Benign Constipation Primer
Understand the Underlying Issues and Learn How To Simply Manage the Condition
WARNING: This is one informative document scribed by Dr. Mike. However it is long – and we do highly recommend printing to better appreciate. Please use the "Download PDF" link located in the Poo Primer box on the Right. Naturally makes for good bathroom reading material.
From the outset, I have made the assumption that you, the adult reader, are constipated. I’d rather do it that way than put this entire dissertation into the third person, making it a bit aloof, but please don’t take offense with my largesse. Maybe you aren’t constipated, which is OK, ‘cause you probably will be, given enough time. Some people have never been consti-pated, nor will they be, either because they have been destined for a short life span or they are gifted with good fortune. The “unconstipated” are convinced their behavior, like following recommended diets, logically explains their regularity, a lot like centenarians who think that what they do got them to live over a hundred years. Unlike the people whose great genes and luck are the key factors that enable their longevity, constipated adults will have to do something for themselves if they are going to feel better. It won’t just happen, like rain falling. Although we are going to discuss what to do, it’s not all that simple. That is why I am giving you information that may help you improve your interventions.
Perhaps you know a close family member, for example, who could find the topic interesting, so please consider sending this “poo” primer to them. If we can help someone who carries the above titled burden, then our mission is largely accomplished and my time well spent. If you are not constipated but the subject is of interest, do have a good time here...or so long.
Since there are numerous causes of adult constipation that are diagnosable, you should know what your condition stems from since a few are rather dangerous. There is a risk a correctable, potentially disabling or even fatal underlying disease can be missed if you assume your constipation stems from a completely benign cause. The most common causes of chronic constipation in adults are inadequate dietary practices, too little exercise, medicinal use, bad bowel habits, slow bowel transit and advancing age. Chronic diseases (some genetic) or acquired disabilities have been recognized for many years as causes of constipation and may be responsible for many of the severest cases. This dissertation is not directed toward, nor does it address, any form of pediatric constipation.
The approach to diagnosing organic causes of constipation (physiologic and/or anatomic) is fairly well known but still grow-ing. The newest research is focusing on chronic constipation caused by slow bowel transit, not the easiest diagnosis to make and one that has many causes, including diabetes. Slow bowel transit may be amenable to prescription drug therapy on a case by case, trial and error basis. Once you have a medical evaluation that includes appropriate testing, you can con-sider the matters we are discussing here with a lot more confidence about your safety. You might find that there are com-ments made throughout this document that could be useful even though you have a medical regimen worked out for your particular condition. I strongly recommend that you consult your personal physician if you recognize that you are frequently or chronically constipated.
In my opinion, the safety of the constipated person is always a foremost consideration when it comes to therapeutic modali-ties. I will be discussing interventions like abdominal massage, bland rectal enemas and mild laxatives whereas I leave the issue of diet to those who have written and proselytized ad nauseum. To my view the interventions I will comment upon are pretty safe but their differences could affect how you use them. As to the physician directed evaluation mentioned above, you do not have a good alternative to getting a thorough medical workup for chronic constipation, self-help articles and books notwithstanding, so please get it done if you haven’t, already. Vince Lombardi and Milton Berle didn’t and although they were 30 years apart in age, they both died from colon cancer because no one looked…in time to save them.
GUT ANATOMY AND PHYSIOLOGY
Just so we are on the same page, your abdomen is your belly but it is not your stomach, the latter being a stretchable, bag like storage organ in your abdomen that is not involved with constipation. Big eaters have big stomachs and when you swal-low food, the first stop is the stomach. Then comes one’s small bowel, a narrow, complex and considerably longer, tubular organ than the colon. The small bowel does major digestion on stuff it gets from the stomach and empties its contents di-rectly into the large bowel at a junction that is also home to the appendix. The adult large bowel, or colon, is of great interest to us. It is a stretchable, muscular-walled tube about 5-7 feet long and a few inches in diameter. The colon tends to lie along the perimeter of the abdominal cavity whereas the small bowel fills up the center of it. Combined, they are known as the guts or intestines. The large bowel moves semi-liquid stool from its intake end to solidified stool at its output end, ab-sorbs water (and a few other things, too) and stores feces for a while. The colon is normally inhabited by billions of bacteria that are kept at bay every minute of everyday by various arms of the immune system, all very normal and mundane.
The colon’s principle task is to absorb water from the liquid stool it receives from the small bowel. As it turns out, the colon’s obsession with water absorption prompts it to store feces to increase its ability to dehydrate them and thereby form the stool. Stool that lingers in the colon has water resorbed from it continuously, a potentially ominous characteristic as we shall see. Ordinarily, you’d think feces would shrink when it dehydrates, and it does. However, various factors, including the normal bacteria that make up the great majority of the stool’s bulk, conspire to increase the diameter of the stool while the progres-sive dryness hardens it. The longer stool lingers in the colon, the more pronounced are these changes, worsening the con-stipation until, if left unchecked, obstipation occurs; oops and ouch.
When something bad happens to the colon to prevent it from reabsorbing water, a distressing event best known outside the armed services as diarrhea occurs, i.e., the runs, to them, which is entirely descriptive. If you are wondering, uncontrollable diarrhea can be fatal (more common than you may think in underdeveloped countries) and in its vicious, epidemic forms such as cholera, diarrhea can kill thousands of people in a week, dehydrating them so severely they go into shock within just a day or two of becoming symptomatic, even without much toxicity from the infection. No such bad luck with constipation, fortunately; try to envision an epidemic of lethal constipation.
