By: The Canadian Virtual Hospice Team 

What is constipation?

On average, people have a bowel movement once or twice a day, but some go more or less often. Most people have at least one bowel movement every three days. 
 
We say that someone is constipated when stool (poop) moves too slowly through the digestive system. When this happens:
  • The body takes more liquid out of the bowel than usual.
  • This leads to drier and harder stool.
  • Stool that is hard and dry can be difficult – even painful – to pass out of the body.
  • Fewer bowel movements occur than usual. 
Constipation can affect quality of life
  • You may feel bloated and have stomach discomfort or pain
  • You might not feel like eating – food isn’t enjoyable if you’re uncomfortably full and nauseated.
Contact your healthcare provider if you have: 
  • No bowel moment for three days, and that’s unusual.
  • An unusually high number of stools each day.
  • Blood in the stool or anal area.
  • Persistent cramps.
  • New or more abdominal pain.
  • New or worsening bloating.
  • New or worsening swelling of the abdomen.
  • Nausea or vomiting.

Causes of constipation

Constipation can be caused by:
  • Diet and activity level.
  • Not drinking enough.
  • Social and emotional problems.
  • Medications.
  • Medical conditions.
  • A combination of these.

Diet, liquid, and activity

What we eat, how much we drink, and our activity level plays a role in how our bowels work. For example: 
  • Eating less means the body makes less stool.
  • Eating food that is greasy or low in fibre can make you constipated.
    • The fibre in food helps to keep liquid in the gut. This liquid keeps stool from drying out, which helps it to travel more quickly through the digestive system. 
  • Drinking less can result in hard stools that are difficult to pass.
  • Being inactive or not exercising makes the gut less active – which slows the stool’s journey through the digestive system.

Social and emotional problems

These include:
  • Difficult access to a bathroom (the bathroom may be occupied, hard to get to or not very private).
  • Needing help in the bathroom because of a physical or medical condition.
  • Needing to use a bedpan or bedside toilet (commode).
  • Being in unfamiliar surroundings or a stressful atmosphere.
  • Feeling depressed or anxious.

Medications

Many medications can cause constipation, including:
  • Opioids.
    • These are used for symptoms such as pain and shortness of breath.
  • Diuretics.
    • These help remove excess fluid from the body. They increase the amount of urine.
  • Anti-convulsants.
    • These prevent seizures and treat many other symptoms, including pain.
  • Iron supplements.
    • These are used to treat anemia (a condition where a person lacks enough healthy red blood cells).
  • Anti-depressants and anti-anxiety medications.
    • These improve mood and treat many other symptoms, including pain.
  • Antacids.
    • These relieve irritation in the stomach.
  • Laxatives and stool softeners.
    • If these are used often or long-term, the gut starts to depend on them and becomes less active on its own. A gut that isn’t active leads to constipation.
TIP: 
Sometimes people don’t want to take pain medication because they worry it will cause constipation. This should never be a reason to undertreat pain! Constipation caused by treatment for pain can be managed and prevented.

Medical conditions 

Constipation can be caused by bowel-related problems or by other health issues that affect how well the bowel works.
 
Bowel-related causes
  • Tumours in the bowel.
  • Irritable bowel syndrome (IBS).
  • Crohn’s disease (chronic inflammatory condition).
  • Poor functioning of the bowel nerves due to:
    • Diabetes.
    • Multiple sclerosis (MS).
    • Spinal cord injuries.
Other causes 
 
Muscle weakness due to advanced disease of any kind.
 
Tumours inside the abdomen that affect the bowel.
 
High levels of calcium in the blood.
 
Hormones that affect how well the bowel works, such as thyroid hormone.

Constipation at end of life

The body produces small amounts of stool even when someone is dying and isn’t eating. For this reason, if constipation appears to be causing distress, it's sometimes explored as a possible issue even toward the end of life. 

Constipation and emotions

Constipation can affect people emotionally as well as physically.
  • The physical discomfort can leave people feeling tired and sad.
  • Most people are private about their body functions, so the location of bathrooms can cause anxiety. For example:
    • Bowel movements in unfamiliar places such as hospital washrooms.
    • Lack of privacy in shared bathrooms.
    • The loss of dignity to have a bowel movement in a four-bed hospital room.
  • Someone who is already anxious can find themselves constantly worrying about their bowel movements.

