Gastroenterologist Joe Soliman, MD, answers questions about when to treat chronic idiopathic constipation (CIC) and what your options are.

It’s true. Most of us get constipated from time to time. That also depends on our definition and understanding of what constipation is. The occasional hard stools, such as when we’re traveling or perhaps not drinking enough water, should be taken in context.

More formally, constipation can be considered a problem if a person has:

  • hard stools
  • a sense of not having completely emptied the bowels after a bowel movement
  • the need to use fingers or enemas to have a bowel movement
  • fewer than three bowel movements per week

You should speak with your doctor if these symptoms are abrupt in onset, have been ongoing for more than 3 weeks, or are associated with concerning symptoms. Examples of concerning symptoms include:

  • fatigue
  • weight loss
  • rectal bleeding

Some of the first things I discuss with my patients include activity levels. At a minimum, the equivalent of brisk walking for 30 minutes per day is helpful. The Centers for Disease Control and Prevention (CDC) recommends adding at least 2 days of muscle-strengthening activities.

Water and fiber intake are also important. Water intake of about 64 ounces (oz) per day is recommended (provided you have no other medical conditions that would make it contraindicated), along with daily fiber intake of about 30 grams (g).

Another key tip to avoid constipation is to listen to your body. Try to “heed the call” if possible whenever you get the urge to have a bowel movement, rather than holding it in. A tip to predicting when you may get the urge is in the morning or following meals.

If these are not helpful, you may try bulk-forming laxatives such as psyllium husk or methylcellulose. Hyperosmolar laxatives (such as polyethylene glycol or magnesium hydroxide) may also help. Stimulant laxatives (such as bisacodyl and senna) may also be helpful, but when taken regularly can have side effects with altering our chemistries. I typically counsel my patients to use them sparingly, if at all.

If the formal symptoms of constipation without concerning symptoms last for more than 3 months, a person is considered to have chronic constipation. The term idiopathic means that no known cause or obvious explanation is apparent. That means that an important part of an evaluation at a doctor’s appointment will include a detailed history for:

  • concerning symptoms
  • medication
  • lifestyle
  • medical history
  • surgical history
  • family history

A physical exam is important, especially focusing on any parts of the abdomen that are particularly symptomatic. My priority is to evaluate for a potentially serious cause, like obstruction from a tumor. Then, we look for reversible or treatable causes, such as:

  • taking certain medications
  • a prior history of abdominal surgery
  • decreased activity

Unless there are compelling reasons, I counsel my patients on taking a systematic approach in evaluating and treating constipation. This typically means starting with lifestyle and OTC remedies. If these are not successful, then escalating to prescription meds may be appropriate.

Some of the relatively newer prescription medications available include:

  • lubiprostone (Amitiza)
  • linaclotide (Linzess)
  • plecanatide (Trulance)
  • tenapanor (Ibsrela)

People who have a known or suspected gastrointestinal obstruction should not be on prescription treatments. In general, if you have allergic reactions to other medications or substances within medications, it is important to check the labels on the prescription for any such components.

No medication is 100% risk-free. Prescription treatments are no exception. A good rule of thumb to minimize side effects is to take the medications as prescribed. Some medications can be taken at different doses, so it’s always a good idea to proactively work with your doctor to ensure that you’re on the most appropriate dose.

As mentioned above, it is important to be aware of any potential allergic or hypersensitivity reactions you may have to the medication or other compounds mixed with it.

With constipation treatments, one possible side effect is “over-correcting.” This means that diarrhea may ensue. This may result in a spectrum of issues, from inconvenience to altering your electrolyte balances. It is important to follow up with your doctor if this happens.

Herein lies the importance of approaching your care in an organized and systematic manner. Every meeting with your doctor allows for re-evaluation of any potential new changes or information.

If there are no new findings to suggest the possibility of a new diagnosis, one possibility to consider is to try a different medication. Always discuss this with your doctor.

In rare circumstances, for patients who continue to have disabling constipation despite trying all medical therapies available, surgery to remove the colon may be considered. In many of these cases, the person has compromised colonic motility that doesn’t respond to other treatments.

Certain cancers, motility disorders, or defecatory disorders can contribute to constipation. Often, clues to these problems may be uncovered at the initial evaluation. But some of the initial lifestyle and OTC treatments may mask these problems until a later time.

Therefore, it is important to have a good communicative relationship with your care team, so that they may be able to suggest different tests that may be appropriate in getting a diagnosis.

Dr. Joe Soliman is an ABMS board certified internal medicine physician. He is a gastroenterologist at Cancer Treatment Centers of America. Dr. Soliman is passionate about acquiring, organizing, and disseminating accurate medical knowledge.