For women and the elderly, constipation may be significant enough to cause them to seek medical attention. It is one of the most common gastrointestinal complaints and it has been estimated that at least 4.5 million people, two thirds of them women, suffer from constipation that is frequent and problematic enough to require medical attention.
Because of the higher incidence in women, health care practitioners who specialize in women's health play a key role in evaluation and management of constipation. Although a seemingly simple problem, individuals with chronic constipation, new onset of constipation, or severe constipation can have a wide array of possible causes that require evaluation, diagnosis, management, and, at times, referral. To add to the potential complexity, a specific etiology is not found in at least half the cases. Due to the prevalence of constipation in women and in the aging individual, clinicians need to understand the physiology, evaluation, and array of therapeutic approaches to be able to properly address this condition in our clinical practice.
The first line of information is the patient’s subjective perceptions. There are some objective criteria that are helpful and needed in order to define constipation as a clinical entity. Currently, there is a standard of two or more of the following symptoms that an individual experiences for 3 or more months without the use of laxatives:
- straining with defecation more than 25% of the time
- lumpy or hard stools more than 25% of the time
- incomplete elimination more than 25% of the time
- two or less bowel movements per week
All studies are seemingly in agreement that significantly more women than men report constipation and that the prevalence increases with age.1 Constipation was three times more common in women and, after age 65, it was 8% in women and 4% in men. In 1990, the first National Health and Nutrition Examination Survey reported a higher incidence of 12.8% in the general population with the ratio of women to men being more than 2 to 1 (18.2% vs 7%).2 For men and women over 60, it affected 25.3%. Pregnant women frequently have problems with constipation with as many as 38% suffering from it with majority of problems in the third trimester and persisting for several months. Pregnancy and vaginal delivery may also have long lasting adverse effects on bowel function by weakening the pelvic floor muscles.
Most cases of constipation result from no identifiable specific cause (idiopathic). This is described as primary constipation and is divided into two types- delayed transit time and outlet obstruction associated with some kind of anorectal dysfunction. Typical symptoms reported by the patient are pain or straining during defecation. Secondary constipation is due to dietary problems, lack of exercise, lack of enough water intake, laxative abuse, medications, surgeries, or other causes. Most of the cases of constipation are idiopathic and do not involve serious disorders.
In a medical interview and history, it is important for the clinician to gain clear information about bowel frequency, stool consistency and size, presence of blood or mucus, straining, pain, bloating, diet, exercise, medication, supplements, laxatives or enemas, recent life stressors, and a good review of systems in order to recognize indications of other more systemic problems. Physical examination will involve recognizing clues to metabolic and endocrine disorders, digital rectal examination, abdominal and pelvic exam, and neurological exam.
Laboratory tests may include a complete blood count, serum electrolytes and glucose, serum calcium, and thyroid stimulating hormone. More specialized tests need to be done in cases where there is a suspicion of a something more serious. These tests may include occult stool, sigmoidoscopy or colonoscopy, abdominal X-ray, barium studies, transit time studies, anorectal function studies, and other more specialized tests to rule out the numerous disorders that may be an underlying cause.
Most clinicians would agree that the high incidence of constipation in the US correlates with low fiber diets, low fluid intake, and being sedentary. Whether or not this will solve their constipation, it is fundamental to start here when there is no evidence of something more serious.
Because constipation affects women more than men, it especially concerns those delivering primary health care to women. Most women will only need reassurance, education, and basic advice. Others will need further evaluation and/or more sophisticated treatment interventions, whether exclusively natural methods, conventional methods, or an integration of both. The goals are to assure that they do not have a significant underlying cause, provide relief, improve general health, provide prevention strategies for the future, and to accomplish these things with minimal side effects.
1. Sonnenberg A et al. Dis Colon Rectum. 1989;32:1-8.
2. Sandler R et al. Am J Public Health. 1990;80:185-9.