth between constipation and IBS-C [Source: PubMed]
However, it can be more common for those with IBS-C to experience a wider range of symptoms. These can include:
- more abdominal pain (stomach or tummy pain)
- increased sensitivity in the rectum (visceral hypersensitivity)
- heartburn or dyspepsia
- anxiety
- depression [Source: PubMed]
What Causes Constipation?
Perhaps the most common causes of constipation are dehydration and inadequate fibre intake. However, there is a wide range of causes that can contribute to the symptoms seen in constipation as well as IBS with constipation.
These causes of constipation can be classified into 2 categories:
- Primary constipation
- Secondary constipation
Primary constipation can be viewed as an issue that is originating in the gut. For example, in IBS, nerve damage within the gut lining or disordered functioning of the muscles within the gut.
Primary Constipation
Primary Constipation- IBS with constipation
- SIBO
- Myopathy
- Neuropathy
- Dyssynergic defecation
- Prolapse
- Rectocele
Secondary constipation can be viewed as the result of another factor such as medication side effects.
Secondary Constipation
- Metabolic – hypercalcemia, hypothyroidism
- Medications – opiates, calcium channel blockers, antipsychotics
- Neurological disorder – Parkinson’s disease, spinal cord injury, diabetes mellitus
- Primary colonic disorders – stricture, cancer anal fissure, proctitis
What Causes IBS-C (Irritable Bowel Syndrome with Constipation)
A primary cause of constipation is IBS. However, this can be explored further to understand in more detail the underlying cause of this digestive condition.
The causes of IBS that can be considered are:
- Gut dysbiosis
- SIBO
- Food intolerances
- Dysmotility
- Visceral hypersensitivity
- Gut-brain imbalances
- Stress [Source: PubMed]
The gut microbiome in IBS is understood to be altered with certain imbalances in these microorganisms leading to alterations in bowel function. In particular, patients with IBS-C often have a higher prevalence of methane-producing organisms in the digestive tract.
This is partly understood to be due to the impact methane has on serotonin receptors along the gut lining. The serotonin receptors are responsible for muscle contractions, however, methane impacts this signalling process thus preventing appropriate contractions of the muscles required for a bowel movement.
The overgrowth of methane-producing organisms within the digestive system is referred to IMO. This stands for intestinal methane overgrowth. [Source: PubMed]
Read more about methane and constipation in our blog here.
Dyssynergia and Constipation
Dyssynergia is detected in 2/3rds of adult patients with constipation. This is understood to be the result of factors that include inappropriate toilet training, parent-child conflicts or behavioural problems.
Dyssynergia leads to constipation due to an inability to coordinate the contractions of the various muscles required for a bowel movement. These muscles are the abdominal, recto-anal, and pelvic floor muscles. This inability can lead to the overconcentration and/or under contraction of a combination of these muscles in the gut. [Source: PubMed]
What side of the body hurts when constipated?
Constipation can lead to pain but pain does not have to be present for there to be constipation. With irritable bowel syndrome (IBS), however, pain is a central feature with this type of pain often improving following a bowel movement.
The location and intensity of the pain can vary between patients. For some, this can be a general pain and pressure across the stomach or abdomen while for others this can be located in a specific region. However, the most common location of IBS pain can be on the left side. [Source: PubMed]
How to relieve stomach pain from constipation
Pain from constipation can have several causes so understanding the underlying issue, is a crucial part of the treatment process. However, there are foundation steps that can be taken to address and relieve stomach pain from constipation.
These can include:
- Fluid intake
- An appropriate level of dietary fibre
- Daily movement
- Seated position on the toilet [Source: PubMed]
In addition to these foundational aspects, several supplements have been indicated to improve bowel movements and the associated symptoms.
These supplements include probiotics for constipation. When selecting probiotics for constipation, using specific strains of probiotics bacteria that have been researched for constipation and pain is important.
These probiotics for constipation include:
- Bifidobacterium lactis BB-12 [Source: PubMed]
- Bifidobacterium lactis HN019 [Source: PubMed]
- Bifidobacterium lactis DN-173 010 [Source: PubMed]
- Lactobacillus rhamnosus GG [Source: PubMed]
As well as probiotics, additional supplements can work to address and support the digestive tract.
These include prebiotics such as PHGG which has been used to normalise bowel movements when taken over an 8-week period. [Source: PubMed]. In addition, herbal antimicrobials can support the balance of the gut microbiome and improve bowel function and symptoms of IBS [Source: PubMed]
Immediate Constipation Relief
Whereas a long-term approach for constipation pain and IBS is to address the underlying cause of the digestive symptoms, short-term relief can also be considered.
There are shorter-term forms of symptom management to help improve bowel movements and reduce symptoms such as pain.
2 foods that can be introduced to improve bowel movements are flaxseeds and kiwifruit. These both contain non-fermentable fibres that support fibre and fluid balance with the bowel to support motility and improve constipation. While these can be a helpful and reliable way to support constipation and pain, they make take 1-2 days to improve symptoms and do not offer an immediate or quick fix. [Source: PubMed]
Lactulose is a non-absorbable carbohydrate that can improve bowel motility. This is understood to be due to its ability to draw and move the liquid into the bowel. This is defined as having an osmotic effect. Lactulose is used for constipation but it also is prebiotic, meaning it feeds a select population of some of the gut bacteria in the gut. However, these prebiotic effects do mean that it can increase bloating, gas and pain in some with digestive issues such as constipation and IBS so it is not suitable for all patients with constipation or IBS-C. [Source: PubMed]
Forms of magnesium such as magnesium oxide can also be helpful for constipation, pain and IBS with constipation. [Source: PubMed]
Is Magnesium Good for Constipation?
Magnesium can be helpful for constipation, pain and IBS with constipation. In particular, magnesium oxide is well understood to support bowel movements and improve constipation.
As magnesium oxide enters the digestive tract, it is converted into magnesium carbonate. This form of magnesium increases the water content as well as the volume of the stool which then adds pressure to the gut wall, stimulating muscle contractions and ideally a bowel movement.
70% of participants in a recent study reported a significant improvement in their symptoms of constipation when using magnesium oxide. Importantly, no adverse reactions or side effects were reported in the participants.
Depending on the individual and the severity of symptoms, the dose can be personalised, however, a dose of up to 1000mg per day is often suitable.
There are, however, concerns around high-dose magnesium in those with kidney dysfunction or kidney disease. This can be due to impaired rates of magnesium filtration.
Other supplements used for constipation, such as senna and rhubarb can lead to tolerance which means higher and higher doses may be needed to that they can stop working altogether. [Source: PubMed]
How Long Does Constipation Last?
Constipation can last for a short period of time but it can also be a chronic and long-term issue for many people. This can be leading to discomfort and prolonged periods of time on the toilet. It can also increase the likelihood of other digestive problems such as haemorrhoids and fistulas. [Source: PubMed, PubMed]
As mentioned in this article, there are certain criteria that need to be met for constipation to be diagnosed. This includes the requirement for symptoms to be present for a period of at least 3 months. While someone may have trouble going to the toilet, symptoms need to be present for a certain period of time for constipation to be officially diagnosed by a doctor. [Source: The Rome Foundation]
Long-Term Solutions for Constipation
While certain approaches for constipation, pain and IBS-C can be a helpful form of symptom management, the long-term approach is key for remaining symptom-free.
This approach can be multi-factual and include options such as:
- Appropriate hydration
- Finding the right balance of fibre intake
- Supporting the gut-brain connection
- Support the balance of the gut microbiome
- Addressing the root cause of constipation and pain
Working with a gut-health nutritionist can help guide your through these steps at the right time and in the right way.