COLON STORAGE ACTIVITY
Most of the colon’s storage activity occurs in the last third of the organ which anatomists and surgeons have (artificially) segmented into descending colon, sigmoid colon (because of its S shape) and rectum. The rectum, about 12-15 inches long, terminates in the anus, well known to us on the street as the asshole. The anus is a doughnut shaped muscle that plays an interesting and important role as the gate keeper of what leaves or enters the colon from below; it is one of the bet-ter known parts of the GI tract. Once it detects a certain degree of fullness, the normal rectum sends signals to your central nervous system that it’s time to go to the lavatory to move your bowels (take a dump), prompting the anus to relax and let that stuff get out of there. The rectum is of particular interest to us and will be discussed again.
Whilst the colon normally harbors legions of bacterial organisms, on occasion limited numbers of fungal, protozoan and/or viral species can also inhabit this playground. The number and variety of organisms is great enough that very few laborato-ries in the world would attempt to isolate and define all the bowel organisms from any person, and then only for investiga-tional purposes, i.e., it’s not a routine, clinical lab request because it isn’t all that helpful. Furthermore, a full stool evaluation is extremely difficult to do correctly and the process is both lengthy and expensive. Interestingly, the colon’s organism stor-age capacity is seemingly a normal, universal characteristic of large bowels that serves several useful purposes. To illus-trate, we mentioned that the bowel movement of a normal person is largely made up of bacterial organisms, not leftover foodstuffs, providing much needed bulk to the stool. Furthermore, the metabolism of some colon bacteria produces vitamin K, an essential vitamin that is absorbed, preventing vitamin K deficiency from appearing even in the face of dietary defi-ciency. Elephants, especially younger ones, find their mature compatriots’ feces tasty and regularly eat it for the essential bacteria contained therein, i.e., they want those particular organisms in their guts, too, in order to remain healthy elephants. People don’t fare as well with cross fertilization of gut organisms since it can spread nasty diseases, so hand washing after bathroom forays is always recommended. Although it is not obvious, a population of normal organisms in the gut tends to suppress the proliferation and destructive behavior of pathogens that might be present, as well as moderating the potential pathological behavior inherent in themselves. Whereas a number of bowel organisms are potentially pathogenic, they often remain obscure and unobserved in the gut, like a NYC subway rider during rush hour. How comforting.
How your stool and gas (flatus, farts) smell depends to a large degree on what you ate and the composition of the organ-isms (usually the bacteria) populating your colon, i.e., their metabolic end products largely determine the final odor of feces and gas. You can be sure that whatever you ate, the bacteria can eat it better, a statement to which everyone with lactose intolerance or a passion for baked beans can attest, i.e., the gas, alas, the gas. I suspect strict vegetarians buy a lot less bathroom deodorizer than us carnivores as the bacterial processing of meat is notably odiferous. Sometimes the smell of a fart can give a person clues about their own bowel activity but it is not something most of us pay attention to or stick around trying to analyze. Our small cat, Nibby, could clear our entire family from a room with one stealth-like fart, an outstanding example of SBD (silent but deadly). And yes, we all could identify it as coming from that 10 pound cat.
If the stool happens to hang around for a bit too long in the colon the stool enlarges further, especially in diameter, while it continues to dehydrate, becoming harder. Anybody in the audience ever felt like they crapped a handball after being consti-pated for more than a few days? This analogy usually arises when screaming signals from your abominably stretched anus fly up to your brain while you are earnestly trying to get that thing out of you. Yup, I’d call that constipation. Prolonged con-stipation can lead to obstipation, the inability to defecate because the stool is too hard and too large; yuck! Obstipation, a very undesirable and ungracious outcome, is a form of bowel obstruction, the latter a potentially fatal condition unless re-lieved. I think it’s fair to say that obstipation is nasty business for the person who has it and the professional who has to use a finger up the butt to relieve it. Obstipation is something we want to prevent by managing constipation successfully.
So how is constipation defined? Actually, there are different opinions and definitions in the literature, depending on whom you consult. You are welcome to believe in any of them but in my view, constipation is a state of large bowel inactivity re-sulting in infrequent defecation to the degree that some kind of problem occurs. The range of bowel movement intervals considered normal probably extends from one every couple of days to a few per day. Whilst there are people who shit like horses, not everyone has to defecate like that to be considered normal (feeling consistently fine with relatively stress-free bowel movements). Constipation (which is not feeling so fine due to delayed defection) can result in a variety of symptoms and signs including, but not limited to, abdominal enlargement, a feeling of bloating, loss of appetite, anal hemorrhoids, belly cramps, diverticulosis/diverticulitis, lethargy, anal fissures, anal stretch pain and a variety of emotional issues. Constipation or obstipation from colon cancer can lead to premature death, an endpoint that might be prevented by a timely, competent medical evaluation.
