Constipation Management

Constipation means you are unable to move your bowels normally, often leading to significant abdominal discomfort. You may be having bowel movement less often than you usually do or finding them more difficult to pass. Ideally, a bowel movement should happen at least every 2 – 3 days.

Establish a Routine

• Eat small frequent meals through the day, every 3 – 4 hours. Eating increases contractions in the GI tract.

• Try to have a bowel movement at the same time each day.  Mornings are a common time for bowel movements, especially after eating and/or drinking a warm beverage.

• Move your body, every day. Physical activity changes neurotransmitter levels in the brain which increases movement through the intestine.

• Regular use of over-the-counter stool softeners and laxatives may be needed.   Talk to your doctor about a bowel program that includes Senna (an herbal laxative) or Miralax, combined with a stool softener.  Generic versions work well.

Stay Hydrated

One of the colon’s main jobs is to reabsorb water. When fluids are scarce, the stool will lose the competition for fluid, resulting in hard painful bowel movements. 

• Drink a minimum of 64 oz of liquids every day to keep stools soft. Pace it by drinking a quart through lunch and another through dinner.

  • Anything liquid at room temp counts: soup, popsicles, jello, sherbet.

• Keep fluids next to your chair, drinking a couple ounces during TV commercials.

• Warm liquids can stimulate a bowel movement. Have hot tea or coffee, warm juices (prune/OJ blend works well), or you can try hot water with honey.

• Smooth Move herbal tea includes Senna and is sold at most grocery stores.

Dehydration will make nausea, fatigue, and pain worse. Patients can become dizzy when moving from sitting to standing, from a drop in their blood pressure. Urine is usually darker (an apple juice-color) and urination less frequent. Keep it light and clear!

Add Fiber, with a long-term goal of 30 g. But stay hydrated too.

• Fiber acts bulk to the stool, making it travel more quickly through colon. However, if the fluid is not available, fiber can make constipation worse.

• Consider over-the-counter psyllium, a soluble fiber supplement (Metamucil®). It is not fermented by bacteria, so it remains available to hold water in the colon, helping with both constipation and diarrhea.

  • Increase amounts gradually and spread doses through the day.

• Compare food labels on cereals, crackers, etc. looking for “dietary fiber”. Key words are “whole wheat”, “whole grains”, or “bran”.

• Make “Fruit ‘n Bran”: 3 parts bran; 2 parts applesauce, 1 part prune juice

• Leave skins on fruits and vegetables you eat.

Note: Fiber is food for probiotics, the friendly bacteria living in the colon. The bacteria then make short-chain fatty acids that keep the colon healthy. Avoid increasing fiber too quickly though, causing more fermentation by the bacteria and increased gas.

Food	Serving size	Dietary Fiber (grams)
FRUITS
Apple, pear with peel	1 medium	4 - 5
Banana	1 medium	2
Orange	1 medium	3
Prune	3 medium	3
Raspberries, blackberries	½ cup	4
GRAINS
Bran cereals	½ cup	3-13
Popcorn	3 cups	3
Rice, brown	½ cup	3
Wheat/multigrain bread	1 slice	2-3 g, check labels
VEGETABLES
Carrots	½ cup	2
Corn	½ cup	2 - 3
Potato with skin	1 medium	3
Broccoli, Brussel Sprouts	½ cup	3
Spinach	½ cup	3
LEGUMES/NUTS
Chickpeas/garbanzo	½ cup cooked	6
Dried beans	½ cup cooked	6 – 7
Almonds	1 ounce	3

Dealing with Gas

• Foods that can increase gas include carbonated drinks, broccoli, cabbage, cauliflower, cucumbers, dried beans, peas, and onions.

• Limit use of straws and avoid talking while eating and chewing gum. This limits the air you swallow and the gas/burping that can result.

• Over-the-counter supplements with simethicone (for example, Gas X) break down gas bubbles, and upper GI gas/bloating. Beano capsules have enzymes to break down fiber, with less fermentation by the bacteria that create gas.

• Probiotic supplements may help if there is an imbalance in the colon bacteria.

Bowel Program Suggestions 

Start with a stool softener (helping water get into the stools) and a gentle laxative that increases contractions of the bowel, helping stool move though more rapidly. Working together, they prevent the colon from reabsorbing too much fluid from the stool. Both are found over-the-counter (OTC) so neither need a prescription.

Choose EITHER:

• Senna (Senokot®), contains an herbal laxative with many generic versions. One dose includes 8.6 mg of sennosides. Several generics will include both senna and docusate (described below), with names like Senna S, Senna +.

• Take one tablet in the morning and one in the evening

• Talk to your medical team about gradually increasing your dose (as needed) to a maximum of 4 morning and 4 in the evening.

OR

• Polyethylene glycol (Miralax®) is a non-absorbable carbohydrate that pulls fluid into the bowel. Generic options are available. Some people experience less cramping than with senna, but it may take several days to work.  

• Mix 17 g powder in 4-8oz of liquid daily

• You can increase dose, frequency and/or can use ½ doses

TOGETHER WITH:

• Docusate (Brand name Colace®) is a stool softener that is also available as a generic. As noted above, it is often combined with senna (as Senna S or Senna +), though sometimes with a lower dose of docusate.   

• 1- 2 tablets (100 mg) a day; increasing as needed.

If there is no bowel movement within 48 hours, ADD one of the following for initial relief (rescue), but then increase the doses of your Senna (or Miralax) and stool softeners for day to day management.

• Milk of Magnesia, one to two tablespoons at night

• Bisacodyl, a stimulant laxative

• Miralax, if not added previously

If there is no bowel movement in 72 hours, CALL your doctor or nurse. 

They may want to prescribe Magnesium Citrate, a Fleet enema, or suppositories.

Health Step stools fit on the base of the toilet, positioning the pelvis in the position that allows complete emptying of the bowel.  www.healthstep.com.

NOTE: Decrease laxatives and stools softeners by 1/2 if you experience loose stools or diarrhea. Unless treatment changes explain the diarrhea, it is best not to eliminate them altogether, to avoid swinging back to constipation.

Goal: A bowel movement at least every other day, Type 3 - 4 on the Bristol Scale

Reference:

Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterology 32(9): 920–924, 1997