The guide's purpose is to provide understanding and advice to individuals with constipation symptoms. The Constipation Guide should be used as a complement to your formal evaluation by a doctor, not as a substitute for office-based care. The Constipation Guide will provide recommendations relating to both evaluation and treatment based on the answers you give to a series of questions.

The number of questions you are asked will be determined by your symptoms. You will be asked a minimum of 12 questions, with additional questions relevant to your age, gender, or symptoms.

Time to complete this decision guide: ten to 20 minutes.

Click here to begin.

"Progress reports" with advice about evaluation and treatment will be highlighted as you progress through the questions. These progress reports will be personalized for you based upon your answers.

Some progress reports contain detailed advice that you may wish to keep for your future reference; you are welcome to print individual progress reports as you proceed. You will need to print pages using your browser, under the "file" menu.

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What is constipation?

Contrary to popular myth, it is not necessary for you to be "regular" (have daily bowel movements) for your bowel pattern to be normal. If your bowel movements are so infrequent that they cause you discomfort, or if bowel movements are an effort for you, then you are experiencing constipation.

Please choose an option:

Review symptoms in more detail before starting.

Begin now.

The symptoms of constipation come from slowed or stalled movement of stool through the colon, rectum, or anus.

People with true constipation usually have at least two of the following symptoms:

• A need to strain (forcefully contract) the muscles in your abdomen or pelvis in order to have bowel movements.

• Hard or lumpy stools.

• Urges to have bowel movements that do not lead to successful passing of stool.

• Fewer than three stools per week.

• Fullness (bloating) in the abdomen.

• A sensation of a blockage in your rectum during bowel movements.

• A need to push your fingers into your rectum, against the skin near your rectum, or (if you are a woman) into your vagina in order to have bowel movements.

• A feeling after bowel movements that you did not empty your rectum completely.

Begin now.

By answering a short series of questions, you will allow us to individualize our advice for you.

The following symptoms may indicate a serious complication of constipation, such as a complete blockage of stool:

• Nausea

• Vomiting

• Severe abdominal pain

• Stool leakage or diarrhea (despite also having prominent symptoms of constipation within the last 24 hours)

• A persistent urge to move your bowels

Have you experienced any of these symptoms within the last 24 hours?

Yes, I have one or more of these symptoms.

No, I do not have these symptoms.

Constipation can be the result of a medical problem, and sometimes it is a valuable clue to a medical illness that has not yet been diagnosed. Sometimes, it signals that you may have a neurologic illness or injury.

Please consider the following questions:

Did your symptoms develop following a back or neck injury?

or

Have you been diagnosed with any neurological illness (Parkinson's, Multiple Sclerosis, or other)?

or

Do you have unexplained numbness, weakness, or shaking (tremor) in any localized area of your body?

or

Do you have leakage of bowel contents or urine that you are not able to control?

Choose a response:

One or more of these concerns applies to me.

I do not have these symptoms.

Your symptoms may signal an emergency!

When they occur with constipation, these symptoms could represent a medical problem that needs emergency care today, such as a stool impaction (fecal impaction) or another cause of a blocked intestine. A stool impaction is a large accumulation of solid stool that will not move.

If your symptoms are new or severe, you are advised to exit this questionnaire and to contact your physician now for urgent evaluation.

Click here to continue if your symptoms are not new or severe.

Constipation can be the result of a medical problem, and sometimes it is a valuable clue to a medical illness that has not yet been diagnosed. Sometimes, it signals that you may have a neurologic illness or injury.

Please consider the following questions:

Did your symptoms develop following a back or neck injury?

or

Have you been diagnosed with any neurological illness (Parkinson's, Multiple Sclerosis, or other)?

or

Do you have unexplained numbness, weakness, or shaking (tremor) in any localized area of your body?

or

Do you have leakage of bowel contents or urine that you are not able to control?

One or more of these concerns applies to me.

I do not have these symptoms.

It does not sound likely that your constipation has resulted from a nerve injury in the brain or spinal cord area. However, there are also nerve endings within the intestines that may be affecting your bowel function and the function of these nerves should be considered. A common cause of constipation is nerve damage local to the intestines that is known as autonomic neuropathy. This is a common complication of diabetes.

Do you have diabetes?

Yes, I have diabetes.

No, I do not have diabetes.

Constipation can be a sign of a spinal cord injury or other neurological problem.

Because you have reported neurological symptoms, a complete neurological examination is needed as a part of your constipation evaluation. An imaging test of your brain or spinal cord may be recommended.

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We have considered the possibility of a brain or spinal cord injury or abnormality. There are also nerve endings within the intestines that may be affecting your bowel function and the function of these nerves should be considered. A common cause of constipation is nerve damage local to the intestines that is known as autonomic neuropathy. This is a common complication of diabetes.

Do you have diabetes?

Yes, I have diabetes.

No, I do not have diabetes.