Permit me to emphasize that preventing constipation is much better than relieving it, a grand understatement! For the ma-jority of cases, an alteration in diet and/or an increase in exercise suffice. If you have not tried any or all of the sensible rec-ommendations made by reputable medical and public health organizations oriented toward proper amounts of dietary bulk (fiber) and exercise, I wholeheartedly encourage you to do so in order to alleviate or eliminate chronic constipation. But even if you have not gone looking for it, the chances are you already have been exposed to advice and advertisements from many sources that are oriented toward helping you crap with comfort. Sometimes, they imply that you can live to about 111 years of age doing so; you can believe what you want. Much to our chagrin, the issue we too often face is that diet, exer-cise, naturopaths, herbal supplements, medicine men, alternative medicine concoctions, doctors and prayer have not pre-vented a large number of people in modern society from being constipated. The truth of the matter speaks out in that over 750 million dollars are spent each year in the US on over the counter (OTC) constipation remedies by over 40 million peo-ple. Constipation is an active topic on the web and Americans visit their doctors over two million times a year because of it! Approximately four million people in the US are constipated at any one time. Someone you know could be full of shit; really? I do not know if these statistics are accurate but I chose the more conservative ones I found. If the data are realistic, a lot of people don’t follow good advice and/or it hasn’t worked.
As we age, especially by the sixth decade, the hormone like substances identified as stimulating the muscular activity of intestines called peristalsis become deficient or absent. My mother-in-law humorously told me after her third heart attack that getting old was not for the weak of heart (or bowel, Sylvia). Failing health often affects bowel function detrimentally ei-ther directly by a disease process or, more commonly, indirectly via medicines used to treat unrelated medical conditions. A growing number of people depend upon an expanding list of medications in order to remain functional and comfortable but many have side effects that negatively affect the function of the large bowel, a disconcerting outcome for patients both young and old. For example, medicines that slow down peristalsis often induce constipation. Ever know anyone being treated for serious pain or depression who became constipated? No? That’s because they didn’t tell you the embarrassing stuff.
POPULARISMS ADDRESSING THE COLON
If our goal is to allow a person with chronic constipation to exercise some degree of control over it, I think it’s prudent to un-derstand a few more practical aspects about gut function. While some of the following popular issues touch on colonics, all deserve a look with a bit of a scientific eye. That generally means I like to see statistically significant results from well de-signed and generated studies testing a contention (hypothesis), i.e., good studies, which immediately eliminates all forms of hearsay, advertising claims and most studies funded by companies that have a vested interest in the subject. You’d be sur-prised how the latter biases the outcome of published studies. Researchers (including doctors) are human and can be swayed by money; really? While a discussion of the scientific method is beyond the scope of this document, it is pivotal and leads directly to the conclusion that testimonials (regardless of whose they are) are junk; period. Alas, I have now of-fended or angered every constipated marketer and supporter of most TV infomercials where testimonials reign supreme. In fact, you can have some fun by reflecting on how testimonials have affected your own perspectives and behaviors, too.
FIBER CURE ALL
Constipation is preventable if you follow good health habits. Regular exercise and sufficient roughage (fiber) in the diet do the trick. Eat cereal twice a day, for god’s sake, and you’ll be on the toilet at the end of your daily 3-mile walk.
OK, if it worked for you, why (the hell) have you read this far? The reality is that lots of us can’t exercise or hate exercise or just won’t do it. And there are those of us who are disciplined and have exercised for hours and were constipated for days. Lots of people have been persuaded they did not have enough roughage in their diet. So, they made all kinds of dietary interventions, took fiber pills, poured vegetable grit into pristine juices, ate food fit for horses and wound up no better off, or even worse. They became very unhappy people. Dietary fiber can make chronic constipation worse where slow gut transit is the cause of constipation; how about that!
Bowel cleansing with high colonic enemas is the only way to go to relieve chronic constipation. And besides, it is great for your health as it rids your body of all those nasty toxins flooding you from that dark, crap filled co-lon.
These seemingly logical, enthusiastic, hopeful and enlightening statements have not yet been borne out by good medical studies that addressed the issues…but they do have a following! The notion that high colonic cleansing improves any as-pect of health in any way, at least as far as toxins and physiologic health issues are concerned, is still just a notion (of cult-like dimension, I might add). Whether high colonic enemas have long term benefits or risks has not been adequately stud-ied, to my knowledge. The safety of many insertional devices used in high colonic enemas is unproven from the perspective of perforation and latex allergy. Furthermore, I know of no good study evaluating the safety of repetitive colon fluid loading in the presence of diverticulosis or diverticulitis, ulcerative colitis and regional ileitis. A number of gastrointestinal specialists recommend enema avoidance in the presence of these conditions. Why mention them? Simply because some of us have them and may not be aware of it at a time we decide to undergo a high colonic. It’s just more reason to get the G-I evalua-tion I discussed in the opening paragraphs.
High colonics really do affect the bowel’s behavior and its inhabitants. In some adults, repetitive high colonics can lead to constipation, a rank failure of the technique. One could question why anyone logically would spend considerable personal time and money, and suffer the inconvenience (and often discomfort) of loading quarts of fluid into their colons to relieve constipation for a short while. For those of you doing high colonic enemas for pleasure or because you believe in them (not at all the same as having scientific evidence proving their efficacy) or whatever, please be prudent.
Mild laxatives are universally bad for your health, the function of your colon and the integrity of this organ. Fur-thermore, mild laxatives are habituating to the colon resulting in bowel dependency on them. On top of all this, they really don’t get your bowel clean like a colonic.
