Dr Mark Wong, a general surgeon with special interests in minimally invasive (laparoscopic) and robotic surgery for cancer and bowel disorders, gives us the facts on constipation and how to treat it.
You know you have constipation when bowel movements become difficult or less frequent than what you are normally used to. Normal bowel movements can range anywhere between 3 movements per day to once every 3 days. In general, when bowel movement stops for more than 3 days, stools become harder and more difficult to pass. You may also experience abdominal bloating, cramps, or even vomiting in more serious cases.
Although definitions vary, you will generally be diagnosed with constipation if you have 2 or fewer bowel movements in a week, or if you have had 2 or more of the following symptoms for at least 3 months:
Constipation is one of the most common digestive complaints worldwide. In the USA alone, constipation affects 2% of the adult population, accounting for up to 2.5 million doctor visits annually and medication worth millions of dollars. A local study published in the Singapore Medical Journal in 2000 sets the incident rate in Singapore way above at about 7.3% in those aged 16 years and above.
There are numerous causes of constipation, and some patients may have more than one contributing cause. Laxatives may not always be the solution and in some cases are not required at all! The causes of constipation may include:
Fortunately, the vast majority of patients can be managed conservatively, and the doctor's role is to identify more serious causes that might require surgical treatment, such has colorectal cancer.
Although not usually life-threatening, constipation can nonetheless be uncomfortable and frustrating. But when the cause isn't apparent and the causes above have been ruled out, you may be suffering from functional constipation, a silent culprit!
A significant proportion (up to 30%) of patients with constipation actually fall into this category, classically not having any obvious underlying illness to explain their symptoms. Unfortunately, many of them are misdiagnosed and become chronically dependent on laxatives.
In fact, they could be suffering from 1 of 2 types of functional constipation:
These problems are often under-diagnosed, difficult to manage, or mismanaged due to a lack of understanding of these conditions. As a result, such patients seldom get better or have to use laxatives all their lives, severely affecting their quality of life.
Most people do not need extensive testing for the occasional episode of constipation. However, any of the following symptoms could point to a more serious cause, like colorectal cancer, so you should see your doctor for a diagnosis:
The doctor will conduct tests to rule out life-threatening causes like cancer, then help the patient to manage their constipation and avoid complications caused by long-term constipation.
When the cause of your constipation cannot be explained by dietary changes or other less serious causes, your doctor will want to do some tests to establish the cause.
These tests include:
Further specialised tests commonly performed by colorectal specialists include:
Treatment has to be individualised and depends on the cause and severity of constipation. Whenever possible, treatment is directed at the underlying disease (eg. thyroid hormones for hypothyroidism, surgery for colorectal cancer). When treating constipation, the goal is to achieve at least 1 bowel movement of formed stools every 1 – 3 days without needing to strain.
Treatment begins with dietary advice to moderate fibre intake (avoid excessive fibre as this can cause constipation as well!) and ensure adequate fluid intake. Exercise is also important. Laxatives are also useful and should be tailored for each patient. You may be prescribed different kinds of laxatives to achieve different outcomes.
For functional causes mentioned above, more than one type of treatment may be required to achieve the best outcomes, as defecation (passing stools) relies on a complex chain of coordinated events.
Fortunately, the majority of patients will benefit from conservative measures such as dietary modification and tailored medications. In some cases, specific pelvic floor rehabilitation exercises (anorectal biofeedback) are required to correct pelvic floor muscle incoordination. However, when the above measures fail, specialised surgery may be the only means of correcting anatomical abnormalities (eg. prolapse – when an organ slips or drops from its position) to relieve a patient's symptoms and improve their quality of life.
Piles themselves are normal structures in the anus and are needed for continence (the ability to control faecal discharge and prevent leakage).
The term haemorrhoid or piles has been mis-used. When they are swollen, painful or bleeding, they should be termed haemorrhoidal disease (swollen piles) due to their abnormal enlarged state. If you have prolonged constipation, piles can enlarge and swell due to the excessive straining or hard stools causing damage, hence resulting in pain, swelling, bleeding or a combination of these symptoms.
The aforementioned symptoms of enlarged piles often clear up by themselves if the constipation stops early or medication is taken promptly. Keep your stools formed (ie. of good consistency, not hard or loose) and regular, so that you don't strain when going to the toilet. Moderate the amount of fibre in your diet and drink plenty of water to ensure your stools are formed.
However, if constipation continues to irritate your piles, you may need medication, failing which you may need surgery to remove the swollen portions of your haemorrhoids.
Piles can be surgically removed through a procedure called haemorrhoidectomy. This is an operation to remove haemorrhoids if minor treatments like rubber-band ligations do not work. Performed under general anaesthesia, the swollen parts are removed using a variety of methods depending on the symptoms and severity. This can be done as day surgery where patients can discharge on the same day.