Welcome to episode 33 of the Inside Knowledge. I’m Anna Mapson. Today’s episode all about causes of constipation, or IBS-C, as it’s sometimes referred to.
This is a big challenge for a lot of my clients.
What are the signs of constipation?
I tend to have a lot of constipation clients, people who have really struggled for years and years with slow digestion, painful bowel movements, haemorrhoids, bloating, irritation when you eat certain foods,
This is quite common presentation and pattern in constipation. I thought I’ll just start explaining whether it’s IBS or the doctors might consider it functional constipation.
IBS-C or functional constipation?
Functional gut disorders are slightly different from IBS, but really the only main difference is that In IBS, you get a lot of abdominal pain.
So if you’ve had a diagnosis of IBS-C, that’s constipation predominant IBS, then you’re more likely to have recurrent abdominal pain. But, apart from that, the definitions are pretty much similar.
You probably have:
- less than three bowel movements per week.
- And it involves straining, or hard stools more than quarter of the time you go.
- And also that sense of incomplete evacuation, so a sense of like a blockage.
That’s really common as well.
A helping hand
And also what is common, but really not talked about a lot is using your hand or your finger to help you extract the poo out. This is something that can happen when it is so hard, but people don’t like to talk about it because it sounds a bit embarrassing.
However, I just want to reassure you that, if that has happened to you, and you’ve had to do that. It’s not unheard of, and it is actually quite common. In fact, It’s part of the diagnostic criteria to the extent that, you know, it’s recognised that a lot of people will have that problem.
Stool consistency in constipation
So if you think back to episode 1 where I talked about normal digestion and what we’re aiming for with a normal bowel movement. The difference with constipation is that you’ve got type 1 or type 2. Either very hard, small, pebbly poos or very large, hard, poo that is difficult to pass.
Those are both signs of constipation and also the frequency. So less than three times a week is considered constipated.
Constipated but pooing every day
Now, if you’re going only every other day, you could still be constipated. And that’s the other thing is you can have constipation and be passing poo every day, but still be constipated because they’re small pebbles. Just a little bit each day. That means you’re still constipated. It doesn’t only apply to people who are not going for days and days.
Different types of constipation
There’s three kind of categories, that I divide constipation up into.
- There’s a normal transit time, that food is passing through you, you know, roughly 24, 36 hours. But, it is getting to that point that it’s straining, you’re maybe having a lot of problems with bloating, a lot of abdominal pain, discomfort, and very hard stools. So, It might be coming through you at the correct speed. But when it gets to going to the toilet, it’s difficult,
- You might have a really slow transit time, and that could be down to a couple of things. Slow motility due to the smooth muscles of your intestine and your bowel working slowly, so they’re not pushing things through.
- And then a third type is pelvic floor dysfunction. So this is where potentially your muscles are not cooperating. They’re not coordinated to open and close at the same time. There’s a pelvic floor basket that holds you from hip to hip and holds everything up. If these muscles don’t all open and close at the right time and let the stool out, even when you get an urge to go, that can lead to you being constipated, and it can lead to reduced sensation of the urge to want to go, and sometimes it’s, that you just can’t get it out. So, a number of ways that you can be constipated.
It’s a number of different types that helps in a way, because we’re trying to see how to fix it, and we need to really understand what these different types are.
Constipation red flags to be aware of
Before I jump into any more detail on this, just to flag some red flags with constipation. Some things that you should look out for if you feel like you’ve got constipation, you haven’t seen a doctor about it.
- One would be unexplained weight loss. If you are losing weight unintentionally,
- if you’re seeing a lot of blood in the stool. I will come back to this because haemorrhoids are very common with people who’ve got IBS and have been straining frequently. So it’s not uncommon to see fresh red blood, but if you see any dark kind of coffee granule type black blood. If you see frequent amounts of high bleeding, then these should all definitely be checked out by a doctor.
- If you’ve got unexplained iron deficiency anaemia, then also go to your doctor and make sure that they know that you’ve got constipation problems.
- If this suddenly started after you’re age 50, this is a red flag.
- The significant pain. So I’m talking about not feeling just discomfort and a bit upset, and bloated, but significant pain where you’re needing to take painkillers. You’re needing to lie down. Again, this should be, checked out by your doctor
- also if you have a family history or you have your own history of colon cancer or IBD.
These are all red flags for someone who suffers with constipation. Just make sure you’ve been to your doctor and get them checked out.
Digestion in the large intestine
Food travels obviously from your mouth all the way through your stomach. Stomach, small intestine, and then the large intestine. During processing through the small intestine, a majority of absorption happens there. That’s where we’re getting all the goodness out of our food, and it’s really a lot of waste that gets to the large intestine.
However, There’s a lot of key activity that happens in the large intestine as well that’s really important. One of them is fermentation of the fibres by our gut bacteria. You’ll have heard me talk a lot about gut bacteria if you’re a regular listener to the podcast.