Recent medical reviews of the literature revealed that most people (which is not all people) using mild laxatives show no significant ill health from them. Furthermore, their bowels do not appear to have become dependent on those products. In fact, the entity of bowel dependency is not clearly defined and no reputable medical study so far supports its existence. If the colon in a small number of individuals becomes dependent on laxatives, precisely how or why this occurs has not, as yet, been clarified. Nonetheless, comments along these lines from impressive medical sources can be found. In addition, statements that prolonged, high dose laxative use can be toxic for bowel tissue are not persuasively supported by human evidence. Until convincing data are reported, I regard bowel dependency secondary to laxatives as an unproved, poorly defined condition (myth?) of colloquial significance, only, but one not to be totally ignored, at least for now.
As for bowel cleanliness, no animal can detect bowel cleanliness via innate mechanisms, humans included, whatever that term means. Our bodies have no way of informing us of bowel cleanliness because it doesn’t matter a hoot to a body. If a high colonic enema got a section of bowel wall visually cleaner than a mild laxative, so what? Incidentally, I do not know of a gastrointestinal specialist or any qualified medical recommendation advocating a high colonic enema for any therapeutic intervention or even as preparation for colonoscopy. In fact, bowel wall cleanliness isn’t normal human physiology and I’m not a big fan of self-inflicted abnormal. I do realize that view is not entertained by all. Consider this: the organisms that normally live with you, inside your bowel and your mouth and on your skin, are supposed to be there or they wouldn’t be there. A harmonious balance has been struck between us and them over a period of millions of years. While it is true gut microorganisms can cause problems on occasion, we have learned that trying to eliminate normal microbial populations is not only extremely difficult, it too often results in worse outcomes. You are not as germ free as a blob of honey, even though someone may attach that handle to you. In fact, we have recently learned that honey bees, themselves, are prolific microbe carriers while their honey remains pristine.
BOWEL COMMUNICATIONS AND STRETCHABILITY
Well, what can your bowel tell you? Actually, the bowel is capable of expression and it clearly affects people’s behavior and psyche. I never underestimate a bowel’s complex relationship with its host. Bowels are referred to quite often in common language. If you think about it, the colon can get personalized beyond all the other parts of the gastrointestinal system, i.e., when was the last time you called someone a stupid liver? Communication from the colon rests entirely on its wall, which is great at detecting stretch. The bowel wall relays degrees of stretch information to several parts of your nervous system just about all the time though you often remain unaware of it. Stretch the bowel wall a bit more and you will pass from a state of blissful unawareness to a low grade alert that something is going on, to a sense of bowel fullness, to feeling uncomfortable, to downright pain that is sometimes called cramps, to being disabled by them. A bowel in severe spasm often can be felt by gently probing the abdomen with one’s fingers. It feels like a very tender lump that changes with the intensity of the symp-toms. Some people would call it a knot and it is, in a way. Severe bowel spasm is very much like labor pain in its quality and, rarely, in intensity. Women who have given birth and also have experienced severe bowel spasm have acknowledged the similarity. This comparison is not farfetched since the muscles in the uterus and bowel are very much alike. Men, I hereby offer you a caution: do not tell a woman you have experienced abdominal pain similar to childbirth, an error I no longer make. It may have merit but your persuasiveness and credibility will diminish in direct proportion to the length of the statement.
It seems (to me) that the rectum can become less sensitive to stretch and also less able to empty itself completely in the constipated adult. Feces that remain in the rectum after defecation can give a sense of rectal fullness but not a real urge to defecate, further compromising the ability to defecate later. When ultimately prompted to have a bowel movement, the con-stipated person does a lot of abdominal straining in order to increase intra-abdominal pressure, an aid to emptying the rec-tum by uniformly compressing it. Unfortunately, repetitive, severe abdominal straining promotes and worsens internal and external hemorrhoids, diverticulosis (and, therefore, the potential for diverticulitis) and abdominal hernias. Besides, it is not all that effective in helping the rectum empty itself of low volume or bulky, hard loads. Repetitive, forceful abdominal strain-ing during bowel movements is a hallmark of chronic constipation. I have observed that if the rectum is kept empty of small fecal loads by bland rectal enemas for a few days, a person may have an unexpected, normal bowel movement as a rather satisfying, physiologically sound outcome. Tempted to take a rectal enema now, huh? Don’t, just keep reading, please.
As we’ve noted previously, the ultimate endpoint of constipation is obstipation, the inability to have a bowel movement due to a blockage of stool in the rectum. It is a form of colon obstruction and must be relieved mechanically, typically by a health professional. Obstipation is the bane of bedridden people and the aged infirm. If anyone with chronic constipation con-cludes there is nothing that can be done to manage their condition, they could become obstipated somewhere in their life and at a younger age than they thought possible.
CHRONIC CONSTIPATION MANAGEMENT STRATEGIES
My working view of constipation rests on the observations that stool accumulating excessively in the rectum and sigmoid colon, and even farther back in more extreme cases, causes some type of distress. I do not subscribe to the approach that diagnoses constipation by how many bowel movements per week a person has but recognize that the length of days be-tween bowel movements is a reasonable way of measuring the severity of constipation until obstipation is reached. If you relocate your bowel to the high desert of New Mexico as a methodology to find nirvana and regularity, your spiritual goals are a lot more likely to be met. Chances are that you’ll be constipated there, too, though initially you may not mind it as much. Besides, the fresh air of the high desert has been said to be stimulating, so keep your bathroom window open for whatever good it does.
