If you just started dancing, and singing Salt-n-Pepa in you head, I love you. Already, I digress.
Abdominal pain: So annoying, so challenging, so Google-able. The truth is that there are many possible causes for abdominal pain that can be caused by every pelvic organ from the bladder, to the uterus, to the ovaries, to the bowels. It is very hard to know just by guessing what the cause is of an individual’s pelvic pain or discomfort. I want to focus on commonly misunderstood one: Constipation.
People classically think of constipation as significant, hardworking, what-is-going-on-in-that-bathroom straining, or not having a bowel movement for days at a time. I need to pause right here. A bowel movement is the act of defecation AND the feces discharged during said act. The first time I heard the work defecate was in the song Ready Or Not by The Fugees. Lauryn Hill was the TRUTH. She said,
“I can do what you do, easy, BELIEVE ME
Frontin’ n!&&@$ give me hee-bee-gee-bees
So while you’re imitating Al Capone
I’ll be Nina Simone
And defacating on your microphone.
WHAT!?!? I loved that! 1996 at its finest. Anyway, back to the point. I can’t tell you how many times I have questioned a patient about her bowel movements and I am stopped in my tracks because she doesn’t know what I am referring to. Can you imagine speaking to a grown adult as a physician and trying to figure out the least patronizing, or matronizing way to say defecate? “How often do you… um… poop?” I’m sure that not a lot of those patients are reading this post, but they should. Some of you are 😉
Constipation is NOT just the frequency and difficulty of your bowel movements. Plenty of people are plagued with chronic constipation who have bowel movements every day that they don’t consider difficult. The Rome Criteria, from Thomas et al 1999 define constipation as at least 12 weeks, which do not need to be consecutive, in the preceding 12 months, with 2 or more of the following symptoms in an adult:
- Less than 3 bowel movements per week
- Straining during greater than 25% of defecations
- Lumpy of hard stools in greater than 25% of defecations
- Sensation of incomplete evacuation in greater than 25% of defecations
- Manual maneuvers to facilitate greater than 25% of defecations
- Loose stools are not present, and there are insufficient criteria for irritable bowel syndrome
I wrote about this subject in my book about all things female because I often care for women who complain of abdominal pain. Sometimes the uterus or the ovaries are to blame, and sometimes they are innocent. The bladder is down there, the appendix, and the small and large intestines. An acute diarrhea or constipation in someone who normally has regular bowel movements is an easy diagnosis to work with. Someone with a chronic constipation can be a little harder to diagnose and treat.
If you have ever had a drain that was clogged in your house, you know that the symptoms arise gradually and worsen over time. Sometimes that sudden pain in the person with chronic constipation is trapped gas, like a claustrophobic person in a club full of bouncers. They might just scream, and gas-screams hurt. A person with chronic constipation can also have bouts of diarrhea as the more liquid stool sneaks past the larger bulky stool.
Sometimes alternating diarrhea and constipation can be a symptom of irritable bowel syndrome, or IBS. Sometimes inflammatory bowel disorders or other digestive disorders may be to blame, like Crohn’s disease or Ulcerative Colitis. The take home point here is that the diagnosis of constipation can be bigger than your bulkiest stool.
If you suspect that you may be dealing with chronic constipation, take an inventory of your diet and water intake. Make sure you include a large plant-based component in your diet, and you drink at least 50-60 ounces of water daily. Try a daily dose of an osmotic laxative for one week, like Miralax. If you see an improvement and think you have reset your system, great. If you don’t, you may need to see your friendly neighborhood gastroenterologist or internal medicine physician for a more in depth evaluation and recommendations.
The myth buster in me couldn’t leave this topic without including a section of commonly constipation misconceptions. Okay, okay, it is my gastroenterologist husband, Dr. Ed McDonald, who put me on/made me woke (can I use “woke” like that?) to these constipation myths. He busted out with a phrase that I am going to steal, “you can’t drink your way out of constipation.” That means, contrary to the belief that constipation is a result of too little water intake, unless a person is substantially dehydrated, you won’t change the frequency or consistency of your bowel movements by going from drinking 50 ounces of water per day to 80 ounces of water per day. Who knew?
