Features

Constipation: struggling in silence

07 February 2020

Constipation can be debilitating, distressing – and a drain on the NHS. People also feel ashamed to discuss it with healthcare professionals. Journalist John Windell asks how we can begin tackling the stigma.

It’s not always an easy subject to raise, but we need to talk about constipation.

Poor bowel health and chronic constipation are debilitating and distressing problems for thousands of people in the UK. According to the Bowel Interest Group’s Cost of constipation report (2019), the condition cost the NHS £71m in unplanned hospital admissions during 2017-18. Factor in GP visits, home visits and over-the-counter laxatives, and the cost is likely to be much higher.

In addition, many people are reluctant to talk about constipation – one in five are too embarrassed to discuss it with their GPs (Bowel Interest Group, 2019). And besides the physical problems the condition can cause, such as haemorrhoids, chronic pain and urinary tract infections, it’s also linked to psychological issues such as anxiety disorders and depression.

Commenting on the report, Dr Benjamin Disney, consultant gastroenterologist at University Hospitals Coventry and Warwickshire NHS Trust, said that the condition was ‘under-reported and often poorly managed, leading to a significant cost to the NHS and having a negative impact on patients’ overall health and quality of life’.

Symptoms and causes

Constipation generally describes bowel movements that are difficult and infrequent – fewer than three a week. The symptoms can vary but usually involve straining and taking a long time to pass a stool, unpleasant flatulence, abdominal and rectal pain, and feeling bloated. Other symptoms can include nausea, headaches, reduced appetite and lethargy.

Once they appear, the stools themselves are often small, hard lumps. Stools consist largely of undigested food remains, plus dead cells and mucus, and muscle contractions push them along the intestines to the rectum, where they sit until the bowels are opened. If the intestine absorbs too much water along the way, the stools dry out, which impairs their transit. They also move slowly if the muscle contractions are weak, causing them to lose yet more water and become even harder.

It’s a common problem and can affect people of all ages. ‘One in three childrenwill suffer with constipation,’ says Benjamin. ‘Above the age of 65, it affects 26% of men and 34% of women. Overall, it affects one in seven adults.’

The underlying causes of constipation are varied. ‘For the majority of people, no specific cause is found for constipation,’ says Benjamin. ‘In this case, patients are often labelled as suffering from functional constipation or irritable bowel syndrome. When a cause can be found, this is termed secondary constipation. It could be a primary bowel problem such as a narrowing in the bowel or bowel cancer. Other causes are metabolic, such as diabetes, hypothyroidism and hypercalcaemia, or neurological, such as multiple sclerosis, Parkinson’s disease and spinal cord injuries, or psychological disorders, such as anorexia nervosa and depression. Medication, including painkillers, iron tablets, diuretics and antidepressants, can also be a factor.’

Most constipation can be treated with a better diet, increased fluid intake, more exercise and regular toilet routines

Fibre and fluids

Lifestyle plays a big part, too, says dietician Jodie Relf. ‘A lack of fibre in the diet, inadequate fluid intake and sedentary habits are all a factor in constipation. In the UK, the average female consumes around 17g of fibre a day and males around 21g. The recommended daily intake is 30g. Young children and the elderly can suffer because of a restricted intake of food and fluids. Pregnant women can suffer with constipation due to hormone changes. Few people are aware of the impact of chronic stress and anxiety. The brain and the gut are closely linked so when we experience stress for a prolonged period it affects our digestive health too.’

A significant proportion of patients say that the condition has reduced their quality of life: ‘Up to 40% report anxiety and depression,’ says Benjamin. He adds that while most people’s constipation will not have a serious underlying cause, for some it could be a sign of bowel cancer. ‘Current NICE guidelines suggest urgent referral for evaluation if there is a change in bowel habits along with other symptoms such as abdominal pain, weight loss, anaemia, abdominal mass or rectal bleeding.’

Changing your lifestyle

Most cases of constipation can be treated with lifestyle changes, including a better diet, increased fluid intake, more exercise and regular toilet routines. These relatively simple modifications can make a huge difference, says Jodie: ‘For example, if medication is causing constipation, poor diet choices will exacerbate the problem. However, good food choices can help alleviate the symptoms. So too can methods such as massaging the tummy to encourage peristalsis of the gut.’