At the present time I have come to believe that low volume, bland, rectal enemas are a tenable, safe, long-term methodol-ogy to help manage chronic constipation if various forms of prevention and/or treatment have proved to be inadequate. In addition, the judicious use of mild oral laxatives combined with the enemas carries a very low risk for harm and often adds significant value to the interventions. Finally, proper abdominal massage is a safe adjunct to the preceding two modalities, improving their outcomes. Keep in mind that laxatives are drugs and, as such, could have the side effect of interacting with other drugs, whether OTC or prescriptive. Ignoring the potential for interaction can put you at unnecessary risk. As with any health related intervention, it is always wise to check with your doctor, especially if you have a significant medical condition, including pregnancy, before using a laxative.
Mild laxatives work via several mechanisms including stool water retention, bowel water retention, increasing stool bulk and irritation of the bowel wall. Regardless of their modalities, all laxatives attempt to promote increased muscular contractions of the sigmoid colon and/or rectum leading to defecation. The means and degree of action varies from one substance to another but we have little in the way of medical guidelines to help us select one over the other. Marketing, including persua-sive testimonials, and word of mouth influence buyers more than scientific comment when it comes to laxatives. As in shampoos and a vast array of cosmetics, the label can be the only real difference between expensive and value priced products. Laxatives are marketed under a variety of brand and generic names. Availability is not usually a limiting factor except for people who become totally embarrassed when buying laxatives in a store. Now, even their privacy and shyness inhibitions are conveniently addressed by select Internet resources. The particular laxative(s) you choose and how you use them will be determined by your willingness to experiment in a trial and error mode to determine which give you the best results with minimal side effects, which advertisements influence you the most, cost, a bit of logic, self observation, your professional caregiver’s advice and some knowledge.
Irritant laxatives generally contain one of several active ingredients: bisacodyl, sennacides, aloe vera, phosphates or phe-nolphthalein. Whether the ingredient is synthetic or naturally occurring, I don’t see any good evidence that it matters. Phe-nolphthalein has been implicated in rat bowel cancers by the FDA even though incriminating human data is lacking after many years and millions of man/days of use. Aloe vera tends to be the active component in herbal preparations and offers no objective benefits, regardless of claims to the contrary. The considerable irritation phosphate solutions (Fleet enema) provoke in the bowel wall has reduced its popularity by the public and medical profession. When taking phosphates via the oral route, the urge to defecate can be precipitous so you’d better be near a toilet after you swallow some.
Irritant laxatives have the potential to provoke cramps ranging from very mild to downright painful when the bowel is vigor-ously stimulated. I have observed that emptying the rectum with an enema can reduce or eliminate cramps, possibly be-cause stool that is being pushed along by the irritated bowel has an empty bowel lumen to enter with little or no resistance. Laxative use leading to bowel cramps depends upon several factors including the degree of constipation, the laxative dose and potency, the time of administration and the inherent sensitivity of a bowel to a particular product. Keep in mind that the longer one waits before using an irritant laxative, the more likely cramps of increasing degree could occur. What isn’t com-monly appreciated is that irritant laxatives often have a stool softening effect much like some osmotic and bulk laxatives.
Osmotic laxatives pull water into the stool or bowel cavity (lumen), ultimately softening the stool by increasing its water con-tent, enlarging its bulk and improving lubricity. Stool softeners do not, by themselves, stimulate peristalsis. The principal osmotic laxative ingredient is magnesium oxide (MgO) but propylene glycol has recently become OTC available and is grow-ing in popularity. Its skinnier sibling, ethylene glycol, is best known as the active and poisonous component of antifreeze. Osmotic laxatives are non-irritating and less prone to cramping than the irritant group. Bulk laxatives (fiber, regardless of source) work by absorbing water and swelling. As they do so, they increase the volume of the stool, sometimes quite sub-stantially. Foods high in fiber are universally promoted as healthful (correct in the majority of cases) and bulk laxatives are a shortcut solution to good dietary habits. Osmotic and bulk laxatives don’t work as well as irritant laxatives for people with sluggish bowel transit and may actually promote worsening of the constipation.
The traditional warm water rectal enema is delivered by a clamped rubber tube connecting a red, natural rubber bag (now available in other, more costly materials) to a butt hole somewhere down below it, delivering up to a quart of fluid by gravity to the lowest portion of the bowel once the tubing clamp is released. Small enema volumes (less than 10 ounces) are lim-ited to the rectum but larger volumes get to the sigmoid colon. Having the sigmoid or higher regions involved is not neces-sarily a benefit, as we shall discuss. When the bowel is just squealing to empty itself of the rapidly appearing volume load, one has to figure out how to shut that damned clamp located somewhere behind your behind and then get to sit on the toilet before all hell breaks loose. Occasionally, mild soap can be added to the water to aid in lubrication, reduce odor and im-prove both rectal emptying and anal cleansing. The latter is particularly desirable for those with hemorrhoids or anal scar-ring. Unless you’ve got really long arms and decent flexibility, self-administering a Fleet or bulb type rectal enema can be an interesting challenge; yoga classes are a must. For bedridden individuals, taking a conventional rectal enema can be trying even though it is worthwhile.
