Understanding Constipation: A Guide for Patients

1. Understanding Constipation: It's a Real Medical Condition

Constipation is a common and often distressing medical complaint that is frequently misunderstood. While it is often perceived as a minor issue defined solely by infrequent bowel movements, a deeper understanding reveals that it is a complex condition that can significantly impair an individual's quality of life. Patients may experience considerable distress and discomfort even if they have a bowel movement every day, underscoring that the quality and pattern of defecation are just as important as the frequency. The impact of constipation extends beyond physical discomfort, affecting productivity and psychosocial well-being. For these reasons, this condition should never be taken lightly, even when no organic or underlying disease can be found.

For many, the physical symptoms are compounded by feelings of embarrassment or the belief that their condition is not serious enough to warrant medical attention. However, recognizing that constipation is a legitimate medical concern is the first step toward effective management and relief. This guide aims to provide a clear, comprehensive overview of constipation, empowering individuals to understand their condition and to seek the right help when needed.

2. Constipation in Singapore: You Are Not Alone

Understanding how common constipation is within a community can be a reassuring first step for those who feel isolated by their symptoms. In Singapore, a survey conducted in the Bishan community reported that chronic constipation affects approximately 7.3% of adults, which means that about 7 in every 100 adults may be living with this condition. This figure is consistent with findings from other parts of the world, suggesting a shared experience across different populations.

A notable finding from the local survey is the significant difference in prevalence between genders. Chronic constipation affects women in Singapore at a much higher rate (11.3%, or about 1 in 10 women) compared to men (3.6%, or about 3 in 100 men). This observation aligns with global trends where women's stool types often tend toward hard and lumpy on the Bristol Stool Form Scale.

The survey also highlighted some key patterns in patient behaviour. Most people, nearly 94%, attempt to manage their symptoms on their own before consulting a doctor. Of these, about 80% try laxatives. Despite these efforts, many report being dissatisfied with self-treatment because of its ineffectiveness or the long time it takes for relief.

A crucial point revealed by the research is why people delay seeking medical care. Many individuals do so due to the perceived "stigma" associated with discussing what they consider an embarrassing ailment. There is also a common belief that "constipation is not a medical condition" or that "it will stop on its own". By confronting these misconceptions, it becomes clear that consulting a healthcare professional is the most effective way to receive a proper diagnosis and an appropriate treatment plan. This approach can provide faster, more effective relief and address the underlying issues that self-treatment often misses.

3. Defining and Diagnosing Constipation

An accurate diagnosis is the cornerstone of effective management for constipation. Rather than relying on a single symptom, a doctor's diagnosis is based on a combination of a patient's history, a physical examination, and standardized criteria. Medically, chronic constipation is defined as unsatisfactory defecation characterized by infrequent stool, difficult stool passage, or both, which has persisted for at least three to six months.

When a doctor evaluates a patient, they look for specific symptoms that indicate difficult stool passage. These may include straining, a feeling of incomplete emptying, a sensation of blockage, or the need to use manual manoeuvres, such as pressing on the pelvic area, to pass stool. The consistency of the stool is also a key indicator, with hard or lumpy stools being a common sign.

To help patients and doctors communicate about stool consistency in a clear and objective way, a tool called the Bristol Stool Form Scale is often used. This scale, which categorizes stool into seven different types, provides a simple visual reference that can help a person describe their experience without feeling embarrassed.

Figure 1: Bristol Stool Form Scale

A thorough physical examination is also an essential part of the diagnostic process. This can include abdominal palpation to check for tenderness or masses, as well as a careful rectal examination. While the rectal examination can be a source of anxiety, it is a critical step that allows a doctor to screen for a range of issues, including anal diseases and problems with the pelvic floor muscles. By assessing things like anal tone and muscle contraction, a doctor can gain immediate clinical clues about potential underlying issues that might not be obvious from the patient's symptoms alone. This initial screening can help a doctor decide if a referral to a specialist is necessary.

4. The Different Kinds of Constipation

Chronic constipation is not a single, one-size-fits-all condition. Instead, it is a syndrome with distinct subtypes, each with a different underlying cause. Understanding these different types can help a person better describe their symptoms to a doctor and receive a more targeted treatment plan.

The "Slow-Moving" Type (Slow Transit Constipation)

This type of constipation is characterized by reduced movement of waste through the large intestine. It is the least common of the chronic constipation types, but it often causes very difficult-to-treat symptoms. The condition is more common in young women between the ages of 20 and 40. A classic presentation involves a person who has very infrequent bowel movements, sometimes only once every one to two weeks, and little to no urge to go to the toilet. They may have tried many different laxatives with no success.

