Symptoms of constipation include:
- Few bowel movements (especially no bowel movement after three days) and straining when having a bowel movement.
- Hard, compacted, small stools that are difficult to pass.
- A feeling of incomplete emptying after going to the bathroom.
- Stomach aches that are relieved by bowel movements.
- Cramping and pain in the rectum from the strain of trying to pass dry, hardened stools.
- Some bloating and nausea (or vomiting in extreme cases).
- Appetite may be suppressed.
- Sometimes small amounts of bright red blood appear on the stool from anal fissures or haemorrhoids.
- There may be decreased interest in usual activities.
- Urination may be more frequent because of pressure on the bladder. In the case of chronic constipation, there may be involuntary release of urine (incontinence).
- Psychological distress or obsession with having to go to the bathroom.
- Possible aggravation of diverticular disease, haemorrhoids and rectal prolapse (protrusion of part of the rectal lining through the anus).
One of the most significant factors appears to be the painful passing of a stool once constipation has already developed. The longer a person resists making a bowel movement, the larger and harder the stool becomes, which may cause pain when it’s passed.
Children in particular may then withhold a stool, which causes cramping. After some time, the child may be unable to resist the urge to have a bowel movement and will pass a large mass of faeces.
This can be painful, as the child may have to “push hard” during the bowel movement. Passing the stool relieves the pressure until another mass of stool collects and the cycle repeats itself.
Rome III criteria for chronic constipation
To confirm a diagnosis, the Rome III criteria for chronic constipation is often used. This involves:
- Three or more days of constipation per month in the past three months with symptom onset at least six months prior to diagnosis with two or more of the following:
- Straining more than 25% of the time.
- Lumpy or hard stools more than 25% of the time.
- Sensation of incomplete evacuation more than 25% of the time.
- Sensation of ano-rectal obstruction or blockage more than 25% of the time.
- Manual manoeuvers more than 25% of the time.
- Less than three defecations per week.
• Loose stools rarely present without the use of laxatives.
• Insufficient criteria for IBS.
The most common symptoms of dyssynergic constipation (where the muscles of the pelvic floor don’t work properly and may even perform the opposite function of what they’re supposed to) are:
- Frequent straining
- Incomplete evacuation
- Need for manual manoeuvers (e.g. digital stimulation or pelvic floor support)
Slow transit constipation
The most common symptoms of slow transit constipation (where the colon moves slowly) are:
- Infrequent stools (less than one bowel movement per week)
- Lack of urge to defecate
- Generalised symptoms including malaise and fatigue
- Poor response to fibre and laxatives
Complications of constipation
Chronic or long-term constipation can lead to health problems such as anal fissures, haemorrhoids, rectal prolapse, or faecal impaction.
Anal fissures are small tears in the anus that may cause itching, pain or bleeding.
Haemorrhoids are swollen and inflamed veins around the anus or in the lower rectum. They’re caused from the strain of passing dry, hardened stools. The result is bleeding in the rectum. This can be seen as bright red blood in the stool, on the toilet paper, or in the toilet after a bowel movement.
Haemorrhoids can be the result of anal fissures, which make the passing of stools very painful. The fissures and haemorrhoids generally heal once the constipation is controlled.
Rectal prolapse happens when the rectum slips and sticks out of the anus. Rectal prolapse can occur from straining during bowel movements. It’s most common in older adults with a history of constipation and is also more common in women, especially after menopause.
Rectal prolapse may cause mucus to leak from your anus.
Faecal impaction is when a stool becomes stuck in the rectum. This happens when hard stool packs your intestine and rectum so tightly that the normal pushing action of your colon isn’t enough to push the stool out. Generally, faecal impaction is experienced as constipation alternating with liquid diarrhoea.
Causes of constipation
Reviewed by Kim Hofmann, registered dietitian, BSc Medical (Honours) Nutrition and Dietetics, BSc (Honours) Psychology, December 2017.