Sometimes constipation is caused by an abnormality in the body's calcium or electrolyte balance, or it can be the result of low thyroid function. These problems can result in many other symptoms in addition to constipation. If you have several symptoms that are suggestive for an electrolyte or thyroid abnormality, then it will be important for you to have some blood tests to evaluate this possibility.

You may experience the following symptoms if you have a calcium or electrolyte imbalance or a thyroid problem:

• Fatigue

• Depression

• Difficulty staying warm

• Weight gain

• Coarse and dry skin

• Muscle cramps or muscle weakness

• Slowness of memory or thinking tasks

• Facial swelling, particularly around the eyes

• Coarse hair or hair loss

• A sensation of a lump in the throat

• A change in menstruation (lighter or heavier, or more or less frequent)

How may of these symptoms do you have?

Fewer than two.

Two or more.

Your diabetes may be a cause of your constipation.

Diabetes can result in poor nerve function within the colon and elsewhere in the body. This complication is named "autonomic neuropathy." Constipation is one result of autonomic neuropathy. Meticulous control of your blood sugars may help your bowel function, and treatment to encourage bowel motion may be offered by your doctor.

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Sometimes constipation is caused by an abnormality in the body's calcium or electrolyte balance, or it can be the result of low thyroid function. These problems can result in many other symptoms in addition to constipation. If you have several symptoms that are suggestive for an electrolyte or thyroid abnormality, then it will be important for you to have some blood tests to evaluate this possibility.

You may experience the following symptoms if you have a calcium or electrolyte imbalance or a thyroid problem:

• Fatigue

• Depression

• Difficulty staying warm

• Weight gain

• Coarse and dry skin

• Muscle cramps or muscle weakness

• Slowness of memory or thinking tasks

• Facial swelling, particularly around the eyes

• Coarse hair or hair loss

• A sensation of a lump in the throat

• A change in menstruation (lighter or heavier, or more or less frequent)

How may of these symptoms do you have?

Fewer than two.

Two or more.

You have several symptoms that are suggestive for low thyroid function or an electrolyte or calcium problem, so obtaining some basic blood tests to scout for these problems should be a high priority in your case.

Keep that in mind for your evaluation, and we will move on to some additional considerations.

Persistent constipation always warrants a basic physical examination and a discussion of your diet and medicines.

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Great! Fortunately, you do not have enough symptoms to specifically suggest an electrolyte, calcium or thyroid problem at this time.

You may not need a blood test to assess your electrolytes, calcium level, and thyroid function now, but if your constipation remains unexplained these tests may be helpful.

Persistent constipation always warrants a basic physical examination and a discussion of your diet and medicines, so we will move on to discuss medicines and constipation.

Click here to continue.

Are you taking any medications from the following list?

• Narcotic pain medicine

• Pain medicine to treat electric or burning pain (such as amitriptyline (Elavil), desipramine (Norpramin), nortriptyline (Aventyl, Pamelor) and imipramine (Tofranil))

• Migraine prevention medicine

• Cough syrup containing a narcotic

• Muscle relaxant

• Medicine to treat an overactive bladder

• Antidepressant

• Antiacid medicine containing aluminum (such as sucralfate, Maalox, or Mylanta)

• Diarrhea medicine

• Diuretic (or "water pill")

• Blood pressure medicine in the calcium channel blocker class (particularly diltiazem (Cardizem, Tiazac, and others) and verapamil (Calan and others))

• Anticancer drug vincristine or vinblastine

• Nausea medicine that is used with chemotherapy (such as ondansetron (Zofran)

• Iron

Yes, I am taking one or more of these medications.

No, I am not taking any of these medications.

Constipation can occur at any age. Some medical problems that cause constipation, such as colon polyps or cancer, are more likely to develop as you get older.

How old are you?

Younger than 50.

50 or older.

It is possible that your medicine may be contributing to your constipation.

It may be possible for you to discontinue one or more constipating medicines after discussion with your doctor.

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Constipation can occur at any age. Some medical problems that cause constipation, such as colon polyps or cancer, are more likely to develop as you get older.

How old are you?

Younger than 50.

50 or older.

Your age group puts you at risk for colon polyps or cancer, so it would be valuable to know if you have symptoms that are suggestive for one of these problems.

Do you have any of the following symptoms?

• Unexplained weight loss

• Abdominal pain

• Stools that contain blood or are black and tar-like in texture

Yes, I have one or more of these symptoms.

No, I do not have any of these symptoms.

We are glad to hear this. You have not reported any symptoms other than your constipation that increase the likelihood of colon cancer.

Nevertheless, constipation is occasionally the first symptom of cancer in the colon. Your age places you at increased risk. An examination of your colon would be recommended due to your age, using a colonoscopy or related test.

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Your symptoms suggest you could have a polyp or cancer in the colon. Your age increases your risk for these problems.

It is important for you to have an examination of your colon, using a colonoscopy or related test. Please speak with your doctor very soon about your symptoms if you have not already been scheduled for a colon examination.

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For people in your age group, it is possible that constipation is related to fluid buildup (congestion) within the wall of the bowel. When this occurs, it is usually caused by congestive heart failure.

