Family Medicine Diseases and Conditions: Constipation

"Sir, New Cadet Jonas has properly showered and dried, powdered and inspected his feet, brushed his teeth and has not had a bowel movement for 3 days."  This was the nightly report format for West Point New Cadets (during the first two months of Beast Barracks- boot camp before Plebe year and academics started).  One of my classmates in the next squad had 17 days without a bowel movement, which I assume was a record, but no honors were given.  Hearing of the record, other cadets found it humorous, but the constipated New Cadet may not have agreed.  Constipation causes considerable discomfort.  I believe it to be among the worst of human symptoms.

What is constipation?  Why do people get constipation?  How do they get rid of it? 

Constipation relates both to the frequency of bowel movements and difficulty with evacuation.  Less than three bowel movements in a week and or difficulty of stool passage is a reasonable definition of constipation.  The individual patient has the last call as to what constitutes constipation for them.  Often it is the difficulty in stool passage that causes the distress which makes it imperative to perform a good history and physical, including a thorough listing of all medication and nutritional supplements.  Surgical history in the abdominal, pelvic and rectal areas is important, too.

With many, especially younger people who are very active, lifestyle and cultural issues may be important.  Is the patient ingesting enough food, fiber, and fluids to support their usual bowel frequency?  Is their usual routine altered by their current situation?  In the summer with athletic activity, many become dehydrated, leading to constipation.  Certainly, the New Cadets mentioned above had a very rigorous schedule inflicted on them, in the summer with unusual meal habits and variable access to fluids.

Hemorrhoids, hypothyroidism, diabetes, hypercalcemia, parkinson's disease, recent intestinal infection, intestinal tumors, diverticulosis, rectal fissure, chronic lung disease and more may lead to constipation in family medicine settings.  There are examinations and medical tests to help with the diagnosis of these conditions.

In the absence of a specific disease process, the initial treatment is diet change.  Increased fluids and fiber  (both soluble and insoluble) are a good start. Several fiber rich foods that may be helpful include apples, prunes, almonds, pineapple, grapes, walnuts, peppers, wheat bran, whole grains, watercress, watermelon and others.  Other nutritional supports may include Vitamin C, Magnesium, chamomile tea and dandelion roots.

Medications to treat constipation are now non-prescription, including methylcellulose (not soluble so less gas and bloating), psyllium products such as Metamucil (soluble so more gas and bloating are possible), then the powerful polyethylene glycol (Miralax) which is more costly.  Others include the time honored Milk of Magnesium or Colace.  Initially they should be taken as directed on the container, but higher doses may be suggested by your family physician if needed.

Constipation in small children requires a more delicate strategy not covered in this post.  They may also have psychological issues associated with constipation that become more challenging.  More complicated surgical conditions are not included in this post, either.  These would be diagnosed after referral by your family physician to the appropriate surgical or intestinal specialist.

I'm not sure what was done to help my classmate with the seventeen day constipation, but I know he made it through Beast Barracks to start Plebe year.