Assessing and diagnosing

To learn more about your constipation, your healthcare provider will ask questions, do a physical exam, and may order tests. This will help them decide how best to manage the constipation.

TIP: 
Keep track of your symptoms in a daily symptom diary. Sharing this information with your healthcare provider will help them to help you.

Questions

  • How bad is the constipation?
    • Mild, moderate, or severe?
    • Rate the constipation on a scale from 0 to 10. Zero means no constipation and 10 the worst possible constipation.
  • How often do you normally have a bowel movement?
    • Once a day? Twice a day? Every two days?
  • When was your last bowel movement?
  • What was the last bowel movement like?
    • Hard or soft?
    • How much?
    • What colour?
    • Any signs of blood? If so, was it bright or dark? Was it in the toilet or on the toilet paper or both?
    • Was the bowel movement painful?
  • Have you felt the push to have a bowel movement but had no stool?
  • Have you been nauseated or vomiting? 
  • What about pains or cramps in the stomach?
  • Are you passing gas?
    • How many times a day?
  • Are you taking medication now to help with bowel movements?
    • Is it working?
    • How long does it work for?
    • How often do you take it?
  • What medication have you taken in the past to help with bowel movements?
    • Did it work?
    • How long did they work for?
    • How often did you take it?
  • What has helped with constipation in the past?
  • How is constipation affecting your quality of life?
    • What kinds of things does it stop you from doing?
    • Do you feel discouraged or depressed?

Physical exam

Your healthcare provider might examine you in two ways.
 
General exam
This may include:
  • Pressing on your abdomen, feeling for tenderness or masses. 
  • Listening to bowel sounds with a stethoscope in different areas of the abdomen.
Digital rectal exam
  • Your healthcare provider will insert a gloved finger into the rectum, feeling for stool or hard masses. 
  • A pressure will be felt in the rectum like the pressure felt during a bowel movement.

Tests

Abdominal X-ray
  • X-rays take pictures of the inside of your body.
  • This type of X-ray can show where stool is sitting in your bowel.
Blood samples
  • These check for levels of calcium and thyroid hormones. 
  • Changes to the amount of these in the blood can lead to constipation.

Medications and other treatment

Since constipation is often related to both diet and low activity level, treatment usually focuses on improving both of these if possible. If constipation continues to be a problem, then medication is given. 
 
Oral laxatives are often the first medication given to treat your constipation. If these aren’t effective, then rectal medications may be given. 

Oral laxatives

These laxatives are sometimes necessary to keep the bowels emptying regularly and effectively. 
  • They may also be prescribed if your illness keeps you from drinking enough or being physically active. 
  • Certain medications cause constipation. (Opioids, for example, used to manage pain or shortness of breath).
    • In most circumstances, laxatives should be prescribed with constipating medications in an effort to keep the bowels moving. Your healthcare provider will know if this is right for your circumstance.
There are different kinds of oral laxatives, including:
  • Stimulant laxatives.
  • Osmotic laxatives.
Stimulant laxatives
These are one of the most commonly used laxatives in palliative care. They help to move stool through the intestine. 
 
This group includes:
  • Senna.
  • Sennosides.
  • Cascara.
Their side effects include:
  • Cramps.
  • Diarrhea (if too much of this medication is used).
Stool softeners
 
These have long been a popular approach to treating constipation. However, recent evidence shows these are not effective in treating this symptom.  
 
TIP: 
All opioid medications (such as morphine and hydromorphone) are constipating. However, this is never a reason to avoid this medication. Your healthcare provider can help prevent constipation by also recommending laxatives when prescribing this medication. 
 
To learn more, go to:
  • Potential side effects and myths about opioids in Managing Pain.
  • Common concerns about use of opioids in palliative care.
Osmotic laxatives
 
This type of laxative relieves constipation by increasing the water in the bowels. 
 