A word of caution is due at this time about latex allergy, a potentially dangerous, even life-threatening condition. Natural (gum) rubber contains allergenic latex proteins and any device containing it (like the dyed red rubber in classic enema bags or latex rubber tubing) is contraindicated for use by a latex allergic person. Furthermore, I do not recommend the use of latex containing enema paraphernalia to anyone who is already a highly allergic individual or to anyone who intends to fre-quently use an enema technique of any kind, a precaution to minimize the development of latex allergy. Incidentally, syn-thetic latex in paints is neither allergenic nor cross-reactive with natural latex rubber.
EVALUATION OF CONSTIPATION
For the purpose of instituting a behavioral change (like yours), let’s break up our chronic constipation remedy into two cate-gories, evaluation and intervention. If either of these falters and the baseline situation remains unchanged, constipation will remain or recur since, by intent, we are dealing with a chronic form that is not going to go away by itself. I have found that people are greatly tempted to ignore that they have become constipated. This is so common I’m thinking it is a primitive form of denial whose origin is obscure and probably ancient. Imagine having to leave your cave in minus 30F weather to take a shit with hungry saber tooth tigers prowling around. OK, maybe that’s not a good example of holding it in. And so, people who become constipated seem to hope for the best. Perhaps the recognition of something going slightly wrong is more uncomfortable than the condition, itself, at least initially. If you ignore it long enough, it’s going to go away, right? Maybe the fix is too embarrassing to bear, or going to a drug store to buy a laxative is beyond visioning. Or, there isn’t a safe way to deal with it: “I will not insult my body!” Or, nothing worked well enough before, so why bother with something else? Or, your psychotherapist found another, more profound reason why you are holding it in...
As for the reasons prompting you to ignore the presence of constipation, you’ve got to deal with them and move on. The longer you wait before acting, the more severe it will get, the longer it will be an undesirable part of your life and the worse you will feel. Procrastinate and the fix is likely to be more intense and potentially uncomfortable, too. Denial or procrastina-tion inhibit your ability to improve the condition, CHRONIC CONSTIPATION, to the point that it could play a minor roll in your life; yes, I said minor! If you are going to obsess over something, I know you can pick a better subject than taking a shit. Use exercise and dietary fiber as the most wholesome interventions. If you find you cannot improve, you can forget about it or intervene. Scratch the “forget about it” part and keep reading.
NORMAL BOWEL MOVEMENT INTERVAL
In order to realize you are constipated, it is helpful if you know what your normal bowel interval is, or was. Most (but not all) people start off having normal bowel habits. That means the defecation interval, size of the stool, quality of the stool and defecation effort were no problem. Just ask most babies. It happens, regular as clockwork; get the call, take a crap and get on with the day. Tomorrow it will occur again without another thought. Or, sit on the pot for 10 minutes every day and the rest will follow, if not daily then soon enough. For these people, it’s relatively easy to recognize a change from their normal patterns. Now it is true some people have had a lifetime of constipation and so regard it as their normal. People whose bowel habit has been regular, effortless, reliable and a daily expectation do not understand a lifetime of constipation. Hint: If you are possessed of the latter, do not try to explain it to one of the former; it will not help solve your problem. The chal-lenge for those with a lifetime of constipation is to recognize it as abnormal. Then they must experiment enough to discover just what bowel movement intervals result in feeling good every day and having relatively effortless, nicely formed bowel movements when they do occur, at least the majority of the time.
I have spent some time discussing laxatives and enemas, with a passing mention to abdominal massage, but not how to use them effectively to help relieve chronic constipation. That’s what we’re about in the next sections. But why should you con-sider using several techniques instead of just one? Well, using more than one technique has a better chance of helping more constipated people and more importantly, it probably reduces the chances of side effects from any one of them, a sound strategy for a person contemplating repetitive interventions for the long term.
Although I will not belabor it, be aware that there is growing interest in probiotics as it concerns bowel habits and constipa-tion. Briefly, the idea is to ingest up to several specific, bacterial species that are deemed harmless but have the potential of promoting regularity. I don’t know who this approach would benefit or whether it really works at all. So far, the kinds of or-ganisms I have seen in foods (as an additive) or pills would not predictably harm normal people. However, the bacteria are alive and designed to multiply in the bowel. Whether or not they could pose a risk for immune compromised people has not been determined, as yet, and I would advise these folks to tread cautiously.
EXAMPLE INTERVENTION CASE
Let’s look at a typically constipated 66 year old man, NotsoFat Albert, who is treating a highly irritable bladder and moder-ately severe left knee arthritis with prescription medications, both of which cause constipation. When he does not use the medicines for a few weeks, his constipation is considerably less troublesome but it’s not gone. However, he becomes way more miserable from pain than being constipated. Al at 56 years old had a bowel habit as regular as a high noon church bell. As for diet, he was worse off after increasing his dietary fiber, especially since it made him less popular at the weekly poker game for reasons that included farting and emotional irritability. He never learned to swim, making exercise almost unobtainable until he gets total knee replacement surgery, about which he is phobic. Al’s doctor has found no pathology to explain the constipation, chalking it up to age, sedentary life style and medication. So, the doctor suggested stool softeners. They really did not alter the constipation pattern. A regular feature of the pattern is that once he had a bowel movement or two in a day, the first being very stressful and painful for obvious reasons, his hemorrhoids got some rest since he would rarely have a bowel movement the following day, clicking right back into the pattern. Alternating diarrhea was not part of Al’s cycle as it is in a lot of chronically constipated people.
