A Constipation Guide
A Checklist of Possible Causes and Treatment Approaches
With a touch of humor, right?
Turtling is my cardio
Please use this guide as a quick reference to identify possible causes and potential treatment approaches to your constipation.
This guide is not intended for self-diagnosis or to offer a thorough explanation of these factors. Instead, it can serve as a springboard for additional research or assist you in creating questions to ask your doctor during your visit.
What is constipation?
- Let's review the Adult Rome IV criteria for functional constipation:
 Functional constipation may be indicated if you have had two or more of the following symptoms over the past six months: |  Fewer than 3 spontaneous bowel movements per week. |
|---|---|
 Straining for more than 25% of defecation attempts. |  Lumpy or hard stools for at least 25% of defecation attempts. |
 Sensation of anorectal obstruction or blockage for at least 25% of defecation attempts. |  A sensation of incomplete defecation for at least 25% of defecation attempts. |
 Manual maneuvering required to defecate for at least 25% of defecation attempts. |
- Another helpful tool to determine if you may have constipation and which you can use when you talk to your doctor is the Bristol Stool Chart:
According to the Bristol Scale, types 3 and 4 are considered normal. Constipation usually comes with types 1 and 2. Some people with Type 1 or Type 2 or the Bristol Scale experience a lot of anxiety wanting to have softer stools. When you have Type 1 and Type 2, it is more crucial to learn how to avoid straining during a bowel movement. Please be aware that long-lasting changes in the bowels take time.
Tortally the truth:
The best parameter for constipation is not how many times you go a week, but how difficult it is to have a bowel movement.
What other symptoms could be associated with constipation?
Some additional symptoms of constipation may include:
 Bloating |  Abdominal pain or cramps |
|---|---|
 Frequent burping or gas |  Fecal incontinence or smears in underwear |
What can be a cause or contributing factor to constipation?
1. Lifestyle causes:
The following lifestyle-related factors may contribute to constipation:
 Being too busy to allow for bathroom breaks |  Ignoring the urge to go |
|---|---|
 Holding back bowel movements |  Sitting scrunched up for hours in a day |
 Stress, anxiety and depression |  Changes in routine |
 Not exercising regularly |  A disrupted circadian rhythm |
 Travelling or going on vacation |  Being distracted when on the toilet, disrupting natural processes |
 "Not my toilet" anxiety |
2. Dietary causes:
The list of diet-related factors that contribute to constipation may include:
 Not drinking enough fluids |  Not eating enough dietary fiber |
|---|---|
 For some milk and dairy products |  Changing your diet |
 Dehydration resulting from beverages like soda, coffee, and alcohol |  Processed foods and meats, fried foods, and refined carbs |
 A diet heavy in meat |
3. Medical causes:
The following health problems may contribute to constipation by affecting your nerves, muscles, or hormones - and therefore your bowel movements:
 Constipation-predominant irritable bowel syndrome (IBS) |  SIBO with intestinal methane overgrowth |
|---|---|
 Overgrowth of bacteria or a fungus |  Celiac disease |
 Rectocele (prolapse) or mega-colon (dilation of the colon) |  Diverticular disease |
 Nerve dysfunction or damage, and other neurological conditions |  Diabetes |
 Hypothyroidism, or hyperparathyroidism |  Multiple sclerosis or other autoimmune diseases |
 Parkinson's disease |  Kidney disease |
 Colorectal cancer |  Eating disorders |
4. Medication causes:
The list of medications that can contribute to constipation includes:
 Pain medications, such as narcotics and NSAIDs |  Over-the-counter antacids containing aluminum or calcium |
|---|---|
 Antihistamines | Anticholinergics used for overactive bladder, urinary urgency or frequency |
 Blood pressure medication such as channel blockers and diuretics |  Oral contraceptives |
 Antidepressants (SSRI's) and tricyclic antidepressants |  Antispasmodics used for COPD or asthma medications |
 Anti-nausea medication |  Iron and calcium supplements |
 Cholesterol medications such as statins and bile acid sequestrates |
Please consult your doctor about your medications and how it may relate to your constipation.
5. Pelvic floor causes:
Let's first consider what the pelvic floor is:
The pelvic floor is a group of muscles at the bottom of the pelvis:
 The pelvic floor forms a sling to hold your organs in place. |  It requires good coordination to perform its various functions. |
|---|---|
 Contracting, or pulling the pelvic floor muscles up and in, is also called a Kegel. |  The pelvic floor muscles support physical activity. |
 The pelvic floor supports your pelvis, spine and core during heavy lifting. | It controls urination. |
 The pelvic floor is essential for sexual activity. | The pelvic floor needs to be able to lengthen and relax while having a bowel movement. |
 The pelvic floor helps to prevent leakage of urine, stool and prevents gas to escape at inappropriate times. |
The following list outlines pelvic floor dysfunction, as well as other structural factors that can lead to constipation:
Poor pelvic floor muscle coordination (dyssynergia) |  A weak pelvic floor and core. |
|---|---|
 A tight pelvic floor. |  A pelvic floor that has lost structural integrity, such as in organ prolapse. |
 Inability of the pelvic floor to relax when having a bowel movement or voiding. | Inability to isolate the pelvic floor muscles when needed. |
 Habitual straining. |  Weak sphincters. |
 Scar tissue after giving birth or surgeries. |  History of pelvic floor injuries from falling on your tailbone. |
Nerve damage in your pelvic floor or anal area. |  Altered integrity of pelvic blood flow. |
 Spasms of the pelvic floor muscles. |  Habitual sitting and movement postures affecting the pelvic floor. |
Please consult a pelvic floor therapist to see if any of these apply to you.