Symptoms that would be suggestive for heart failure include:

• Swelling of your ankles

• Shortness of breath with minimal exercise

• Breathing difficulty when you lie flat

• Awakenings at night due to shortness of breath

Have you been diagnosed with heart failure, or do you have any of these symptoms?

Yes, I may have heart failure symptoms.

No, there is no concern for heart failure in my case.

The diet we eat determines a lot about our bowel function and stool consistency.

Do you typically eat a diet full of breads, fruits, cereals, vegetables, nuts, and grains?

Yes, I have a high fiber diet.

No, I more often eat meat, eggs, milk and cheeses

You should discuss your heart health in detail with your doctor.

Heart failure is a cause of bowel congestion and therefore it is a potential cause of constipation.

Click here to continue.

The diet we eat determines a lot about our bowel function and stool consistency.

Do you typically eat a diet full of breads, fruits, cereals, vegetables, nuts, and grains?

Yes, I have a high fiber diet.

No, I more often eat meat, eggs, milk and cheeses

Your age group puts you at somewhat lower risk for colon polyps and cancer.

Certain symptoms increase the level of concern even at a younger age.

Do you have any of the following symptoms?

• Unexplained weight loss

• Abdominal pain

• Stools that contain blood or are black and tar-like in texture

Yes, I have one or more of these symptoms.

No, I do not have any of these symptoms.

One condition that commonly causes constipation in your age group is an "irritable bowel." This problem typically causes some additional symptoms.

Do you frequently notice one or more of these symptoms in between episodes of constipation?

• Abdominal pain episodes

• Loose and frequent stools during pain episodes

• Mucus in the stool

• Relief from pain after bowel movements

Yes, I have one or more of these symptoms.

No, I do not have any of these symptoms.

Your age group is not at high risk for a polyp or cancer in the colon. However, your symptoms can be consistent with one of these conditions. You should discuss your symptoms with your doctor, and discuss whether a colon examination is appropriate for you, using a colonoscopy or related test.

Click here to continue.

One condition that commonly causes constipation in your age group is an "irritable bowel." This problem typically causes some additional symptoms.

Do you frequently notice one or more of these symptoms in between episodes of constipation?

• Abdominal pain episodes

• Loose and frequent stools during pain episodes

• Mucus in the stool

• Relief from pain after bowel movements

Yes, I have one or more of these symptoms.

No, I do not have any of these symptoms.

The diet we eat determines a lot about our bowel function and stool consistency.

Do you typically eat a diet full of breads, fruits, cereals, vegetables, nuts, and grains?

Yes, I have a high fiber diet.

No, I more often eat meat, eggs, milk and cheeses

Great! Still more fiber may help.

You already emphasize the right foods in your diet, but more of your favorite fiber-rich foods may help. Since it passes through your bowel undigested, all fiber helps to enlarge the stool. Larger masses of stool are easier for the colon to push against and to propel forward. You can increase two separate types of fiber in your diet.

"Insoluble" fiber (the straw-like material and binding matter found in many natural foods) promotes contractions within the colon.

Good sources include:

• Fruits

• Vegetables

• Whole grains

• "Soluble" fiber can soften the stool by absorbing water and forming a gel. Good sources include:

• Breads

• Cereals

• Oats

• Lentils

• Barley

• Apples

• Over-the-counter fiber supplements. Examples of over-the-counter fiber supplements include psyllium (Metamucil), methylcellulose (Citrucel), and calcium polycarbophil (Fibercon). These fiber preparations are sometimes named "bulk laxatives."

Drink plenty of fluid! Your stool will be softer if it contains more water. Increasing your water intake is especially important if you increase your fiber with diet or supplements.

Click here to continue.

In some cases, the anatomy within the pelvis can relate to constipation symptoms.

Are you a man or a woman?

I am a man.

I am a woman.

The symptoms you just selected suggest you might have irritable bowel syndrome (IBS).

What is IBS?

In the case of an irritable bowel, the nerves within the bowel are unusually sensitive. They can react in a disorderly or exaggerated way to normal stretching from food residue that is passing through the intestines, or they can stall the bowel, causing constipation. IBS is not a medical disease; it is an uncomfortable pattern of digestion that may develop on its own or may be triggered by emotional stress or an intestinal infection.

The next several screens will take you through some important information about fiber recommendations for an irritable bowel, foods that may trigger symptoms, and additional treatment for irritable bowel problems.

Click here to continue.

The diet we eat determines a lot about our bowel function and stool consistency.

Do you typically eat a diet full of breads, fruits, cereals, vegetables, nuts, and grains?

Yes, I have a high fiber diet.

No, I more often eat meat, eggs, milk and cheeses.

Get some fiber in your diet!

Definitely, increased fiber in the diet can improve constipation. Since it passes through your bowel undigested, fiber helps to enlarge the stool. Larger masses of stool are easier for the colon to push against and to propel forward. You can increase two separate types of fiber in your diet.

