Chronic Constipation

What is Chronic Constipation?

Chronic constipation is a long-lasting problem with passing stool, usually defined as three or fewer bowel movements a week along with difficulty or straining.^[1] Straining, a sense of incomplete emptying and a feeling of blockage in the rectum matter as much as how often you go.^[2]

Common symptoms

Chronic constipation shows up as a mix of symptoms, not just a low count of bowel movements.^[2]

• Three or fewer bowel movements a week^[1]
• Straining, and hard or lumpy stools
• A feeling that you have not fully emptied your bowels
• A sense of blockage in the rectum^[2]
• Bloating and abdominal discomfort

Causes and risk factors

Chronic constipation is either primary or secondary. Primary types include normal-transit constipation, slow-transit constipation, where the colon moves stool slowly, and defecatory disorders, where the pelvic floor muscles do not coordinate with the rectum.^[2] In most people no single cause is found.^[1]

Secondary constipation can come from medicines such as opioids, from medical conditions, or rarely from a physical change in the bowel.^{[1, 2]} Diet, fluid intake, low activity and ignoring the urge to go are commonly named contributors.^[1]

How it is diagnosed and treated conventionally

A physician diagnoses chronic constipation from your history and examination, and may check for medicines or conditions that cause it.^[2] People who do not respond to over-the-counter products can have anorectal and colonic transit tests to look for defecatory disorders or slow transit.^[2]

Treatment usually starts with fiber supplements and stimulant or osmotic laxatives, followed if needed by prescription drugs that increase intestinal fluid or movement.^{[2, 3]} A review of over-the-counter products found good evidence for polyethylene glycol and senna, and moderate evidence for psyllium and magnesium salts.^[4] Fiber supplements improved constipation in a meta-analysis of 16 trials, with psyllium and higher doses over at least 4 weeks working best, though the results varied between trials.^[5]

Defecatory disorders often respond to biofeedback therapy, and surgery is reserved for selected people with slow-transit constipation.^[3]

Why Chronic Constipation calls for a whole-person approach

Chronic constipation rarely has one cause. Colon movement, pelvic floor coordination, medicines, diet and the nervous system all contribute, so people often need more than one kind of help.^{[1, 2]}

Complementary care is a reasonable addition to medical treatment when it targets these other factors and the symptoms that go with them.

Colon movement and gut nerves

Many people have a disturbance in how the colon senses and moves stool.^[2] The gut has its own nervous system, linked to the brain through the autonomic nervous system, which is one reason nerve-based therapies are studied.^[6]

Pelvic floor coordination

Some people strain because the pelvic floor and anal muscles do not relax when they try to pass stool. This is a different problem from slow transit, and it is treated differently, with biofeedback.^{[2, 3]}

Medicines

Opioids and several other prescription medicines can cause constipation, so your medication list matters.^{[1, 2]} Never stop a prescribed medicine without talking to your prescriber.

Diet and daily habits

Low fiber intake, low fluid intake and low activity are named contributors, and fiber supplements help many people with chronic constipation.^{[1, 5]}

Acupuncture for Chronic Constipation

What the research shows

Research suggests electroacupuncture can increase bowel movements in severe chronic functional constipation, though most trials were done in China. In a sham-controlled trial of 1,075 patients at 15 hospitals, 28 sessions over 8 weeks raised weekly complete spontaneous bowel movements by about 1.8, compared with about 0.9 with sham treatment, and the gap persisted to week 20. Side effects were mild or temporary.^[7] The authors noted that acupuncturists could not be blinded and long-term follow-up was not assessed.^[7]

A trial of 560 people with severe chronic constipation found electroacupuncture was noninferior to the drug prucalopride for the main outcome, with fewer adverse events, and the effect lasted 24 weeks after treatment ended.^[8] Another trial of 684 patients found three acupuncture approaches improved stool frequency about as much as mosapride after 4 weeks. It had no sham group, so the size of the treatment effect is unknown.^[9]

Reviews agree in direction. A meta-analysis of 6 studies (1,457 people) found electroacupuncture beat sham electroacupuncture for weekly complete bowel movements, but it warned that results may depend on the points, needle depth, intensity and frequency used.^[10] A network meta-analysis of 33 trials ranked acupuncture among the better non-drug treatments for stool frequency, with a caution about small study effects.^[11] An earlier review of 15 trials, all in China, called the evidence limited by small samples and methodological quality.^[12]

Constipation caused by opioids has also been studied. In 100 patients with cancer, 8 weeks of electroacupuncture gave more responders than sham treatment, without changing cancer pain or opioid dose.^[13]

How acupuncture may work

Researchers propose that acupuncture acts through several pathways. A review of constipation studies lists effects on gut movement, gut microbes, brain-gut signaling, intestinal inflammation and rectal sensitivity.^[14] A broader review describes the autonomic nervous system as one route by which acupuncture signals reach the gut.^[6] These are proposed explanations, drawn largely from laboratory work, not settled facts.