4. Other causes:
 Female gender |  Age >65 years |
|---|---|
 Pregnancy |
What is the treatment of constipation?
1. Initial treatment:
Lifestyle modifications and the use of over-the-counter medications.
Food ideas:
Increase fluid intake. | Increase fruits, vegetables and whole grains. |
|---|---|
 Distinguish between soluble and insoluble fiber, especially with slow motility. |  Take a daily fiber supplement if you need to. |
 Consider consulting a professional about diet options. |  Consider eliminating gluten. |
Consider cutting out dairy for a while. |  Talk to a specialist about a low fodmap diet. |
 Clean out your pantry and stock with healthy foods. |  Try a hot drink in the morning. |
 Some people benefit from drinking coffee in the morning to facilitate a bowel movement. |  Considering drinks high in caffeine can lead to dehydration. |
 Drinks containing alcohol, and those with excessive sugar can lead to dehydration. | Talk to your doctor to see if your medications are causing constipation. |
 Consider over-the-counter options |  Consider other natural treatment options. |
No rush I'm on tortoise time:
Introduce additional fiber slowly, while also increasing your fluid intake. Adding fiber too fast may make you more constipated or cause bloating or abdominal pain. Make sure to focus on soluble fiber vs insoluble fiber when you have slow motility or your bowels move slowly.
Movement and other ideas:
Do some form of exercise for at least 30 minutes every day. |  A daily walk for 20 min or 1 mile is great! |
|---|---|
Use the bathroom 20 min after a meal. |  Don't ignore the urge to go. |
 Adjust your toilet posture by adding a footstool. |  Try leaning forward and then back a few times when on the toilet to facilitate a bowel movement. |
 Massage your stomach to help with the constipation. |  Make sure you get a good night's sleep. |
2. The second step:
An evaluation by a pelvic floor therapist for possible pelvic floor dysfunction.
After a thorough evaluation, your therapist may address the following:
Reviewing your toilet posture and suggest a foot stool. | Teaching you correct bearing down mechanics. |
|---|---|
Re-training of your pelvic floor muscles to contract and relax at the right time. | Refine pelvic floor muscle coordination. |
Teach Kegel exercises only if necessary and how to perform them correctly. |  Teaching you breathing exercises for optimum pelvic floor function. |
 Adressing posture as it relates to your pelvic floor. |  Suggesting pelvic floor stretches if appropriate. |
 Provide you with a personal strengthening program. |  Reviewing your lifestyle, diet, and habits with you. |
Releasing scar tissue from surgeries or post birthing. |  Providing visceral manipulation techniques to loosen adhesions between organs. |
Strategies to help the nervous system for optimum vagus nerve function. |  Biofeedback which allows you to view your pelvic floor performance on a computer screen. |
 Balloon biofeedback or bowel re-training if appropriate. |
3. Surgery is rarely needed and is usually only done when there is a structural cause to your constipation.
Why is straining while I have constipation a problem?
Occasional straining is not a problem, but repeated straining can cause the following health problems:
 Frequent straining can cause pelvic floor dysfunction and lead to: |  Anal fissures |
|---|---|
 Hiatal or other hernias |  Diverticula |
Rectal prolapse |  Heart arrhythmias or cardiac events if you are at risk |
 Fainting |  Hemorrhoids |
 Urinary incontinence | Pelvic organ prolapse |
When should I go see my doctor?
The following symptoms should prompt you to schedule an appointment with your doctor:
 Bleeding from the rectum |  Black stools or blood in your stools |
|---|---|
 Vomiting | Stomach pain that is severe or does not go away |
 Change of shape or color of your stools |  Weight loss that you cannot explain |
 Constipation symptoms affecting your life |  Your symptoms last longer than three weeks or you cannot get rid of it |
Shell me more!
Here are some interesting facts about constipation and our gut:
 Two thirds of our immune system is situated in our gut. |  The gut temporarily becomes more porous after antibiotics, stress or alcohol. |
|---|---|
 Our small intestine works better to extract all the good stuff when we are relaxed after a meal. |  If we stop listening to our body (urge), then it just gives up and stop talking to us. |
 Giving birth can decrease the communication between the sphincter and pelvic floor muscle. | When you bounce on a trampoline, your gut bounces with you. |
 Cooked food can contain more soluble fiber. |  Cooked food helps with bowel movements by making some foods easier to digest. |
 Soup can be a fun way to increase fluid intake, especially during winter. |  Rumbling in the tummy does not mean you are hungry, it means your intestines is cleaning itself. |
 Chewing your food well, gives your stomach a break. |  Be patient. Everything with the large intestine takes time. |
 Withholding just twice trains the muscles and nerve to start working backwards. | Ignoring the urge for two days can lead to constipation. |