Slow transit constipation is a genuine neuromuscular disorder of the colon, meaning it is a physical problem with the nerves and muscles that control the large intestine. The smooth muscles of the colon may have reduced contractions, and the pacemaker cells that generate the electrical signals for movement may be impaired. Because this is not a simple "functional" problem, patients with this condition may require more advanced diagnostic tests and targeted management strategies from a specialist.

The "Blocked-Up" Feeling (Obstructed Defecation Syndrome)

This type of constipation is defined by a difficulty in emptying the rectum. Key symptoms include a feeling of blockage, the sensation of not having fully emptied the bowels, prolonged or excessive straining, and the need for manual manoeuvres to help pass stool, such as pressing on the perineum or vagina. Explicitly mentioning these specific actions to a doctor can be a critical clue that points toward this diagnosis.

The reasons for this type of constipation can be categorized into two main issues:

Muscle Coordination Problems (Physiological): This occurs when the muscles involved in a bowel movement do not work together properly. For a bowel movement to happen, the rectal pressure must increase while the pelvic floor muscles and anal sphincters relax. In a coordination problem, these muscles might contract instead of relaxing, or they may not relax enough, making it difficult for stool to pass.
Physical Issues (Anatomical): This involves a downward displacement of the pelvic floor and rectum, which can create a physical blockage. A common example is a rectocele, which is a bulge of the rectal wall into the vaginal wall, creating a pouch where stool can become trapped. These physical issues can be caused by weakened pelvic floor muscles, often a result of pregnancy, vaginal childbirth, or chronic straining. This highlights a vicious cycle where chronic straining from constipation can actually cause or worsen pelvic floor disorders, which in turn make the constipation even more difficult to manage.

The "Common" Type (Normal Transit or Idiopathic Constipation)

Normal transit constipation, also known as chronic idiopathic constipation, is the most common type of chronic constipation. People with this condition experience the typical symptoms of constipation, such as straining and hard stools, but their large intestine moves waste at a normal speed. The stool may simply be harder than normal, making it difficult to pass despite the normal transit time. This diagnosis is made after a doctor has ruled out other underlying causes as well as slow transit and obstructed defecation.

The underlying causes of this type of constipation are often multifactorial and not fully understood. Contributing factors may include insufficient intake of fiber and fluids, subtle changes in gut contractility, and other lifestyle factors. Because this type of constipation is often related to these modifiable factors, the primary treatment approach focuses on lifestyle and dietary changes.

5. Your Step-by-Step Guide to Managing Constipation

Effective management of chronic constipation begins with a structured approach, starting with the most fundamental and impactful changes before moving on to medications if necessary.

5.1. Lifestyle and Diet First

These are the most important and foundational steps for managing constipation and should be initiated by everyone, especially those with the "common" type of constipation.

Fluid Intake: Drinking enough water and non-caffeinated beverages is critical, especially when increasing fiber intake. The recommended amount is about 8 to 10 cups (2 to 2.5 litres) daily to help keep stools soft and prevent the gas and bloating that can be associated with fiber.
Fiber-Rich Foods: Fiber adds bulk to stool, helps it hold water, and facilitates its movement through the colon. Both soluble fiber (found in whole grains, apples, bananas, and cooked vegetables) and insoluble fiber (found in the skins of fruits and vegetables, leafy greens, and nuts) are beneficial. Certain foods, like prunes and dragonfruit, are particularly effective because they contain natural agents that draw fluid into the gut. It is important to increase fiber intake gradually and to avoid excessive amounts, which can cause cramping, gas, and even worsen constipation if fluid intake is not adequate.
Regular Physical Activity: Regular exercise helps improve the movement of stool through the colon. A doctor may encourage patients to exercise most days of the week, as movement helps to stimulate bowel motility.
Good Bowel Habits: It is important to go to the toilet when you feel the urge to defecate and not to delay. Conversely, it is equally important to avoid straining if you do not feel the urge. A simple yet effective tip is to place your feet on a short stool while seated on the toilet, which can help to straighten the anorectal junction and make it easier to pass a bowel movement. It is also important to remember that having a bowel movement every single day is not a requirement for good health. Up to three days between bowel movements is considered normal as long as there is no discomfort or difficulty with evacuation.

5.2. Understanding Medications

When lifestyle changes are not enough, medications can be introduced, usually starting with over-the-counter options. A doctor will determine the most appropriate medication based on the specific type of constipation a person has and the severity of their symptoms.

