Definition

Constipation is a condition characterized by infrequent bowel movements, typically less than three times a week. The regularity of bowel movements varies among individuals, with some people having several bowel movements per day while others may have them less frequently, even just a few times per week. If a person experiences a delay in passing stool for more than three days, the stool may harden, making it more challenging to pass.

Constipation is a common issue that can affect people of any age. Globally, the incidence of constipation in adults is approximately 16%, and in children, it is around 12%. The specific incidence rate in Indonesia is not well-established, but a study conducted between 1998 and 2005 reported that 9% of 2937 colonoscopies were performed due to constipation-related concerns.

Causes

The primary function of the colon is to absorb water from the residual food that traverses the digestive tract. As the food residue transforms into stool or feces, the peristaltic movements in the intestine propel the feces through the rectum and anus. If the feces remain in the colon for an extended period, it can become hardened, making expulsion difficult.

Constipation can have various causes, and sometimes it occurs without clear reasons. The most common factors contributing to constipation include:

• Inadequate fiber intake from fruits, vegetables, and whole grains
• Insufficient water consumption
• Lack of physical activity or prolonged periods of sitting or lying down
• Lack of exercise
• Holding back bowel movements regularly
• Changes in diet or daily activities
• Side effects of certain medications
• Stress, anxiety, or depression
• Pregnancy
• Excessive use of laxatives
• Irritable bowel syndrome (IBS)
• Neurological or muscular disorders affecting the digestive tract
• Neurological conditions like Parkinson's disease or multiple sclerosis

Risk factor

Constipation can affect individuals of all ages, but certain factors can increase the risk of experiencing constipation, including:

• Old age: Elderly individuals tend to be less active, have a slower metabolism, and experience reduced digestive tract muscle strength compared to younger individuals.
• Gender: Females, especially during pregnancy or postpartum, are more susceptible to constipation. Hormonal changes can contribute to this increased risk.
• Inadequate fiber intake: Insufficient dietary fiber can slow down the movement of food through the intestine, leading to constipation.
• Certain medications: The use of specific medications can contribute to constipation as a side effect.
• Neurological problems: Disorders affecting the brain or spine can impact the normal functioning of the digestive tract, leading to constipation.
• Digestive issues: Individuals with underlying digestive problems may be more prone to constipation.

Symptoms   

The frequency of bowel movements varies among individuals. While some people may have bowel movements three times a day, others may have them three times a week. Constipation is a condition characterized by various symptoms, and individuals experiencing constipation may exhibit the following:

• Defecation frequency less than 3 times a week
• Hard stool
• Straining during defecation
• Feeling of blockage in the anus or rectum during defecation
• Pain during defecation
• Sensation of inability to fully empty the feces from the anus
• Abdominal fullness or density
• Blood in the stool

Constipation is considered chronic if an individual has two or more of the symptoms listed above for the last three months.

Diagnosis

To diagnose constipation, doctors will conduct a medical interview and various examinations, including physical examination and diagnostic tests. Some tests that may be performed to diagnose constipation and identify its causes include:

• Blood test: To identify systemic disorders such as hypothyroidism or high levels of calcium.
• X-ray imaging: To detect blockages in the intestine or feces trapped in the colon.
• Sigmoidoscopy: A lighted tube is inserted into the anus to examine the rectum and lower part of the intestine.
• Colonoscopy: To examine the entire colon using a flexible tube with an attached camera.
• Anorectal manometry: To evaluate the strength of the rectum and anus muscles.
• Colon transit study: The patient consumes a capsule with a dye substance, and its passage through the digestive system is recorded over several days. X-ray imaging is used to observe any disorders in intestinal muscles and the movement of food through the colon.
• Defecography: A substance filled with barium is introduced into the rectum and expelled similarly to feces. Barium is visible on X-ray, helping identify disorders in muscle function or coordination.
• MRI examination: To visualize colon muscle function and diagnose conditions causing constipation, such as rectocele (weakness of the muscle wall separating the rectum and vagina) or rectal prolapse.

Management

The management of constipation depends on its severity, and treatment should be initiated as early as possible. It is essential to differentiate between acute and chronic constipation. The goal is to ensure smooth stool passage. Here are some ways to treat constipation:

Lifestyle and diet changes

• Increase fiber intake by consuming fruits, fresh vegetables, whole grain bread, and cereal. This helps speed up the passage of feces through the intestine.
• Regular exercise, as physical activity, increases the muscle activity of the intestine.
• Avoid holding back the urge to defecate. Take the time to use the toilet without disturbance or haste.

Laxatives

There are several types of laxatives, each with its mechanism of action to address constipation:

• Fiber supplements such as psyllium, calcium polycarbophil, and methylcellulose to soften the feces.
• Stimulant laxatives like bisacodyl to induce intestinal contractions.
• Osmotic laxatives that increase fluid secretion to help move feces through the colon. Examples include magnesium hydroxide, magnesium citrate, lactulose, and polyethylene glycol.
• Lubricants to ease the passage of feces.
• Fecal softeners that absorb fluid from the small intestine.
• Enemas and suppositories, such as sodium phosphate, can be used to soften feces and stimulate the urge to defecate.

If over-the-counter drugs are ineffective, a doctor may prescribe medication to relieve constipation.

Pelvic muscle exercises

Hip training under the guidance of a therapist. This involves learning to relax and tighten the hip muscles. Loosening the hip base muscles during defecation can make it easier to pass stool.

Surgery

Surgery may be considered if other treatments are unsuccessful, and chronic constipation is caused by conditions like rectocele, anal fissure, or anal stricture. In some cases where treatment fails and there is abnormal motility of the intestine or passage of feces through the colon, partial removal of the colon may be necessary.

Complications

Untreated constipation can lead to chronic constipation, which can cause several complications, such as:

• Hemorrhoids: Straining during defecation can cause the blood vessels in the anus to swell.
• Anal Fissure: Large and hard feces can cause tears in the tissues around the anus.
• Fecal Impaction: This occurs when hard feces block the intestine.
• Rectal Prolapse: Straining during defecation can lead to the lowest part of the colon (rectum) protruding from the anus.

Prevention

There are several ways to prevent constipation:

• Increase the consumption of fruits, vegetables, and whole grains.
• Include high-fiber foods in your diet.
• Consider incorporating prunes or cereals into your meals.
• Ensure an adequate intake of water.
• Limit alcohol and caffeine consumption.
• Maintain regular exercise.
• Consider adding probiotics to your diet, such as yogurt.
• Engage in exercises targeting hip muscles or the muscles around the anus.
• Avoid holding back the urge to defecate.

When to see a doctor?

Visit a doctor when:

• Constipation is sudden and accompanied by abdominal pain or cramps.
• Unable to pass gas and defecate at all.
• Constipation is experienced for the first time, and lifestyle changes are ineffective.
• Presence of blood in feces.
• Unexplained weight loss.
• Abdominal pain during defecation.
• Constipation lasts for more than 2 weeks.
• Size, shape, and consistency of feces change drastically.