"Insoluble" fiber (the straw-like material and binding matter found in many natural foods) promotes contractions within the colon. Good sources include:

• Fruits

• Vegetables

• Whole grains

"Soluble" fiber can soften the stool by absorbing water and forming a gel. Good sources include:

• Breads

• Cereals

• Oats

• Lentils

• Barley

• Apples

• Over-the-counter fiber supplements

Examples of over-the-counter fiber supplements include psyllium (Metamucil), methylcellulose (Citrucel), and calcium polycarbophil (Fibercon). These fiber preparations are sometimes named "bulk laxatives."

Drink plenty of fluid! Your stool will be softer if it contains more water. Increasing your water intake is especially important if you increase your fiber with diet or supplements.

Click here to continue.

IBS fiber recommendations

Almost all of us can afford to increase the amount of fiber we are getting in our diet. Since it passes through your bowel undigested, all fiber helps to enlarge the stool. Larger masses of stool are easier for the colon to push against and to propel forward. Many people have temporary symptoms of increased gas or bloating when they first increase their fiber, so it is not practical to judge your benefit in the first few weeks.

Increase your soluble fiber

Soluble forms of fiber are able to mix evenly with water, forming a soft gel. This fiber type can improve every symptom of an irritable bowel. Soluble fiber gel thickens stool that would otherwise cause diarrhea, and it prevents constipation by softening and hydrating stool. It may be helpful to make a food high in soluble fiber the first thing on your plate that you eat. Good sources include:

• Breads

• Cereals

• Oats

• Lentils

• Barley

• Apples

• Over-the-counter fiber supplements. Examples include psyllium (Metamucil), methylcellulose (Citrucel), and calcium polycarbophil (Fibercon). These fiber preparations are sometimes named "bulk laxatives."

Emphasize insoluble fiber only if it is right for you

The straw-like materials and binding matter that give vegetables and other plants their pulp and structure are found in whole grains, fruits and vegetables. Insoluble fiber does not mix well with water, instead remaining as a stringy or bulky material that mixes into your stool.

Insoluble fiber can help or hurt your symptoms if you have irritable bowel, depending on your bowel activity. If you have pain or diarrhea in between episodes of constipation, it is possible that this fiber may cause increased symptoms. On the other hand, insoluble fiber improves constipation because it encourages movement of the colon and adds to the weight and bulk of the stool that you form. Good sources include:

• Fruits

• Vegetables

• Whole grains

Drink plenty of fluid! Your stool will be softer if it contains more water. Increasing your water intake is especially important if you increase your fiber with diet or supplements.

Click here to move on to IBS Food Triggers.

You may have arrived at your present diet by trial and error, finding foods that seem to work well for you. You may benefit from knowing a little of the "food science" behind irritable bowel care, so that you may further adjust your eating habits to minimize constipation.

IBS fiber recommendations

Almost all of us can afford to increase the amount of fiber we are getting in our diet. Since it passes through your bowel undigested, all fiber helps to enlarge the stool. Larger masses of stool are easier for the colon to push against and to propel forward. Many people have temporary symptoms of increased gas or bloating when they first increase their fiber, so it is not practical to judge your benefit in the first few weeks.

Increase your soluble fiber:

Soluble forms of fiber are able to mix evenly with water, forming a soft gel. This fiber type can improve every symptom of an irritable bowel. Soluble fiber gel thickens stool that would otherwise cause diarrhea, and it prevents constipation by softening and hydrating stool. It may be helpful to make a food high in soluble fiber the first thing on your plate that you eat. Good sources include:

• Breads

• Cereals

• Oats

• Lentils

• Barley

• Apples

• Over-the-counter fiber supplements. Examples include psyllium (Metamucil), methylcellulose (Citrucel), and calcium polycarbophil (Fibercon). These fiber preparations are sometimes named "bulk laxatives."

Emphasize insoluble fiber only if it is right for you:

The straw-like materials and binding matter that give vegetables and other plants their pulp and structure are found in whole grains, fruits and vegetables. Insoluble fiber does not mix well with water, instead remaining as a stringy or bulky material that mixes into your stool.

Insoluble fiber can help or hurt your symptoms if you have irritable bowel, depending on your bowel activity. If you have pain or diarrhea in between episodes of constipation, it is possible that this fiber may cause increased symptoms. On the other hand, insoluble fiber improves constipation because it encourages movement of the colon and adds to the weight and bulk of the stool that you form. Good sources include:

• Fruits

• Vegetables

• Whole grains

Drink plenty of fluid! Your stool will be softer if it contains more water. Increasing your water intake is especially important if you increase your fiber with diet or supplements.

Click here to move on to IBS Food Triggers.

IBS Food Triggers

By keeping a food diary or by trial and error, you may identify that one or more of these foods are a trigger for your symptoms:

• Milk and milk products

• Eggs

• Wheat

• Salicylates: natural ingredients contained within various fruits, vegetables, nuts, tea and coffee, honey, numerous spices, beer and wine, juices, and peppermint flavoring.)