First-line medications are typically over-the-counter options that are generally safe and effective. These include bulk-forming agents, which are essentially fiber supplements that absorb water to increase stool bulk and make it easier to pass. It is important to drink plenty of water with these to prevent a blockage. Another type is osmotic laxatives, which work by drawing water into the intestines to soften the stool and help it move along. These are generally safe for long-term use.
Second-line or short-term medications are used when the first-line options are insufficient. Stimulant laxatives work by causing the intestinal walls to contract, which forces stool to move. While there were past concerns about long-term use, studies have not established a link to nerve damage. In cases of rectal impaction or when other treatments fail, a doctor may recommend enemas or suppositories.
Prescription-only medications are reserved for difficult-to-treat cases that have not responded to a structured trial of conventional laxatives. These include intestinal secretagogues, which increase fluid secretion in the gut to improve stool passage, and serotonin agonists, which promote bowel motility. It is important to know that these prescription medications are considerably more expensive than standard laxatives. For this reason, a doctor will typically prioritize the cost-effective and proven first-line options before moving to these newer agents. The detailed table of medications from the original medical guide has been removed to simplify this information and to emphasize that the choice of medication should always be a discussion between a patient and a doctor.

6. When You Must See a Doctor

While primary care is well-suited to managing chronic constipation, there are specific "red flag" symptoms that necessitate a prompt and urgent consultation with a doctor or specialist. These symptoms may suggest a more serious underlying medical condition that requires immediate investigation.

You must see a doctor immediately if you experience any of the following:

New onset or worsening of severe constipation
A sudden or acute change in your bowel habits
An unexplained inability to pass stool and gas
Unexplained weight loss
Rectal bleeding or blood in the stool
Anemia
Persistent abdominal pain, vomiting, or abdominal distension
A family history of colon or rectal cancer

It is crucial to understand that these warning signs should not be ignored or simply treated with more laxatives. They are a mandate for urgent diagnostic workup, which may include tests like a colonoscopy or imaging.

In the absence of these serious "red flag" symptoms, a specialist referral may be indicated when a person's symptoms are persistent and bothersome despite a structured trial of lifestyle changes and first-line medications. These cases may require specialized investigations to rule out slow transit constipation or obstructed defecation, which may then be managed with more advanced treatments or, in some cases, surgery.

7. Expert Help for Complex Cases

For complex or difficult-to-treat cases of constipation, particularly those involving difficulty with bowel emptying or pelvic floor disorders, specialized multidisciplinary care is often the best approach. A multidisciplinary team brings together experts from various fields to provide comprehensive and integrated care that goes beyond a single, siloed consultation.

The SGH Pelvic Floor Disorders Service is a prime example of such an integrated approach. This service specializes in the diagnosis and management of a wide range of pelvic floor conditions, including chtonic constipation. By bringing together specialists from fields such as Colorectal Surgery, Gynaecology, Urology and Gastroenterology the service creates a "one-stop platform" for patients to receive holistic care, with weekly clinic sessions to address patients’ needs. The complex nature of these conditions often requires the expertise of a diverse team, and an integrated approach is far superior to seeing individual specialists in sequence.

Ultimately, the first point of contact for a patient is their general practitioner (GP). A GP plays a crucial role in normalizing discussions about bowel and pelvic health. By being aware of and referring to specialized centers when necessary, a doctor not only provides access to expert care but also implicitly validates the patient's concerns, helping to overcome the psychological barriers that often lead to delayed treatment and prolonged suffering.

8. Key Takeaways

Constipation is a common but often underestimated condition that can significantly impact a person's quality of life. This guide has explained that:

Constipation is a real medical condition that affects many people, especially women, and should not be dismissed or brushed off.
Diagnosis involves more than just how often a person has a bowel movement; it is also about the quality and pattern of defecation. Tools like the Bristol Stool Form Scale can help facilitate this discussion with a doctor.
Chronic constipation has different types, from the most common type related to lifestyle, to more complex kinds that involve a "slow-moving" gut or a "blocked-up" feeling due to muscle or physical issues.
Management begins with a structured approach, starting with fundamental changes to diet and lifestyle. If these are not sufficient, a doctor can recommend medications in a stepwise manner.
It is critical to be aware of "red flag" symptoms, such as unexplained weight loss or rectal bleeding, that require immediate medical attention to rule out a serious underlying condition.
For complex or chronic cases, a multidisciplinary team of specialists can provide comprehensive and integrated care.

Constipation is a manageable condition, and people should feel empowered to discuss their symptoms openly with a doctor to find a personalized and effective solution, enhancing their overall well-being and quality of life.