First, let’s have Al start his constipation intervention with simple abdominal massage, twice a day, every day. He can do it in any position he chooses and he likes massaging his belly in bed. Al was a daily "goer" as we know from his history so we will use that interval, every day, as his norm. To start, Al will take a dose of a senna laxative the morning following his most recent bowel movement and use the massage twice a day. No bowel movement occurred that day but he noted a bit of fullness and he sat on the pot for half an hour, straining from time to time, worsening the burning of his hemorrhoids but not relieving the rectal fullness. So, that was unproductive and uncomfortable this time. Furthermore, he wants that sense of fullness to resolve because he feels stool is partially filling the rectum yet it’s not enough to cause him to take a crap.
Al gave himself a belly massage followed by a warm water, soap suds rectal enema, about 8 ounces of fluid. In short order he emptied a fair amount of small pieces of hard stool from the rectum and felt completely relieved. Sleep was better than expected and he had a bowel movement right after a late breakfast. He forgot the massage. He took a magnesium oxide 250 mg laxative tablet with plenty of water at breakfast and again at dinner. That night he had brief, mild left abdominal cramps and the next day he had two bowel movements where the stools were softer and somewhat lubricated. He had to push a lot less than usual, an improvement. Well, now, this was better.
The following day he took a rectal enema before dinner. Again, the rectum emptied small pieces of stool and, much to his surprise, a normal bowel movement occurred two hours after the meal. We note that Al never ignored his urge to defecate. He went to sit on the pot soon after recognizing the call to go. That was his usual, lifelong behavior so he had no retraining to undergo.
No bowel movement occurred the next day. Al used to just keep on waiting until he had the urge to move his bowels but not this time. He took a laxative dose before bed and a rectal enema the next morning. By noon, Al took a big crap and had no cramps from the laxative.
Comment: Al embarked on a course of action that allowed him to learn about and begin to control his chronic constipation, a needed change from it controlling him. He can avoid becoming obstipated in the future with these techniques, especially with the enema, a very important goal since he absolutely hated the doctor digitally relieving him. He has just started to learn how to intervene and must continue to evaluate himself and his responses. If he ever decides that he is just fine and does not need to fuss like this in the future, Al will be reminded of that lapse in well known ways. However, if Al gets a total knee replacement and eliminates opiates, his situation will improve but not likely resolve completely. It’s a bit like having diabetes: if you can’t cure the damned condition, manage it because your other choices usher in really lousy outcomes.
INTERVENTION #1: ABDOMINAL MASSAGE
The simple goal of this technique is to mechanically help your colon move formed stool toward the anus by rubbing your belly. Colon massage can be done supine (lying on your back), standing or sitting, and as often as desired. People with obese abdomens might find it more difficult to do effectively. The most convenient and revealing times to perform abdominal massage are upon awakening and when you retire, natural times when you are lying on your back, nice and relaxed. In other positions, your hands will not gain as much information about your abdominal contents, a worthwhile objective. Ab-dominal wall tension of any degree reduces success while massage oil can increase comfort and pleasure. Check with your surgeon first if you have had any type of bowel or serious abdominal surgery. It’s not likely that colon massage, alone, is sufficient to relieve constipation but it is harmless. Abdominal massage should not be used in the presence of obstipation and it is not a substitute for digital manipulation performed by a health professional to relieve the blockage. By that time, you’re too far gone. If abdominal massage reduces cellulite, do let me know.
Place one or two hands flat on the abdomen just below the right ribs, applying firm but gentle pressure. Sweep the hands across your belly towards the left ribs, then down the left side of the abdomen to the pelvic brim and then toward the pubic bone in the midline. Repeat the stroking about half a dozen times. If you stand before a mirror, your hands will trace the number seven on your belly, floating over the “normal” course of the transverse and descending colon. The final sweep along the left side of the abdomen from ribs toward groin is key. A tender area anywhere may signal excess bowel wall stretch and a place that deserves a tad more gentle massage as long as the tenderness does not significantly increase. Uncomfortable lumps with smallish, pointy areas that change in location reflect the presence of backed up, hard lumps of dehydrated stool. A bowel in spasm will be both painful and tender, firm but not hard, feeling like a rounded lump, not edgy or pointed . Spasm wanes and waxes, sometimes over a period of hours. It’s not unusual for spasm to reappear in favorite locations that you will come to identify. However, once the spasm resolves and the feces moves on, the lump should be gone. If you discover an area that is repeatedly tender, lumpy and/or hard, it should be evaluated by a doctor without ex-cessive delay.
INTERVENTION #2: RECTAL ENEMAS
The golden rule here is to self-administer small volume, bland enemas quickly, conveniently, easily and safely whether at home or while traveling. If all these criteria are not met, the technique will become burdensome and underutilized. By defi-nition, rectal enemas will have small fluid volumes in a range of 8-16 ounces. Furthermore, the enema equipment should be latex free. Consider adding a small amount of a bland cleanser, on occasion, like a natural castile liquid soap, e.g. liquid olive oil soap, to the enema water. It aids in lubrication, rectal emptying and cleansing of the anus, especially helpful for people with hemorrhoids, rectal fissures or rectal strictures. Dating back to the 1800’s, this has been a safe, physician-recommended intervention called a soapsuds enema. The following tidbits may help you use rectal enemas more success-fully. Ultimately, you must experiment a bit to determine what works best for you at any given time.
