What affects our health, how we feel, and how we look, but is rarely discussed ? You guessed it: Bowel movements, or lack or them, or problems with them. Today we will give some attention to the humble colon, indeed the whole female pelvis, as we contemplate the well being of this part of the body.

Those of us that operate on the female pelvic organs the uterus tubes and ovaries can tell you that they are in close proximity to the bladder and the colon. In fact, they are sandwiched between the bladder in the front and the colon (large bowel) in the back. Constipation can affect the way the uterus and bladder feel and function, and visa versa.

Definition

A common definition of constipation is bowel movements less than every three days. The American College of Gastroenterology defines constipation more completely, factoring in all sorts of problems with bowel movements, such as straining, small or hard stools, a sense of not being able to empty the bowels, or difficulty passing stool. Bloating, abdominal pain and excessive gas are also related issues.

Risk factors

Risk factors for constipation include being a woman, being pregnant, being older, dehydration, low fiber diet, being sedentary.

Causes

The basic cause of constipation is an unduly slow passage of stool through the bowel such that the stool becomes hard and relatively dry. This slow passage may be caused by a blockage in or near the colon such as a tumor, or a narrowing of the bowel from a stricture or a scarring of an anal fissure.

Since the colon moves stool forward using muscular contractions, poor muscle function can cause constipation. This can be from problems with the nerves that innervate the colon, such as in diseases like MS, stroke, and spinal cord injury. The colon muscles also function poorly if they do not contract and relax normally, or if the surrounding pelvic muscles are weak. Weak pelvic muscles can be caused by injury at childbirth, overweight, poor conditioning, poor posture, or all of the above. Hypothyroidism and diabetes can cause constipation.

Constipation can also be caused by medications, most famously narcotic pain medications and sedatives. Certain high blood pressure, antidepressant antacid and allergy medications can do it as well. Diuretics like caffeine and alcohol can cause constipation.

Poor bowel habits can start a vicious cycle of constipation. Ignoring the urge to go for reasons of convenience or modesty leads to more time for water to be extracted from stool, a harder stool, and a more difficult passage. The urge to go may even go away, compounding the problem.

Poor dietary habits are probably one of the most common causes of constipation. A diet high in saturated fat and sugar can predispose to constipation. A diet low in fruits, vegetables and fiber will surely cause constipation.

Complications

Untreated constipation may damage the area around the anus, either by producing sore dilated veins (hemorrhoids) or by causing small tears (anal fissures). The pressure and straining associated with constipation will worsen the condition of the pelvic muscles. It may do this to such an extent that the bladder may also start to have problems emptying, holding urine in, or both ! Constipation may even predispose a person to frequent urinary tract infections.

Evaluation

Persons suffering from constipation should not suffer in silence. Constipation is one of the most common reasons people go to the doctor. The workup of constipation consists of a history, physical exam, and possibly some imaging procedures.

Treatment

Treatment is determined after the workup is complete. Taking care of serious pathology is critical. But this is less common than lifestyle factors. Dietary and activity changes are front and center in the treatments for most people. Fiber, both soluble and insoluble, are key, along with ample hydration all through the day. Supplements of fiber are widely available if patients just cannot seem to get the right foods into their diet. Finally enemas and medications can be utilized.

Enemas and suppositories can be used for serious cases. Other classes of medications can be useful, but one must be aware of how they work.

Stool softeners like Colace do just that.
Bulking agents like Citracel or Metamucil hold additional water.
Osmotic agents like Milk of Magnesium chemically hold water in the colon.
Stimulant laxatives like senna or bisacodyl stimulate the colon muscles to contract more.

The first two are generally safe for everyone, but the last two should be used with the supervision of a doctor, since there can be medical consequences. Laxatives should be used with great caution, since they can even be addictive like narcotics, with more and more being required to get the desired effect.

Those with pelvic floor dysfunction can be treated with pelvic floor physical therapy. More and more medical communities are incorporating this treatment modality into their centers. This is key since these issue disproportionately affect women. These women have often curtailed their work, social lives, or exercise because of problems with bowel and bladder, and this is a significant loss, especially when treatment is available.

Stay tuned for this week’s Food Friday, when we will explore the dietary remedies for constipation in more detail.