From the American Journal of Gastroenterology, the AJG, and evidence based, peer reviewed, no bull s#!+ journal (you can’t believe EVERYTHING you read, but peer reviewed journals are very trustworthy), here is a summary of myths. I am including by own constipating translator for clarity.
- There is no evidence to support the theory that diseases may arise via “autointoxication,” whereby poisonous substances from stools within the colon are absorbed.
- Translation: Your colon detox’s have no scientific support. Detox yourself by having a healthy diet low in processed foods, not by “cleansing” your dirty a$$ colon. Your dirty a$$ colon, is supposed to be dirty. (I just like saying dirty a$$ in reference to the colon. I don’t even curse though.)
- During pregnancy they may play a role in slowing gut transit.
- Translation: Your baby may be slowing you down in more ways than one.
- Hypothyroidism can cause constipation, but among patients presenting with constipation, hypothyroidism is rare.
- Translation: If you have a low functioning thyroid, you may find yourself more often constipated. The opposite, however, is unlikely to be true. If you are often constipated, there is a low chance that it is due to low functioning thyroid.
- A diet poor in fiber should not be assumed to be the cause of chronic constipation. Some patients may be helped by a fiber-rich diet but many patients with more severe constipation get worse symptoms when increasing dietary fiber intake.
- Stay tuned for more on fiber below.
- There is no evidence that constipation can successfully be treated by increasing fluid intake unless there is evidence of dehydration.
- I just said that, based on this article though. Not an original thought.
- In the elderly constipation may correlate with decreased physical activity, but many co-factors are likely to play a role. Intervention programs to increase physical activity as part of a broad rehabilitation program may help.
- Tell an elderly friend or care giver that increased activity can help their bowel function.
- It is unlikely that stimulant laxatives at recommended doses are harmful to the colon. A proportion of patients with chronic constipation is dependent of laxatives to achieve satisfactory bowel function, but this is not the result of prior laxative intake. Tolerance to stimulant laxatives is uncommon. There is no indication for the occurrence of “rebound constipation” after stopping laxative intake. While laxatives may be misused, there is no potential for addiction.
- Translation: Stimulant laxatives of the Ex-Lax-like persuasion are unlikely to cause harm or lead to addiction and dependence. That doesn’t mean throw caution to the wind. Work with your physician on the best possible regimen if you are in need of laxatives frequently.
All fiber is not created equally.
- “A number of contrarian studies had suggested that popular sources of dietary fiber, such as bran, cereals, vegetables, and fruits, might actually aggravate symptoms in IBS [Irritable Bowel Syndrome] as these foods also contain large amounts of FODMAPs (e.g., fructans, excess fructose, galacto-oligosaccharide, and sugar polyols) (124). The symptoms that appeared to be aggravated most commonly were flatulence, bloating, and abdominal pain.”
- Message: Beware of certain types of fiber if you find yourself with those adverse symptoms.
- “When fiber is recommended for FGIDs [functional gastrointestinal disorders], use of a soluble supplement such as ispaghula/psyllium is best supported by the available evidence. In constipated patients, it can be helpful for pre-existing hard stool to be eliminated (e.g., with an osmotic laxative) before initiating fiber therapy. Fiber should be started at a nominal dose and slowly titrated up as tolerated over the course of weeks to a target dose of 20–30 g of total dietary and supplementary fiber per day.”
- Translation, if your stools are generally very hard, start with a Miralax-like laxative, which pulls more water into your stool, then follow it up with a psyllium containing fiber supplement (like Metamucil).
My conclusion to this long a$$ (couldn’t help it) post: Include your friendly neighborhood gastroenterologist if you suspect constipation as the cause of your abdominal pain or discomfort and these initial measures don’t improve it.
I could not end a post about constipation without quoting one of the greats. Andre 3000 said it best in his song entitled Roses: “I know you like to think your s#!+ don’t stank, but lean a little bit closer and see that roses really smell like boo-boo-oo.”