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When the going gets tough: Constipation causes and treatments

Consumer Reports News: January 02, 2008 04:44 PM

Remember summer camp? Carefree days of new friend-ships, arts and crafts, swimming and boating, noisy mess halls, sing-along campfires, and the quiet time at the end of the day, followed by “Taps” and lights out. But not before the camp nurse, in her starched white uniform, made her appearance, clipboard and pencil in hand, and directed the question of the day to each, in turn: “Soft, medium, hard, or none?”—and she wasn’t taking egg orders for breakfast. A teaspoon of castor oil was the unwary respondent’s reward. Although that barbaric ritual has gone the way of public hangings, America’s obsession with daily bowel movements has persisted, largely due to persistent misconceptions. One myth is that waste products can accumulate and contaminate the rest of the body. Another is the belief that constipation can cause colon cancer. Patients have varying ideas about what constitutes constipation. One survey of nearly 600 constipated patients found that the main complaint of 79 percent was straining to pass the stool. Hard stools were a problem for 71 percent, while 57 percent complained of infrequent bowel movements. (Some had more than one complaint.)

The standard medical definition of constipation includes both of the following: 1. Infrequency (less than three bowel movements per week); and 2. Difficult passage of hard, dry stools. Most everyone agrees that anything between three times a week to three times a day can be considered normal. Constipation, as defined above, affects as many as one of every four Americans at one time or another, occurs more than twice as often in women as in men, and is more frequent among older people. Laxative sales in the U.S. are projected to exceed $850 million annually by 2010.

The cause may vary
Most of the time constipation is transient and related to changes in diet or schedule. Going on vacation, starting the Atkins diet, cutting out your usual exercise routine, or ignoring the morning urge in order to catch a train can play havoc with your bowels. A host of medications can cause constipation, including iron and calcium supplements, antidepressants, painkillers, and some blood-pressure drugs. Constipation can occur in pregnancy or be caused by serious conditions, such as an underactive thyroid, elevated blood-calcium levels, Parkinson’s disease, multiple sclerosis, irritable bowel syndrome, and actual blockages of the intestine by colon cancer. All can cause difficulty in moving one’s bowels.

Loosening up
Although a lack of fiber in the diet and dehydration can cause constipation, treating the problem by increasing dietary fiber and drinking eight glasses of water a day lacks the certainty of evidence-based medicine and often results in bloating, flatulence, abdominal distention, and increased urinary frequency. As long as you’re consuming adequate amounts of fiber (at least 25 grams per day) and drinking enough fluids to keep your urine a pale yellow, increases are not likely to help. Resuming your usual lifestyle after a vacation or switching the medication that was the cause usually does the trick. You won’t suffer permanent harm from a few days of constipation, but there’s nothing wrong with the temporary use of a laxative if you’re truly uncomfortable. But how to choose from the myriad products that line the shelves of your pharmacy?

The trick is to select a single-ingredient product that matches your particular complaint. If your main symptom is straining to pass hard, dry stools, try docusate (Colace and generic), an emollient type of laxative better known as a stool softener. If your problem is infrequency, choose a bulk laxative such as methylcellulose (Citrucel and generic), polycarbophil (Equalactin, FiberCon, and generic), or psyllium (Fiberall, Metamucil, and generic). If you have both complaints, take both kinds. Despite lore to the contrary, both types of laxatives are relatively safe for long-term use, but check with your physician. For more stubborn cases, as can occur in seniors with aging bowels, the occasional use of a stimulant laxative such as bisacodyl (Correctol, Dulcolax, and generic) may be necessary. Drawbacks are painful cramping and diarrhea with urgency. As with any symptom treated with an over-the-counter medication, if constipation persists longer than a week or two or recurs after treatment, it’s time to see your physician to find out if something more serious is going on.—Marvin M. Lipman, M.D.

Dr. Lipman has been Consumers Union's chief medical advisor since 1967. He is a diplomate of the American Board of Internal Medicine (certified in endocrinology and metabolism) and is clinical professor of medicine emeritus at New York medical College.

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