• Amines: byproducts in aged or fermenting products such as cheese, wine, beer, yeast extracts, vinegars, and soy sauce, and also a substance found in chocolate, bananas, avocados, tomatoes, and some fish products.

What would you like to do now?

Review prescription medicines that may help an irritable bowel.

Continue with the guide.

Prescription medicines that may help an irritable bowel

In addition to laxative medicines (discussion will come later), several medicines may help:

• Medicines in the tricyclic class include amitriptyline (Elavil), nortriptyline (Aventyl, Pamelor), or desipramine (Norpramin). These medicines can be quite helpful because they decrease nerve sensitivity. People with IBS who are treated with tricyclic medicine be useful for your symptoms are about four times as likely to report improvement in symptoms as are people who are treated without medicine.

• Tegaserod (Zelnorm) has been recently developed and marketed specifically for constipation due to irritable bowel. This drug appears to have only a limited benefit for symptoms. Long-term side effects have not been studied.

• Antispasmodics could worsen your constipation. They can help at times when you have cramps or diarrhea as your main symptoms of IBS. These medicines reduce the strength of contractions (peristalsis) in the colon. Preparations include dicyclomine (Bentyl), hyoscyamine (Donnatol, Levsin, NuLev) and calcium channel blockers (Diltiazem and others).

Continue with the guide.

In some cases, the anatomy within the pelvis can relate to constipation symptoms.

Are you a man or a woman?

I am a man.

I am a woman.

If the path out of your rectum is partly blocked due to your anatomy, you are likely to have some specific symptoms relating to your constipation.

Do have any of the following symptoms?

• Bowel movements happen more easily if you push your fingers into your vagina or against the skin near your rectum

• Solid stool (either soft or hard) remains in your rectum after a bowel movement

• You may need to use your finger to remove stool from your rectum

• You may need to position yourself on the toilet in unconventional ways in order to have a bowel movement

• You have sensation of a blockage in your rectum during bowel movements

• You have urges to have bowel movements (felt in your pelvis) that do not lead to successful passing of stool.

Yes, I have one or more of these symptoms.

No, I do not have any of these symptoms.

Fortunately, you don't have symptoms that would suggest a blocked pelvic outlet. Your symptoms can probably be safely treated with medicines by mouth. We will review laxatives now, and then we will offer you some additional advice after you complete our final questions.

Oral laxatives

If you still have constipation after increasing your dietary fiber, oral laxatives may be useful. Oral laxatives may be tried in the following order:

1. Bulk laxatives. (These have already been discussed in the soluble fiber section. They are over-the-counter fiber supplements.)

2. Salt-based laxative pills or liquid. The safest laxatives for frequent use function by drawing extra water into stool as it forms, and they are known as "osmotic" laxatives.

Over-the-counter osmotic laxatives include concentrated salt solutions containing magnesium hydroxide or magnesium citrate:

• Milk of Magnesia

• EvacQMag

Several others are available by prescription:

• Lactulose (Chronulac and others)

• Sorbitol

• Polyethylene glycol (Miralax, GoLytely electrolyte solution, and others)

• Lactulose and sorbitol commonly cause gas or bloating side effects but they are safe and effective

3. Stimulant laxatives

Laxatives that make your colon contractions more forceful are known as "stimulant" laxatives. Long term repeated use of oral stimulant laxatives should be avoided, and maximum use should be three times in a week. Stimulant laxatives are a danger because long-term use can be habit-forming, can cause nerve damage in the colon or can interrupt or damage your normal digestion, resulting in protein malnourishment or electrolyte abnormalities.

Stimulant laxatives that are found over-the-counter include:

• Bisacodyl (Correctol, Dulcolax, FeenAMint, BisacEvac, BiscoLax, Carter's Little Pills, Clysodrast, Dacodyl, Deficol)

• Cascara

• Casanthrol (PeriColace)

• Castor oil

• Senna (ExLax, Senokot, Fletcher's Castoria, SennaGen, Senexon, Black Draught)

One over-the-counter laxative, mineral oil, can cause lung irritation at the time it is swallowed. It should not be taken by mouth, particularly in people who are elderly or who have swallowing difficulties. Products with added aloe (also known as casanthrol) frequently cause cramps and are not preferred.

Click here to continue.

Your symptoms suggest that the support or position of other pelvic structures relative to your rectum may be interfering with your passing of stool. In women, one of the most common causes of a narrowed pelvic outlet is prolapse (downward sagging) of the uterus. Prolapse of a pelvic organ would be suggested by some additional symptoms.

Do you have any of the following symptoms?

• Pain in the vagina, pelvis, lower abdomen, or groin

• Heaviness or pressure in the vaginal area, or the sensation that something is about to "fall out" of the vagina

• Leakage of urine that is worse with heavy lifting, coughing, laughing or sneezing

• Frequent urinary tract infections

• A bulge of moist pink tissue from the vagina

Yes, I have one or more of these symptoms.

No, I do not have any of these symptoms.