Fermentation of fibre in the large intestine
The large undigestible fibres that reach the gut bacteria from our food, so from vegetables, whole grains, fruits, pulses, nuts and seeds.
These are all really important to eat regularly because if we’re eating a diverse set of fibres, it’s going to feed a diverse set of gut bacteria and that is good. Good for our immune system, for our general overall well being and regular bowel movements. The other thing that also happens in the large intestine is there is some absorption of nutrients but really critically water is reabsorbed.
Water reabsorption in the large intestine can cause constipation
I think it’s quite astounding that up to one to two litres of water or liquid is reabsorbed from the stool content back into the body. Now this is key when you hear people say, ‘oh have you been drinking enough water’ when you’re constipated?
And one of the reasons is if your body doesn’t have enough water in the tissues, it will start reabsorbing more and more from the large intestine and that will lead you to have a hard stool.
So we want to try and make sure we’ve got sufficient water from drinking so that we’re not reabsorbing lots of water in the large intestine.
Gut motility as a cause of constipation
And then the other thing that’s really happening a lot in the large intestine that is important for constipation and regular bowel movements is the peristalsis. That’s the movement of food through the large intestine as it’s moving up, and across, and down across around our tummy, ready to be excreted.
This peristalsis, this movement, is affected by eating.
The gastrocolic reflex
So when we eat certain foods, or when we eat a meal, the gastrocolic reflex kicks in. That can sometimes cause you to want to go to the toilet. There’s something called 5-HT, which is, a precursor to serotonin, that also influences motility. Then our gut microbes and the gases that they’re producing can also affect the speed of transit through the large intestine.
I’ll come back to this in the next episode, but that’s particularly methane. There is a type of microbe that can produce methane gas and it is known to slow down the transit time. the more methane gas that you have. So that is also something to be aware of, that gut health is key and making sure you’ve got a good mix of microbes can help you protect against constipation, but also to treat it.
If we think about now the causes of constipation, I’m going to start off with a common one, which is dehydration.
Dehydration can cause constipation
It’s really important that you are drinking enough water. And especially during the winter. It can be hard to meet those fluid targets because it’s cold. And you don’t want to drink cold water. You can drink hot water. You can drink herb teas. And they do count towards your fluid intake.
So aim for around 2 litres of water a day and try and space it out throughout the day as well. Not just downing 2 pints of water in the middle of the day and then not drinking for the rest of the day. If you’re worried about fluid intake and needing a wee before bed, then definitely try to preload your fluid intake. Drink as much as you can in the morning. Try and get your liquid intake then.
Low fibre diet as a cause of constipation
In terms of dietary patterns that typically cause the most constipation, it’s a low fibre, high fat diet. Fibre is known to promote regular bowel movements by adding in the mix of different fibres.
So you’ve got bulk forming fibre which helps you create an urge to want to go as well as soluble fibres that’s more gel forming that helps to create a softer stool that creates a nice easy motion through your gut.
So low fibre diet is going to put you at danger of constipation. Also a very high fat diet, because we know that when you’re eating very high fat foods, it slows the body down. If you listen to my episode on fats, episode 23, that explains a lot more about how different fats affect our digestion. Generally we are known to slow down transit time when we have high fat foods because the body wants to try and get as much energy from it as possible.
Undereating can cause constipation
The other episode that will be really helpful for you is listening to episode 24 about abnormal eating patterns because under eating is a common cause of constipation and people are surprised by this. Not eating enough food slows down your transit time. And can lead you to be more constipated.
I know that the majority of people who come and see me are not eating enough food because you’re worried about the symptoms.
I completely understand you’re worried about the bloating, the pain, the gas. However, unless you’re having three meals a day, you are going to struggle to get enough movement coming through to kick start that process.
Those are the main sort of dietary things that are, oh, I say ‘easy to adjust’ or easy to address. They’re not necessarily easy because if you’re eating a low fibre, high fat diet now, it could be massively difficult to change to a high fibre, low fat diet. However, those are the dietary triggers that you can think about.
The gut-brain connection can slow down gut transit time
Then there’s also like another whole section around the gut brain connection. Because stress, anxiety, and Psychological distress, really, just can influence your gut through the gut brain connection. The vagus nerve that travels from your brain into your digestive system, can transmit a lot about how we’re feeling and can cause physical symptoms.
So it can definitely create this sensation of holding on. And I’ve worked with quite a few clients recently who have noted throughout our work and just other times they’ve been in therapy, that they may have a predisposition to kind of emotionally hold on to things and not want to let go.
They’re afraid of losing control, they’re afraid of what happens when you stop, so they’re always ‘busy busy busy’. These things, although it might sound a bit odd, they can actually really contribute to someone’s bowel habits and constipation.