There are three kinds:
  • PEG (polyethylene glycol). 
  • Lactulose. 
  • Saline.
PEG (polyethylene glycol, polyethylene glycol 3350)
  • These help to soften stool and empty the bowels by pulling water into the bowels. 
  • They cause less bloating and cramping than lactulose.
  • There are several brands in this group. Some have electrolytes (salts) and some do not.
Lactulose
  • This is a type of sugar that isn’t absorbed into the body (so it’s safe for people with diabetes). 
  • It helps soften stools by drawing water into the bowels, and it helps the bowels to empty. 
  • Lactulose makes some people feel bloated and gassy, and its sweet taste can be nauseating.
    • It may taste better mixed with juice or ice.
Saline laxatives
  • These draw liquid into the bowel and help to get the bowels moving.
  • Many of these also have magnesium, which stimulates the bowel. For example:
    • Milk of magnesia (magnesium hydroxide).
    • Magnesium hydroxide with mineral oil.
    • Magnesium citrate.
  • Oral liquid sodium phosphate is a powerful and effective saline laxative. However, it can seriously affect fluid and chemical balance in frail people.
    • This should only be used with medical supervision in people with advanced serious illness.
CAUTION:
The following laxatives can cause significant problems in people who are frail or have serious illness:
  • Bulk-forming laxatives.These often contain psyllium or wheat bran. Both of these can cause bloating and make the bowels work even slower in someone who can’t drink much or be physically active.
  • Mineral oil. People who are weak and spend a lot of time lying down shouldn’t use mineral oil. Small amounts of the oil might seep into the lungs. This can cause inflammation in the lungs.
  • Castor oil. This laxative can cause serious cramping. If it’s used for a long time, the body might lose the ability to absorb certain nutrients from food. 

Rectal medications

As a general rule, a bowel movement should occur at least every three days. 
  • If medication taken orally (swallowed) isn’t improving bowel movements, the dose will usually be increased. 
  • If constipation continues, rectal medications may be needed. These are medications that are inserted into the rectum. There are two kinds:
    • Suppositories.
    • Enemas. 
Rectal suppositories
  • These melt at body temperature when pushed into the rectum with a gloved finger. 
  • They help to move stool from the lower end of the intestine.
  • Suppositories work in different ways. For example:
    • Bisacodyl triggers the bowel to move the stool.
    • Glycerin softens the stool to make it easier to pass.
Enemas
 
These are solutions (liquid mixtures) that are inserted into the rectum to clean out the large intestine and to trigger bowel movements. Check with a healthcare provider before using any type of enema.
 
  • The solution is placed into a small plastic container with a tube attached. 
  • The tube is gently inserted into the rectum and the liquid is slowly sent through the tube into the bowel. 
  • After about 15 to 20 minutes, the enema solution triggers the bowels to empty, so the patient should plan to be sitting on a toilet or bedpan. 
Enemas are also used to treat fecal impaction (a large amount of hard stool in the intestine that isn’t moving). 
 
TIP: 
Talk with a healthcare provider before using an enema. 
  • Oral laxatives are usually the preferred approach. A repeated need for enemas suggests that oral laxatives need to be increased. 
  • Enemas can damage the rectum if they’re not done properly.
  • They often don’t completely address the problem of constipation because they only deal with the lower part of the bowel. 

Other constipation treatment

Constipation is usually managed successfully with only oral laxatives or rectal medications. If constipation remains a problem when you’re taking bowel-slowing opioids, another treatment option can be tried. These are medications are called peripheral receptor antagonists. 
  • These medications aim to block the constipating effects of opioids in the bowel without affecting pain relief. 
  • They’re generally only used for temporary constipation relief. They add to, not replace, oral and rectal laxatives.  
  • Check with a healthcare provider about whether a prescription for these medications is suitable. 
  • Examples include methylnaltrexone (an injection) or naloxegol (a tablet).

Complementary therapies

In addition to medications and other treatments, complementary therapies, such as the ones below, may be helpful in managing the stress and emotional impact of constipation symptoms. 
  • Breathing and relaxation exercises.
  • Distraction techniques.
  • Massage.
  • Mindfulness meditation.
  • Music therapy. 
If you decide to try a complementary therapy:
  • Talk with your healthcare provider first in case they have concerns about a certain therapy and your particular health circumstances. For example:
    • Some herbal remedies may affect how well your prescribed medications work.
    • Heat therapies are best avoided with certain disorders, such as reduced ability to feel hot temperatures against the skin (risk of burns).
  • Experiment with the different approaches until a helpful one is found.
    • A therapy that works for one person might not work for another. 