If you do not have symptoms to suggest "prolapse" of the uterus, then weakness of muscles and ligaments in the pelvis may contribute to difficulty passing stool. Since you have difficulty moving stool through your pelvis, it may be worth your while to undergo specialized testing of your pelvic muscle function.

A video study called "defecography" can observe whether your pelvic and anal muscle movements are appropriately coordinated during a "practice" bowel movement. A thick liquid called barium is used to fill the rectum for this test, or a small balloon may be inflated in your rectum. Rectal pressures can be measured.

These tests usually require an evaluation by a specialist.

Click here to continue.

Your symptoms suggest "uterine prolapse."

In other words, the position of your pelvic organs may be interfering with the passage of stool through your pelvis. Downward sagging (prolapse) of the uterus or bladder can develop with age and is particularly common following childbirth.

As a part of your constipation evaluation (and before other specialized pelvic tests) you may benefit from having a pelvic examination that specifically checks for prolapse of the bladder or uterus. This examination may either be performed by your primary care doctor or by a gynecologist.

Prolapse of the uterus or bladder is not an emergency and does not necessarily require correction. However, identification of a prolapsed uterus or bladder may be helpful in treating your constipation.

Click here to continue.

In addition to prolapse of the uterus, weakness of muscles and ligaments in the pelvis may contribute to difficulty passing stool. Since you have difficulty moving stool through your pelvis, it may be worth your while to undergo specialized testing of your pelvic muscle function.

A video study called "defecography" can observe whether your pelvic and anal muscle movements are appropriately coordinated during a "practice" bowel movement. A thick liquid called barium is used to fill the rectum for this test, or a small balloon may be inflated in your rectum. Rectal pressures can be measured.

These tests usually require an evaluation by a specialist.

Click here to continue.

If the path out of your rectum is partly blocked due to your anatomy, you are likely to have some specific symptoms relating to your constipation.

Do you have any of the following symptoms?

• Presence of solid stool (either soft or hard) that remains in your rectum after a bowel movement

• A need to use your finger to remove stool from your rectum

• A need to push your fingers into your rectum or against the skin near your rectum in order to have bowel movements or to urinate

• A need to position yourself on the toilet in unconventional ways in order to have a bowel movement

• A sensation of a blockage in your rectum during bowel movements

• Urges to have bowel movements (felt in your pelvis) that do not lead to successful passing of stool

Yes, I have one or more of these symptoms.

No, I do not have any of these symptoms.

Oral Laxatives

If movement through your pelvis is your main problem, then you are unlikely to benefit from oral (swallowed) laxatives. If your pelvic symptoms are mild, these medicines may be a worthwhile treatment for your constipation. Oral laxatives may be tried in the following order:

1. Bulk laxatives. (These have already been discussed in the soluble fiber section. They are over-the-counter fiber supplements.)

2. Salt-based laxative pills or liquid

The safest laxatives for frequent use function by drawing extra water into stool as it forms, and they are known as "osmotic" laxatives.

 Over-the-counter osmotic laxatives include concentrated salt solutions containing magnesium hydroxide or magnesium citrate:

• Milk of Magnesia

• EvacQMag

Several others are available by prescription:

• Lactulose (Chronulac and others)

• Sorbitol

• Polyethylene glycol (Miralax, GoLytely electrolyte solution, and others)

Lactulose and sorbitol commonly cause gas or bloating side effects but they are safe and effective

3. Stimulant laxatives

Laxatives that make your colon contractions more forceful are known as "stimulant" laxatives. Long-term repeated use of oral stimulant laxatives should be avoided, and maximum use should be three times in a week. Stimulant laxatives are a danger because long-term use can be habit-forming, can cause nerve damage in the colon or can interrupt or damage your normal digestion, resulting in protein malnourishment or electrolyte abnormalities.

• Stimulant laxatives that are found over-the-counter include:

• Bisacodyl (Correctol, Dulcolax, FeenAMint, BisacEvac, BiscoLax, Carter's Little Pills, Clysodrast, Dacodyl, Deficol)

• Cascara

• Casanthrol (PeriColace)

• Castor oil

• Senna (ExLax, Senokot, Fletcher's Castoria, SennaGen, Senexon, Black Draught)

One over-the-counter laxative, mineral oil, can cause lung irritation at the time it is swallowed. It should not be taken by mouth, particularly in people who are elderly or who have swallowing difficulties. Products with added aloe (also known as casanthrol) frequently cause cramps and are not preferred.

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Since you have difficulty moving stool through your pelvis, it is possible that you have poorly coordinated muscle function in this area as a cause of your constipation. It may be worth your while to undergo specialized testing of your pelvic muscle function.

A video study called "defecography" can observe whether your pelvic and anal muscle movements are appropriately coordinated during a "practice" bowel movement. A thick liquid called barium is used to fill the rectum for this test, or a small balloon may be inflated in your rectum. Rectal pressures can be measured.

These tests usually require an evaluation by a specialist.

