Constipation in adults

The 4.3 million practice consultations for constipation cost the NHS over £22m per annum, yet most cases can be managed effectively through self care. Appropriate guidance and advice for patients is outlined in this, the latest in a series of articles

WHAT IS CONSTIPATION?

We are all different when it comes to bowel habits - some people pass stools only every three or four days, whereas others may go more than once a day. Constipation is when stools become hard and people find them more difficult than usual, or even painful, to pass. A feeling of being unable to completely empty the bowel is common (tenesmus). Opening the bowels may be more difficult because stools are hard, lumpy and dry, or because they are abnormally small or large. Constipation may be accompanied by feeling bloated or nauseous, loss of appetite and abdominal cramps and aches. Common causes include not eating enough fibre (contained in cereals, vegetables and fruit), a change in eating habits (for example, when on holiday or on a diet), ignoring the urge to go to the toilet, not drinking enough fluids, lack of exercise, and mental health problems, such as depression and anxiety. Certain medications, such as opiates, diuretics and antidepressants may also cause constipation.

HOW COMMON IS IT?

Constipation is very common, affecting around 10-20% of people at any one time (though prevalence data vary widely). It is twice as common in women and affects older people and pregnant women in particular.

WHAT CAN PATIENTS EXPECT?

Being constipated once in a while is common and mostly completely harmless. There is usually no need for any investigations or procedures, because the diagnosis can often be made based on symptoms alone. In most cases, constipation is short-lived and settles by itself.

WHAT CAN PEOPLE DO TO HELP THEMSELVES?

Increasing daily fibre intake by eating a higher proportion of fruit, vegetables and cereals can help to alleviate symptoms and prevent recurrences. Bulk forming agents, such as wheatbran, can make stools softer and easier to pass. Exercising more and avoiding dehydration can also help. A key message for people is to respond to their bowel's natural pattern, and not to delay going to the toilet when the urge is there.

WHICH OTC PREPARATIONS CAN PEOPLE USE?

Simple analgesics, such as paracetamol, can help to relieve pain and discomfort. Suppositories, such as glycerol or bisacodyl, can help when a hard stool is filling the rectum. Various laxatives can help with passing stools:

• Bulk forming agents, such as ispaghula husk or methylcellulose, are good first-line treatments and retain fluid within the stool, making them softer and denser. Advise patients to have an adequate fluid intake and avoid taking these agents before going to bed
• Osmotic laxatives, such as lactulose and macrogols, increase the amount of fluid in the bowels, both softening stools and stimulating the bowel to pass them
• Stimulant laxatives, such as bisacodyl or senna, work within six to 12 hours and are usually only used on a short-term basis.

Advise patients to stop taking laxatives when stools have softened and passing has become easier.

WHEN SHOULD PATIENTS RETURN?

People should return if constipation does not improve after two weeks or if red flags (see Box) are present - particularly when they are over the age of 50, have never suffered from constipation before, or if their symptoms have persisted for six weeks or more.

WHAT ARE THE NEXT STEPS?

If OTC medicines are ineffective, patients should see their GP for further assessment and advice.

SUMMARY

Constipation is a common and usually harmless condition, which can cause considerable discomfort and affect quality of life. Various OTC preparations are available for self-treatment.