What you can do

When you are living with illness

Prevention is the best medicine when dealing with constipation. Managing this symptom becomes increasingly difficult as more time passes between bowel movements. The following are some suggestions that might help you to manage constipation. 
 
Talk with your healthcare provider
 
Ask your healthcare provider for a treatment plan that includes:
  • Simple lifestyle changes.
  • How much and what you should eat and drink.
  • When to exercise.
  • When to take medication.
  • Getting or affording constipation medication.
TIP: 
Keep track of your bowel movements using a daily symptom diary. (For example, how often you have bowel movements, what helps, and what makes constipation worse). Sharing this information with your healthcare provider will help them manage your symptoms.
 
Make lifestyle changes
 
Small changes can encourage regular bowel movements. For example:
  • Eating (filling the stomach) triggers the rectum to empty. Try to have a bowel movement 30 to 60 minutes after meals to take advantage of this.
  • Eat foods that are high in fibre such as dried fruits, fresh fruit and vegetables, legumes, and whole grain breads and cereals. 
  • Try making a natural fruit laxative to loosen your stool and increase your bowel movements.  
  • Drink hydrating fluids throughout the day, as tolerated.
  • Avoid foods that constipate such as greasy fried foods and hard cheeses.
  • Try to be more physically active if possible. For example, try a gentle walk each day.
  • If bowel movements are painful, talk with your healthcare provider. 
  • If possible, try to have a bowel movement sitting rather than lying down.
  • Try to make sure you have private time in the bathroom.
  • If you need help going to the bathroom, work with your helpers to ensure you feel respected and you are treated with dignity.
Try relaxation exercises
 
In addition to lifestyle changes, various breathing and relaxation techniques might also help to manage stress. 
 
To learn more, see Complementary therapies.
 
Find support
 
Many people find it helpful to connect with others. These are some suggestions to consider.
  • Talk with someone you trust, like a friend or family member. Sometimes just talking with someone can help you to feel better. 
  • Ask your healthcare provider to refer you to a counsellor such as a psychologist or social worker. They can offer:
    • Counselling and emotional support.
    • Education.
    • Practical suggestions to help you manage your symptoms.
  • Talk with a spiritual care specialist.
  • Find information online.
    • Canadian Virtual Hospice has information on many topics related to serious illness and palliative care.
  • Join a support group.
    • If you can manage it, join a support group where you can meet with people with the same health concerns.
  • Join online discussion forums such as:
  • Learn more about Programs and Services in your area.

When someone you care about is living with illness

It can be difficult to watch someone who is important to you face a serious illness. Helping this person with symptoms such as pain, constipation, nausea, and vomiting can be exhausting. It can also lead to feelings of isolation when other people don’t appreciate how challenging these symptoms can be. The following suggestions might help you through this difficult time. 
 
Find support
 
Many people find it helpful to connect with others when they’re supporting someone with an illness. These are some suggestions to consider.
  • Talk with someone you trust. Sometimes just talking with a friend or family member can help.  
  • Ask your healthcare provider to refer you to a counsellor such as a psychologist or social worker. They can offer:
    • Counselling and emotional support.
    • Education.
    • Practical suggestions to help with stress.
  • Talk with a spiritual care specialist.
  • Ask about a support group for caregivers.
  • Find information online.
    • Canadian Virtual Hospice has information on many topics related to serious illness and palliative care.
  • Join online discussion forums such as:
  • Learn more about Programs and Services in your area.
Try complementary therapies 
  • Various therapies such as relaxation techniques, meditation and yoga can be helpful to manage stress and the emotional impact associated with caregiving. 
  • To learn more, go to: Complementary therapies.
Take time out for yourself
  • Regular exercise is important in managing stress. What physical activities do you enjoy? Walking? Biking? Something else?
  • We’re all different so choose something you enjoy. It might be reading, praying, listening to music, watching sports – or something else. 
Respecting choices
 
You might find you disagree with the choices someone makes about treatments and how they live with their illness. Perhaps you feel their choices are unsafe and might cause harm, or risk losing an opportunity to get better. This can be frustrating and upsetting. It’s okay to tell them, respectfully, how you feel about their choices and how they affect you – but remember, they have the right to make their own decisions. 
 
If you’re concerned this person is no longer able to make good choices, or that their choices may be putting others at risk, speak to the healthcare provider about your concern.
 
 
Updated January 2022
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