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If you and your doctor confirm abnormal pelvic muscle coordination or strength, then pelvic muscle retraining may give you permanent relief from your symptoms. In such a program, "biofeedback" is facilitated by a therapist.

• Sensors identify your pelvic muscle movements.

• Signals show these movements to you.

• You are coached about ways to relax your pelvis floor muscles, and you can see your results.

• You are coached about ways to incorporate abdomen muscle contractions when you have a bowel movement, and you can see your results.

This project requires a specialist's care and some personal commitment. A gastroenterologist (GI) doctor can identify a reliable biofeedback center and therapist for you.

Continue to other treatments.

Since you have pelvic emptying difficulties, laxatives in the form of suppositories might help.

Suppositories are mediations that are inserted directly into the rectum through the anus. They are solid and bullet shaped at room temperature, but they melt when they are warmed in your rectum.

One popular and safe over-the-counter suppository is a "glycerine" suppository. Glycerine is a sweetening ingredient in many candies and when it is used in a suppository it works by drawing water into the rectum, loosening stool and triggering muscle contractions. If glycerine suppositories are ineffective, suppositories containing bisacodyl would be worth trying. These include Dulcolax and other brands.

Laxatives are medicines that accelerate the movement of stool within the colon or rectum. Because you have difficulty moving stool out of your pelvis and rectum, you are more likely to benefit from suppository laxatives than from laxative pills.

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For pelvic emptying difficulties, enemas are also useful.

An enema is a fluid that is gently moved from a storage bag or container into your rectum through a plastic or rubber tube. Enema fluid temporarily expands the rectum, loosens and moistens stool at the end of the colon, and triggers muscular contraction of the rectum.

Enemas typically result in a bowel movement within minutes.

The safest enemas are those that contain salt solutions in balance with your blood salt concentrations, such as pre-filled sodium phosphate and bisphosphate enema kits (Fleets Enemas) that are available at pharmacies. Some enemas contain mineral oil or other oils to lubricate stool that is tightly lodged in the rectum. It is possible to ease rectal emptying with any enema fluid, even tap water, but frequent use of tap water enemas can dilute the concentration of salt in your bloodstream and is not recommended.

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Oral Laxatives

If movement through your pelvis is your main problem, then you are unlikely to benefit from oral (swallowed) laxatives. If your pelvic symptoms are mild, these medicines may be a worthwhile treatment for your constipation. Oral laxatives may be tried in the following order:

1. Bulk laxatives. These have already been mentioned in the soluble fiber section. They are over-the-counter fiber supplements, such as psyllium (Metamucil), methylcellulose (Citrucel), and calcium polycarbophil (Fibercon).

2. Salt-based laxative pills or liquid

The safest laxatives for frequent use function by drawing extra water into stool as it forms, and they are known as "osmotic" laxatives.

 Over-the-counter osmotic laxatives include concentrated salt solutions containing magnesium hydroxide or magnesium citrate:

• Milk of Magnesia

• EvacQMag

Several others are available by prescription:

• Lactulose (Chronulac and others)

• Sorbitol

• Polyethylene glycol (Miralax, GoLytely electrolyte solution, and others)

Lactulose and sorbitol commonly cause gas or bloating side effects but they are safe and effective

3. Stimulant laxatives

Laxatives that make your colon contractions more forceful are known as "stimulant" laxatives. Long-term repeated use of oral stimulant laxatives should be avoided, and maximum use should be three times in a week. Stimulant laxatives are a danger because long-term use can be habit-forming, can cause nerve damage in the colon or can interrupt or damage your normal digestion, resulting in protein malnourishment or electrolyte abnormalities.

Stimulant laxatives that are found over-the-counter include:

• Bisacodyl (Correctol, Dulcolax, FeenAMint, BisacEvac, BiscoLax, Carter's Little Pills, Clysodrast, Dacodyl, Deficol)

• Cascara

• Casanthrol (PeriColace)

• Castor oil

• Senna (ExLax, Senokot, Fletcher's Castoria, SennaGen, Senexon, Black Draught)

One over-the-counter laxative, mineral oil, can cause lung irritation at the time it is swallowed. It should not be taken by mouth, particularly in people who are elderly or who have swallowing difficulties. Products with added aloe (also known as casanthrol) frequently cause cramps and are not preferred.

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Movement through the pelvis can be particularly slowed or difficult if bowel movements cause pain.

Do you have pain with bowel movements?

Yes, I have pain.

No, I do not have pain.

That is good news. As major part of your constipation plan, you should consider your basic bowel hygiene and habits.

Do you need to strain (forcefully contract) the muscles in your abdomen or pelvis in order to have bowel movements?

Yes, I need to strain.

No, I do not need to strain.

You should discuss your pain with a doctor and should have a careful inspection of your buttock.

The fact that you have pain with your bowel movements might mean that you have a cut in the lining of your anus (an "anal fissure") or an infection near to this opening.

In these cases, constipation symptoms may occur if you put off passing stool (either by your choice or without your conscious control) as a way to avoid pain.

