Would you count constipation as a serious health issue? Or would you let it build up, too embarrassed to say the words out loud: I can’t poo.
Our bowels are essential to our overall good health and wellbeing but nearly half of us wouldn’t think it’s worth seeking medical help if we were constipated. Some of us would wait weeks before addressing it, yet the issue is so prolific, a Bowel Interest Group report estimates one in seven adults are impacted.
Constipation cost the NHS £162m in 2017-18, the same report revealed, of which £71m was caused by unplanned, avoidable emergency admissions and £91m was spent on prescription laxatives. In the same year, 71,430 people in England were admitted to hospital with constipation – that’s equivalent to 196 people a day – with women accounting for about 60% of admissions.
It’s easy to jump to conclusions, such as blaming a Western diet, but specialists in this area of medicine say there are multiple reasons why our nation is feeling the strain. So how do we get to the bottom of it?
One challenge is the confusion over what actually constitutes constipation, says Dr Eirini Dimidi, postdoctoral research associate in the Department of Nutritional Sciences at King’s College London. In June 2019, Dr Dimidi’s research found one in three patients who deemed themselves to be “healthy” were, in fact, clinically constipated – they just didn’t recognise it.
This prompted Dr Dimidi and her team of researchers to call for a new medical definition of the issue based around six key symptoms: abdominal discomfort, pain and bloating; rectal discomfort; infrequent bowel movements and hard stools; sensory dysfunction (not getting the typical sensation of needing a poo); flatulence and bloating; and faecal incontinence.
But why has the nation’s problem with its bowels reached this point? Dr Anton Emmanuel, consultant gastroenterologist at University College Hospital, suggests the silence surrounding constipation compounds it. And the stats back him up: nearly one in five people feel embarrassed talking to their GP about constipation, according to the Bowel Interest Group’s report.
“It’s a silent symptom – something that’s slightly embarrassing, a bit of a taboo thing,” says Dr Emmanuel. “We don’t talk about it much at all and the problem grows. Rather than something that’s nipped in the bud and dealt with sooner rather than later, it becomes a more chronic issue.”
Chronic constipation is the label given when symptoms persist for several weeks or longer. In some cases, if people don’t seek help, it can go on for years and, says Dr Dimidi, be linked to haemorrhoids or a higher risk of bowel cancer.
““We don’t talk about it much and the problem grows. Rather than something that’s nipped in the bud, it becomes a more chronic issue.””
Historically, doctors “haven’t been very interested” in constipation issues, says Dr Emmanuel: “They would just prescribe laxatives and say: ‘Oh you’ll be fine.’” Nor does the National Institute for Health And Care Excellence (NICE) have any guidelines on the diagnosis of constipation in adults. A spokesperson told HuffPost UK it’s not an issue that has been referred to NICE by the Department of Health and Social Care.
In our fast-paced society, is it the case that some of us simply aren’t finding time to poo? Lifestyle factors do play a part in constipation, says Dr Emmanuel, whether that’s physical activity, toileting behaviours or stress levels. In fact, he suggests 10-15% of chronic constipation cases are caused by behaviours we can change – such as not leaving your desk to go to the loo because you’re busy, or eating on-the-go without allowing time for your food to digest.
And of course, our lifestyle includes the food we do (or don’t) eat. It’s not clear whether our diet can directly cause constipation but it definitely plays a part, says Dr Dimidi. “Most studies show an association between a low fibre intake and higher rates of constipation, but whether there’s a causal relationship is unclear,” she says, adding that increasing fibre intake does have impact.
This is why the NHS advises those who are struggling to poo to increase the levels of fibre they consume – the recommended amount is 30g per day for adults – yet women, on average, have 17.2g a day and men 20.1g a day.
And sometimes, constipation isn’t linked to diet at all. Women, particularly those who have given birth, are twice as likely as men to struggle with constipation because of structural abnormalities. “There’s a tissue which separates the rectum from the vagina, and that tissue weakens,” explains Dr Dimidi.
For both men and women, certain types of medication also play their part – specifically antidepressants, opioids, calcium-channel blockers, anticholinergics, and allergy medication. Dr Braden Kuo, gastroenterologist at Massachusetts General Hospital, previously told Harvard Health: “A lot of antidepressants that treat the nerve endings in the brain also affect nerve endings in the gut. That can lead to significant side effects.”
Bowel issues can be unavoidable for people with nerve-related conditions like multiple sclerosis (MS), spina bifida or Parkinson’s. Roughly 68% of people with MS will develop bowel problems like chronic constipation and faecal incontinence. Underactive thyroid and coeliac disease can also cause bowel issues and, very rarely, those with bowel polyps or tumours will suffer too.
It can be hugely debilitating. Karen, 27, has MS and said constipation makes her feel “disgusted” with herself. “I can go for maybe 14 days without going to the toilet once, and I mean, it’s indescribable how that makes you feel because you feel completely exhausted all the time and you just feel unconfident,” she told researchers for the Bowel Interest Group report.
What can we do if we’re having bowel issues – or how can we get better at noticing them? Dr Emmanuel suggests people should be going to the toilet anywhere between three times a day to every third day – it’s not clear-cut. For some, constipation might show in hard stools, for others it could mean infrequency, bloating, straining or wind.
“There are people who open their bowels once a day and it’s a struggle for them, and they are constipated,” he says. “It’s not only about frequency and people shouldn’t get too bogged down with that, nor the consistency. We’re more concerned it isn’t taking too long to do it – that it isn’t interfering with quality of life.”
Exercise can help to get your bowels moving, as can making a conscious effort to improve your toilet routine. “Keep to a regular time and place and give yourself plenty of time to use the toilet,” the NHS advises. “Don’t delay if you feel the urge to poo.”
For those who are struggling, Dr Emmanuel says he tells patients to try resting their feet on a low stool, box or phone book while going to the toilet, raising their knees above the hips and leaning slightly forward. “Use the abdominal muscles to help move [the poo] down,” he advises. “Don’t grit your teeth or strain your neck, you need to push down with your abdominal muscles.”
“Keep to a regular time and place and give yourself plenty of time to use the toilet.”
If you’re following all these steps with your diet, physical activity and loo routine but still struggling to poo, it’s essential to speak to your GP. Once you’ve overcome the embarrassment of talking about poo – because come on, everyone does it! – you can discuss with professionals what the underlying causes may be.
A diagnosis is the first step. There are drugs available on prescription, many newly developed in the last decade. You may be suggested a suitable laxative – these usually work within three days but should only be used for a short time. Follow your GP’s guidance on when, and how often, to take any medication.
“People often are misusing laxatives,” says Dr Emmanuel. “They’re often using the wrong one or the wrong dose or the wrong time. A lot of the time people will need laxatives but they’ll need this particular one taken in this particular way.”
Other treatment options include surgery, biofeedback – a behavioural treatment that helps people use the bathroom properly – and pelvic floor therapies, which improve the bowel’s ability to empty. There are also non-laxative drugs and wash-out systems available. “If you have been constipated for a long time, be prepared to consult with your GP,” says Dr Emmanuel, who believes awareness is improving among the medical profession. “They are better informed than they used to be about this. Don’t ignore your symptoms and sit on your hands.”
Correction: This article previously stated 271,430 people in England were admitted to hospital with constipation due to a typo in the 2019 Cost of Constipation report. We have updated the piece to reflect the correct statistic.