Don’t make straining a habit

What is constipation?

Constipation is not only about how often you pass stool. Doctors use the term when bowel movements are infrequent (fewer than three a week) or difficult — hard or lumpy stools, straining, a feeling that the bowel has not emptied, or needing to press on the abdomen to pass stool. Normal ranges from three times a day to three times a week.

Why does it happen?

The colon's job is to absorb water from digested food. When stool moves slowly, more water is drawn out and it becomes hard and difficult to pass. The common reasons are:

• Too little fibre — refined flour, white rice, fast food and too few vegetables, fruit, pulses and whole grains
• Too little water, especially in hot weather
• Inactivity, long hours of sitting, being bedridden
• Ignoring the urge to go, or a rushed morning routine
• Travel, a change in routine or diet
• Pregnancy and older age
• Medical conditions: underactive thyroid, diabetes, Parkinson's disease, spinal cord problems
• Medicines: some painkillers (especially opioids), iron and calcium tablets, aluminium- or calcium-based antacids, and some medicines for epilepsy, depression and blood pressure

If constipation began after starting a new medicine, tell your doctor — often a simple change solves it. Do not stop a prescribed medicine on your own.

Warning signs — see a doctor soon

Most constipation is harmless and improves with lifestyle changes. See a specialist without delay if constipation comes with any of these:

• Blood in the stool or black stools
• Unexplained weight loss or loss of appetite
• A recent, persistent change in bowel habit, particularly after age 45–50
• Anaemia (low haemoglobin) or unexplained tiredness
• Severe abdominal pain, swelling or vomiting, or being unable to pass gas
• A family history of bowel cancer or inflammatory bowel disease

These signs can point to a blockage, a polyp or bowel cancer, which need investigation — usually with a colonoscopy.

What long-term straining can lead to

Repeated straining and hard stools raise pressure in the anal canal. Over time this can cause piles (haemorrhoids), a painful tear called an anal fissure, a feeling of heaviness, faecal impaction in older or bedridden people, and in some cases rectal prolapse. Treating the constipation is the first step in treating all of these.

What helps: everyday measures

• Increase fibre gradually to about 25–30 g a day: whole wheat or millet rotis, dal, rajma, chana, vegetables, fruit with the peel (guava, pear, apple, papaya), and seeds such as flax. Add fibre slowly over two to three weeks to avoid bloating.
• Drink enough water through the day — more when you add fibre.
• Move daily: a 30-minute walk stimulates the bowel.
• Keep a routine: try to go at the same time each day, ideally after breakfast, and never ignore the urge.
• Use a footstool under your feet on a Western toilet so your knees are above your hips; this straightens the anorectal angle and reduces straining.
• Limit time on the toilet — no phones or reading; if nothing happens in five minutes, try later.

Laxatives and medical treatment

If lifestyle measures are not enough, a doctor may suggest a fibre supplement (such as isabgol/psyllium) or an osmotic laxative (such as lactulose or polyethylene glycol), which draw water into the stool. Stimulant laxatives are used for short periods. Long-term, unsupervised use of laxatives or "herbal churans" is best avoided.

When constipation is long-standing and does not respond, tests may include thyroid and sugar levels, a colonoscopy, and specialised tests of how the pelvic floor muscles work (anorectal manometry). Some people have a co-ordination problem of these muscles that responds to biofeedback therapy rather than laxatives.