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We have already reviewed the forms of laxative treatments that might be helpful to constipation. Before you reach for laxatives to relieve your symptoms, you should consider your basic bowel hygiene and habits.

Do you need to strain (forcefully contract) the muscles in your abdomen or pelvis in order to have bowel movements?

Yes, I need to strain.

No, I do not need to strain.

Great! You should continue to avoid straining.

Straining at stools probably creates more problems than you are solving. The formation of hemorrhoids is a common complication of increased abdominal pressure from straining.

The best way to facilitate your bowel movements is to respect the importance of timing:

• Be responsive to urges:  it is best to respond to all signals that your colon is giving you that suggest you are ready to have a bowel movement. If you try to overcome urges to pass stool, then your signals may become fainter. Diminished signals can decrease your notice of and control over bowel movements.

• Try to have bowel movements after your meals: following meals (particularly morning meals), your colon is more active. You can take advantage of this natural increase in bowel activity by being especially responsive to urges that occur after meals. If your morning meal includes a cup of coffee, then the caffeine will also stimulate movement in the colon and promote a bowel movement.

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In your case, we should review bowel habits that help to minimize problems from constipation:

You should avoid straining at stools if possible:

If you are forcefully contracting your pelvic and abdominal muscles but are not quickly seeing results, then you are probably creating more problems than you are solving. The formation of hemorrhoids is a common complication of increased abdominal pressure from straining.

Be responsive to urges:

It is best to respond to all signals that your colon is giving you that suggest you are ready to have a bowel movement. If you try to overcome urges to pass stool, then your signals may become fainter. Diminished signals can decrease your notice of and control over bowel movements.

Try to have bowel movements after your meals:

Following meals (particularly morning meals), your colon is more active. You can take advantage of this natural increase in bowel activity by being especially responsive to urges that occur after meals. If your morning meal includes a cup of coffee, then the caffeine will also stimulate movement in the colon and promote a bowel movement.

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Activity stimulates bowel motion.

Which of the following statements best describes your activity level?

I exercise for at least 30 minutes on most days of the week.

I am not as active as I should be.

If you are usually sedentary, increasing your activity can help constipation.

Exercise encourages bowel activity, even when the exercise is as modest as walking around your home. You are currently exercising less than the amount that is recommended for adults. In addition to improving your constipation, increasing your daily exercise can provide other substantial health benefits.

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For some people with constipation, gas production in the colon can contribute significantly to symptoms.

Do you feel uncomfortable fullness or bloating in your abdomen, or have bowel movements less than three times per week?

Yes, this describes me.

No, this does not describe me.

Congratulations to you on your good habits! Your active lifestyle may be helping to minimize your constipation symptoms.

For some people with constipation, gas production in the colon can contribute significantly to symptoms.

Do you feel uncomfortable fullness or bloating in your abdomen?

Yes, this describes me.

No, this does not describe me.

Do you have stools that are hard or lumpy?

Yes, I have hard and lumpy stools.

No, I do not have hard and lumpy stools.

Minimize your gas

Bloating may arise from excessive gas production in the colon. Poor digestion of carbohydrates is frequently a cause of gas, since bacteria may ferment these carbohydrates within the colon.

Carbohydrates that are culprit because they can be indigestible include:

Lactose

This is the milk sugar found in dairy products. If you are lactose "intolerant," then you can't digest this carbohydrate easily.

Sweeteners

The carbohydrates mannitol, sorbitol, and fructose are added to many liquid medicines, health foods, juices, candies, and chewing gum.

Certain foods also contain fructose, including figs, dates, prunes, pears and grapes, onions, asparagus, artichokes, wheat, and dietetic cookies and cakes.

Cruciferous vegetables and legumes

The natural carbohydrates raffinose or stachyose are not digested well by humans. They are found in cabbage, Brussels sprouts, broccoli, cauliflower, and beans.

Fiber can also cause gas, especially if it is increased rapidly in your diet or by supplements.

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Do you have stools that are hard or lumpy?

Yes, I have hard and lumpy stools.

No, I do not have hard and lumpy stools.

Congratulations! You have received all of our treatment tips for constipation that are relevant to you.

The most successful relief from constipation symptoms usually comes from a combination of treatments.

Remember, our decision guide is no substitute for an office evaluation by your physician. If you have experienced constipation for 12 weeks or longer, it is important for you to have your symptoms evaluated by a physician.

You might consider a "stool softener."

Brands of the popular medicine "docusate" (Colace, Surfak) were designed to make it easier for stools to absorb water through their surface. Although some people report that they have more frequent stools or more ease in passing stools after using these medicines, a significant measurable benefit has not been demonstrated in the several small studies that have examined the medicines in this class.

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Congratulations! You have received all of our treatment tips for constipation that are relevant to you.

The most successful relief from constipation symptoms usually comes from a combination of treatments.

Remember, our decision guide is no substitute for an office evaluation by your physician. If you have experienced constipation for 12 weeks or longer, it is important for you to have your symptoms evaluated by a physician.