If medication for other conditions is thought to be the problem, Benjamin recommends reviewing them with the prescribing professional to see if they could potentially be stopped or switched to an alternative. Another key treatment is laxatives – several different types are available over the counter, and GPs and pharmacists can advise which ones to try. ‘It is also important to consider the cause of the constipation,’ adds Benjamin. ‘For example, those with spinal cord and neurological conditions may not respond well to standard laxatives. In this case, a technique such as transanal irrigation might be used.’

Scientists have also looked at how a healthy gut microbiome can help treat mood disorders such as depression and anxiety. ‘In the studies they replaced antidepressants with probiotics, which were shown to have a positive impact,’ says Jodie. ‘More work needs to be done in this area but it highlights just how interconnected the brain and the gut are.’


Prevent constipationin children

Babies and children can develop constipation because they aren’t eating or drinking properly, or they are anxious about potty training or starting school. To help prevent it, the children’s bowel and bladder charity Eric recommends that they:

  • Drink plenty of fluids: water or well-diluted fruit juice or squash
  • Eat a balanced diet, including fibre from fruit, vegetables and whole cereals
  • Keep active: exercise sends blood to the gastrointestinal tract
  • Adopt a good toileting routine, going at regular points each day, giving themselves plenty of time.

Just too embarrassed?

A major concern with constipation is that many people delay getting treatment because they are reluctant to discuss the issue, even with a GP.

‘Talking about our bowels is nothing to be ashamed about,’ says Benjamin. ‘However, even in secondary care I see patients who feel embarrassed to talk about their bowel and toilet habits. We know that patients often delay seeking help for up to four weeks. Breaking the taboo would help to create a better understanding of the problem, leading to prompt treatment and improved outcomes.’

It’s a subject that’s never far from the minds of dieticians, says Jodie. ‘We often catch ourselves discussing it over lunch and not flinching. It’s a normal bodily function, yet people still shy away from talking about it. With gut health being so frequently discussed across a variety of platforms, I think we are on our way towards breaking down these barriers. As healthcare professionals, I think we have a responsibility to have this conversation with people as often as possible, as a poor functioning gut can have such a negative impact on wellbeing. Everyone should pay attention to their bowel habits to know what their “normal” is and when something is not quite right – and, yes, that means turning around to see what it looks like!’


What causes constipation?

  • Side effects of medication such as opiate-based painkillers (for example, codeine and morphine), anti-sickness drugs (such as ondansetron) and iron supplements 
  • Not eating enough fibre or drinking enough fluids, and irregular meal patterns 
  • A sedentary lifestyle and being overweight 
  • Ignoring the urge to go the toilet 
  • Anxiety and depression 
  • After-effects of an illness or surgery. 

Start a conversation

Community practitioners (CPs) have a key role to play in encouraging people to talk about their bowel movements and to understand what is normal for them. ‘Tell them what a healthy stool should look like,’ says Jodie. ‘Pointing them towards the Bristol stools chart is a good way to do this. And reassure them that “regular” means different things to different people. For some, once every two days is normal and for others it’s twice a day. This way, the CP will quickly be able to identify if there are any problems and then dig deeper to identify potential solutions, such as increasing fluid intake, wholegrains, vegetables and so on.’

Benjamin also feels CPs can help break down the barrier. ‘It is about raising awareness of constipation, ensuring that people don’t feel embarrassed to talk about it, and that they feel able to see a healthcare professional when needed.’


Resources

  • The Bowel Interest Group’s Cost of constipation report can be downloaded at bit.ly/cost_of_constipation  
  • Parents looking for help and advice on constipation in children should head to children’s bowel and bladder charity Eric at eric.org.uk  
  • The NICE summary for constipation is at bit.ly/NICE_constipation

References

Bowel Interest Group. (2019) Cost of constipation report. See: https://bowelinterestgroup.co.uk/cost-of-constipation-report-2019-hcps (accessed 19 December 2019).

 

Picture Credit | iStock

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