Guest Author - Denise Howard, M.D., M.P.H.

Constipation is a very common problem. It affects women more than men and the prevalence appears to be as high as 30% in women. This problem contributes to 2.5 million physician visits a year in the U.S. and more than $800 million are spent on laxative use each year. Constipation is more of a problem in those with a sedentary life style, lower education and lower socioeconomic status.

Constipation is a concern due to the problems that can result. It can lead to abdominal pain and straining while attempting stool evacuation. The straining itself can result in hemorrhoids, bleeding, anal fissures and other pelvic floor problems such as vaginal prolapse. Chronic constipation may result in an acute impaction of stool that could lead to bowel rupture if not treated. Chronic constipation maybe associated with the development of colon cancer and finally, constipation maybe the initial sign of other medical problems.

Constipation is not a disease but merely a symptom of some other underlying problem; just as a cough can be a symptom of bronchitis. Constipation exists when the frequency of defecation (bowel movement) is less than 3 times a week. It is also characterized by excessive straining or discomfort with evacuation or the passage of hard or pellet like stools.

Functional Constipation is the most common reason for the symptoms of constipation. One diagnostic category requires 2 or more of the following in order to be classified as Functional Constipation.
• Straining with >25% of bowel movements (BMs)
• Hard or lumpy stool with >25% of BMs
• Sensation of incomplete evacuation with >25% of BMs
• Sensation of anal or rectal blockage with >25% of BMs
• Manual maneuvers to help with defecation with >25% of BMs
• <3 BMs a week
• Loose stool only with laxatives
• No evidence of Irritable Bowel Syndrome
• The above symptoms present for at least 3 months and onset >6 months prior to diagnosis.

Constipation results from slow transit of the colon or outlet dysfunction or both. Slow transit is due to the lack of peristaltic motility of the colon. Outlet dysfunction results from lack of coordinated muscle relaxation of the pelvic floor and anal sphincter or obstruction of the rectal outlet. A common cause of this obstruction is a uterine or vaginal prolapse.

If constipation does not respond to common treatment measures (see upcoming article that discuss treatments) then a medical evaluation is indicated to determine the underlying cause. Next week’s article will discuss these causes and the evaluation process.