What treatment involves

Treatment uses fine, sterile, single-use needles, often with points on the abdomen, legs and back, left in place for about 20 to 40 minutes. For constipation, trials gave 16 to 28 sessions over 4 to 8 weeks.^{[7, 9]} We reassess after a short course of visits. Electroacupuncture, which passes a mild current through the needles, was used in the larger trials.^{[7, 8]}

Serious problems are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[15] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker, which matters for electroacupuncture.

Ayurvedic medicine for Chronic Constipation

The Ayurvedic view

In Ayurveda, constipation is traditionally called Vibandha or Malabaddhata and is linked to disturbed Vata, the principle said to govern movement, and weak digestive fire (agni). These are traditional categories for choosing treatment, not biomedical diagnoses.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Regular meal times, warm cooked foods, and attention to fluids and fiber-rich foods
• A steady daily routine, including a set time for the toilet
• Gentle oil massage of the abdomen
• Herbal formulas, most commonly triphala, a combination of three fruits that is traditionally used as a laxative^[16]
• Basti, a medicated enema therapy from Panchakarma, traditionally used for Vata disorders

Panchakarma is not appropriate during pregnancy, acute illness or frailty, or before red-flag symptoms such as bleeding or weight loss have been medically assessed.

What the research shows

There is no clinical trial evidence for Ayurvedic treatment of chronic constipation that we could find. A PubMed search found no systematic reviews and no randomized trials of Ayurvedic care for constipation. A review describes triphala as having laxative action and affecting gut microbes, but it summarizes mixed literature and is not a trial of constipation.^[16] Dietary and routine advice in Ayurveda overlaps with conventional advice on fiber, fluids and regular habits, and fiber has trial support.^[5]

Herbal medicine for Chronic Constipation

Herbs and formulas that have been studied

Chinese herbal laxative formulas are widely used in China. One example is Shouhui Tongbian capsule, a mixture of eight herbs including aloe, cassia seed, ginseng, goji berry and bitter orange fruit.^[17] Senna is a well-studied stimulant herbal laxative that is also available over the counter.^[4]

What the research shows

The evidence for the Chinese and Ayurvedic herbal formulas used in practice is very limited. A narrative review of Shouhui Tongbian capsule reported benefit in several types of constipation, but it is not a systematic analysis of randomized trials.^[17] A systematic review of herbal remedies for constipation-predominant irritable bowel syndrome found some benefit for stool frequency, stool form, pain and quality of life. The review called the evidence limited because the trials were too different to pool.^[18]

The strongest herbal evidence is for senna, which a systematic review of over-the-counter products rated as good evidence for use as a first-line laxative. Adverse events were mostly diarrhea, nausea, bloating and abdominal pain.^[4] Because senna is sold without a prescription, ask your physician before starting it, especially if you already use other laxatives.

Safety and herb-drug interactions

Herbs are active substances. Some herbs used for constipation act as stimulant laxatives, so overuse can cause diarrhea and cramping, and they should be used under a practitioner's guidance.^[4] Case reports describe bleeding when warfarin was combined with herbs including dang gui (Angelica sinensis), dan shen (Salvia miltiorrhiza), ginger, ginseng and Boswellia.^[19] Tell us about all medicines, especially blood thinners.

In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[20] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, or have liver or kidney disease.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine locates constipation in the large intestine, with disordered movement there linked to the lung, spleen, liver and kidney.^[17] Researchers studying acupuncture for constipation measure things that loosely parallel this: gut movement, brain-gut signaling, gut microbes and rectal sensitivity.^[14]

Ayurveda's aggravated Vata and weak agni describe irregular, dry stools and sluggish digestion. They may loosely resemble slow gut movement, and no study has shown that a dosha corresponds to a specific biological process.

How this care fits with your medical care

Integrative care for chronic constipation is complementary. Keep your physician or gastroenterologist, and do not stop or change laxatives or other prescribed medicines without your prescriber. We do not diagnose the cause of constipation, so new or changing bowel habits should be medically evaluated.^[2]

Please bring your diagnosis, any colonoscopy or test results, a full list of medicines and supplements including laxatives, and any recent changes in your bowel habits.

When to seek urgent medical care

Some symptoms with constipation can signal a serious cause and need prompt medical assessment.

• Blood in the stool or bleeding from the rectum
• Unexplained weight loss
• Constipation that starts suddenly or changes in a person over 45 without explanation
• Severe or worsening abdominal pain with a swollen abdomen
• Vomiting together with being unable to pass stool or gas
• Fever with abdominal pain
• Black, tarry stools or iron-deficiency anemia

If you have severe pain, repeated vomiting or cannot pass gas, call 911 or go to the nearest emergency department.