Medical conditions linked to constipation
There are a number of other conditions that also affect constipation.
For example, Parkinson’s, multiple sclerosis, these are neurological conditions, but also there’s Ehlers Danlos Syndrome. Which is where the smooth muscles of your body don’t work as effectively. And this can just lead to reduction in the movement of the gut. And often people who have this are hypermobile.
Then other medication that may cause constipation includes morphine.
So we know that morphine slows down the gut. Also things like codeine. So they’re two painkillers. Some antidepressants and some blood pressure medication may also be affecting constipation.
Think about when your symptoms started in relation to other medication that you’re taking. Of course, stopping any medication should only be done after a conversation with a doctor.
If you feel like there’s a link, go back and speak to your doctor and check.
Don’t ignore the urge to poo
Then the last couple of things, that can also slow down our gut transit time include, ignoring the urge to go. So this is actually something people don’t think about much. If you’re one of those people who only likes to go to the toilet in your own home. If you get the urge to go outside the house you just will ignore it and you wouldn’t be able to go.
Do consider revisiting that because if you constantly ignore the messages from your gut up to your brain saying, I need to go, I need to go to the toilet. What happens is those messages become a little bit ignored. And so you can sometimes lose that urge.
So you don’t feel a sensation there where you should.
So it’s really important to go when you need to.
Sedentary lifestyle can contribute to a slow gut
Other things that you might not really think are connected is like having a very sedentary lifestyle So for example people who are bed bound in hospital if you’ve Just don’t move very much.
You sit at your desk all day, and you maybe just watching telly in the evening, and you just don’t do much physical activity. That can also lead to constipation.
Hormones affecting IBS-C
And then finally, hormones. These can also affect, gut transit time, so a low functioning thyroid, because the thyroid is involved in the metabolism and the speed of a lot of processes in our body.
And so when we’re low in hypothyroid, you might find you get more constipation.
Also, just before your period, sometimes people get a week of constipation or constipation becomes worse. Just before the period. That’s down to progesterone.
Why women get constipated more than men
Actually, on that note, women tend to experience constipation twice as much as men.
I think the ratio is 2.2:1, so it’s much more likely that women will be constipated. However, obviously it does affect men as well.
It’s around that slowing down of the gut to prepare for a pregnancy, to extract as much nutrients out of your food as possible. You can listen to episode 7 for more information about periods and IBS, and how hormones may be affecting your digestion.
But there are also a couple of other factors why women may be experiencing constipation more than men.
Sitting correctly on the toilet
One of them is really about the positioning on the toilet. So sometimes we need to get a really good position on the toilet to relax your pelvic floor. Now when you’re learning to go to the toilet, little boys, when they’re sitting down, they put them right far back on the toilet in order that they don’t wee all over the floor.
So when they’re sitting down, they want to put the boys further back. But actually, girls sometimes will balance quite near the front of the toilet and so maybe don’t have the best positioning.
So you might learn to sit differently on the toilet. I’ll come back to that in a moment.
Pelvic floor strength is needed for regular poo
Also, women tend to have a weaker pelvic floor. Or damage from childbirth, tears, prolapses. The impact of fluctuating oestrogen has also got an impact on the strength of the pelvic floor.
Sometimes during menopause this can change and may be contributing to symptoms like constipation.
So there’s a lot of reasons why women might be getting constipation more than men.
Now, our pelvic floor muscles need to open and close and relax and constrict at certain times to allow the poo to come out.
They also need to respond to the urge to want to go. If these pelvic floor muscles don’t contract and coordinate at the same time with the surrounding muscles and the nerves, then it’s difficult to produce a normal bowel movement.
So there is a type of constipation called dysenergic defecation. This is where the constipation is down to pelvic health problems. It’s not necessarily anything to do with your diet. With your gut bacteria, with anything else. It’s really down to the muscles and how they’re coordinating together.
Working with a pelvic health physio
A pelvic health physiotherapist can be extremely useful in this case. Particularly, they look at testing your strength and weaknesses of the anal muscles. They will get you to do some biofeedback. Just asking you to clench and to feel things.
And it is important to get this treated and there are things that you can do. But it does need to be a very specific pelvic health trained physiotherapist, not just any physiotherapist.
Is your diarrhoea actually caused by constipation?
Sometimes you have constipation and then all of a sudden you’ll just get diarrhoea.
And this can be down to what’s called overflow diarrhoea. So it’s where you have a very, hard impacted bit of stool that is literally blocking your intestines. Then the loose liquid watery diarrhoea will spill over that and come straight through you.
So sometimes this is why people get confused and think oh my IBS is all over the place. But actually It is constipation that is just overflowing in diarrhoea.
That’s the final type of constipation that I wanted to explain in this episode. I am going to do part two which will cover laxatives. It will cover a diet for IBS-C, as well as some supplements that can be helpful.
So stay tuned for part two.