How to treat constipation and hard-to-pass stools

Perpetual motion

Daa00906's problems started when she was 10 years old. She developed anxiety about using the school toilets and tended to postpone going to the loo until she got home. This progressed to being anxious about any public toilets.

She now only gets the urge to open her bowels about twice a week, and has to strain really hard to get even a small amount of poop out. The stool is very large and she feels 'backed up', but she's terrified of pushing too hard in case she gets a rectal prolapse.

Daa00906 doesn't find her mum very supportive and dreads talking to her about her constipation. She realises she should be eating more healthily but feels it's too late for changes in her diet to make much of a difference. She wondered whether a doctor could help her but was scared they might suggest a colonoscopy. She had also thought about having an enema.

School of hard rocks

Constipation means different things to different people. Daa00906's difficulties with passing a large stool, needing to go less than three times a week and a feeling of incomplete emptying would certainly come into the medical definition of constipation.

At 15, Daa00906 is in that hinterland between childhood and adulthood. The fact that her problems started at the age of 10 suggests that she doesn't have the sort of developmental condition that one needs to think about with constipation in children. Such conditions (such as abnormal development of the spine affecting the nerve supply to the bowel) are normally picked up shortly after birth.

I'm also assuming that this is a long-term pattern for Daa00906. If she had previously been OK but was suddenly unable to open her bowels for five days this could be a feature of intestinal obstruction, especially if she was also unable to pass wind, developed severe abdominal pain, and started vomiting. Intestinal obstruction is a medical emergency which requires immediate medical attention.

Daa00906 also doesn't mention other 'red flag' signs (features that would alert a doctor that there was a serious problem) such as a blown-out (distended) tummy, severe pain passing a stool, bleeding from the rectum, slime (mucus) in the stools, or weight loss. Such features would suggest she needs to see a doctor sooner rather than later.

However, considering her tender years, her story, and the absence of worrying features, it's likely that Daa00906 has what is called functional constipation. This means there's a problem with the way the muscles of the bowel work rather than any serious underlying disease.

It's not unusual for this to start at school and often begins with children avoiding the perils of the school toilets and waiting until they are in the familiar surroundings of their own home.

When the going gets tough

Although it might take a bit of perseverance, functional constipation often responds to self-help remedies eventually. Daa00906 may well want to give these a try if she is reluctant to see a doctor.

Our forum posters have come up with several good ideas as to how Daa00906 can approach her problem. Laxatives are certainly worth a try. There are several different types and different dose ranges. Most are available over the counter, and a pharmacist can advise on the best options.

Osmotic laxatives

Jimmy06669 found that Miralax helped his daughter. This works by holding water in the stool to soften it. It is known as an osmotic laxative. Hellmum recommended a similar medicine in this group called Dulcolax, whilst Llewelyn suggested lactulose. Vince10 found good old magnesium (often available in the form of magnesium hydroxide) helpful. In view of the fact that Daa00906 needed to evacuate a large stool, an osmotic laxative would in the first instance be helpful to soften it. Llewelyn (who has posted lots of really sensible advice on this page) reminds us that when taking an osmotic laxative it's vital to drink lots of fluid. Any type of fluid will do but I wouldn't suggest you try whiskey or gin, which will bring its own problems.

Stimulant laxatives

Once the stools are softened, a stimulant laxative can be taken. This can be taken in place of the osmotic laxative or added to it. Stimulant laxatives stimulate the nerves in the large bowel, causing the muscles in the bowel to squeeze harder than normal.

Llewlyn recommends senna or a senna-containing preparation. Stimulant laxatives should only be used for a short period of time, because the body can get used to them and you can come to rely on them. However, in Daa00906's case, a short course is probably needed to clear the backlog that has built up.

Fibre

Fibre adds volume to the stools and helps them pass through the body. The best way to take fibre is naturally, by increasing the amount in your diet. Many fruits are high in fibre. Jimmy06669 recommends pears, peaches, prunes and apricots. He suggests avoiding bananas and there is some scientific evidence to support this. Thejudy68 recommends an apple a day to keep the doctor away. She also advises lots of vegetables. Broccoli, carrots, sweetcorn, peas, beans and pulses are all good sources of fibre.

Not everyone is a fan of fibre. Anony48066 advises Daa00906 to avoid fibre as it will just make the stool bulkier. I agree that to start with, a bulkier stool is the last thing that Daa00906 needs. However, once the backlog has been cleared with an osmotic and/or stimulant laxative, long-term fibre is a great way to prevent the problem from happening again.

Increasing dietary fibre may not be enough. If this is the case, there are lots of fibre-based laxatives available. Thejudy68 recommends Metamucil, a product based on psyllium. Other types of fibre laxative include methylcellulose and sterculia.

Other options

Daa00906 wonders whether an enema would help and this is certainly an option if a large stool is blocking the rectum. I wouldn't suggest any old homemade device or solution, however. Purpose-built enemas are available from the pharmacist, including Cleen and Micralax. Glycerine suppositories are less drastic, easier to insert and probably just as effective if the stool is low down in the rectum.

Our posters certainly come up with some novel ideas. Mary99261 wondered if Daa00906la would benefit from propping her legs up when she went to the loo. Apparently, there is a device she could buy on the internet, called a Squatty Potty.

Doctor's orders

I must say I was a little bit worried about Daa00906la's mention of the liquid stools she occasionally gets. Llewelyn raised the possibility of impaction. This is a condition in which a large hard stool forms a blockage in the rectum. Softer stools back up behind it and cannot get through, but occasionally liquid stool will seep out round the blockage. If Daa00906la does not have impaction yet, it sounds as if she will do so soon.

If the measures outlined above don't work after a week or so I would urge her to go to see her doctor. The doctor can prescribe stronger doses of the laxatives she has already been taking, or other stronger medicines. It's likely the doctor may want to examine her, but unlikely that they would want to do any investigations in the initial stages. The prospect of a colonoscopy is highly unlikely.

Finally, mums can be astonishingly receptive when they learn their child has a serious problem. Whatever has gone on in the past, Daa00906la should not assume that her mum would not be sympathetic. My advice to her is to reconsider involving her mum, who may be able to offer more support than she imagines. As she is under 16, there may also be consent issues to consider if she needed treatment from a doctor.