- You could administer a bland rectal enema at the end of every day without a bowel movement and evaluate its results. This is especially applicable if you have always been constipated so you do not really have a history of normal bowel movement intervals. Do not endure more than 3 days of constipation without taking a rectal enema.
- Administer a rectal enema if you feel rectal fullness but little urge to defecate. The enema will help you evaluate your pattern of incomplete emptying, especially when stools have a pasty texture. You think you emptied your rectum com-pletely after a bowel movement but that may not be true. The best way to confirm it is to use the enema a few hours later or the next morning. Train yourself to detect rectal fullness by paying more attention to it.
- Some days may require more than one enema administered at different times. If you choose to use castile soap, limit it to once a day. A note of caution is due about phosphate enemas. They can redden the bowel wall to a degree that mimics acute colitis; I do not consider phosphate enemas as mild or safe to use, except occasionally or by direction of your doctor. Furthermore, do not add phosphates to what should be bland rectal enemas.
- Body position is not all that important while administering a rectal enema. Though lying on the left side or assuming the elbow/knee position will promote the enema water to go past the rectum into the sigmoid, convenience and ease of ad-ministration are often more important than position. The classic position for enema bag self-administration is on elbows and knees, though some can do it while sitting on the pot. With proper equipment, taking a rectal enema is convenient and fast. Lying on the bathroom floor is simply not acceptable, in my opinion. To a substantial degree, what you do will be significantly influenced by the nature of the enema equipment you use.
Let’s close this section with a comment about obstipation. The problem with safe rectal enemas has always been that they loom as big deal interventions. Keep in mind that rectal enemas, alone, may not prevent constipation but they usually can prevent obstipation from occurring. However, they have to be used effectively to do this. Once obstipation occurs, a rectal enema will not usually relieve it and one must call upon a caregiver.
INTERVENTION #3: MILD LAXATIVES
Whereas their modes of action might differ, all laxatives are dependent on several factors including dose, bowel sensitivity, route of administration, time of administration, other medications being regularly used and the nature of the constipation. Their action is generally a bit more vigorous during waking hours so manufacturers tend to suggest bedtime doses to reduce discomfort which ranges from a mild abdominal sensation to overt cramps. A laxative that produces moderate cramps and even diarrhea should prompt a dose reduction or a change of product. At the time of this writing, most (all?) laxative prepa-rations are available over the counter. Some were initially issued as prescription items but their proven safety allowed the FDA to grant OTC distribution. Irritant laxatives can be administered orally or rectally, the former being the most traditional route. Osmotic and bulk laxatives are restricted to oral use. Neither mineral oil nor stool softeners are laxatives but they can aid defecation by their lubricating or softening action, respectively.
Natural (senna, aloe vera) or synthetic (bisacodyl, phosphates, phenolphthalein) laxatives produce their effects by irritating the bowel wall enough to stimulate peristalsis, the muscular, rhythmic contractions of gut. Depending on their particular modes of action, irritant laxatives may redden the bowel wall to varying degrees and, because of their vigor, have the poten-tial to cause the most side effects. Osmotic laxatives ultimately increase water retention in the stool and bulk laxatives in-crease the volume of the stool by absorbing water and swelling. Osmotic and bulk laxatives tend not to cause bowel wall irritation and are less likely to cause cramps; they do not redden the bowel wall. However, they may not be as effective as irritating laxatives if the constipation stems from slow bowel transit and may even worsen it.
Try a few different kinds of mild laxatives to discover which you like best, then experiment to get good results (virtually painless bowel movements of some kind every 1-3 days, hopefully of normal caliber and texture, using the lowest laxative dose that works at the longest effective dosing intervals). You will find laxatives sold for oral use (tablets, powders or liq-uids) and rectally in the form of suppositories or liquids in squeeze bottles equipped with rectal nozzles. The latter route tends to be faster acting, sometimes an advantage, but it may be acting more like a lubricant than true laxative, depending on the preparation and bowel response. When combined with bland rectal enemas and routine abdominal massage, daily laxative use is often unnecessary, a potentially worthwhile goal.
Don’t be surprised if it takes you months to understand your brand of constipation and how to deal with it. In this process, you will learn to avoid procrastination and to take appropriate, timely action. Once you achieve an acceptable state, you need to recognize that what you’ve got is not going away even though you are better than before. The temptation is to take the easy way out and stop spending energy on controlling the condition, the most common reason for recurrence. The more effecitvely you manage your constipation, the better the short and long term results could be and the more likely you will continue to manage it. So, don’t give in, stay tough and take action. Who knows, you just might feel better.
Lastly, we have spoken a number of times about a physician directed evaluation for constipation. Depending upon your age, health, colonoscopy findings and family history, your doctor will make recommendations for future exams of various kinds. This is not to be ignored even though you might be a lot less constipated than before.
As always, put your seat belts on and good luck. It never hurts to have good luck.
THE ANUS [= THE END]