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Stool Formation

Stools are formed in the colon during the last phase of Digestion. A well formed stool is soft
and flexible. Measuring about 1.5 in diameter and about four to seven inches in length.
Well formed stools are easily passed without straining.
Stools are formed from feces. Feces are the particles of waste matter that is left over after
the body has processed and absorbed nourishment from the foods we eat. Feces contain
water, dietary fiber, inorganic salts, dead cells, bacteria, and anything the body cannot or
will not absorb.
Feces first enter the colon in liquid form. During digestion, chemical and muscular actions
work toward changing the foods we eat into a nutrient-rich-liquid called chyme. 90% of
nutrient absorption takes place across the surface area of the 25 foot long small intestine
(the other 10% is absorbed by the stomach and the colon). Villi, projections of mucosa
lining the small intestine, absorb nutritive components from the liquid chyme and increase
the surface area for absorption and digestion. The muscles that surround the small intestine
contract and relax in a mild wavelike motion called peristalsis to move the chyme through
the small intestine. After the nutrients are absorbed, the small intestine passes the
remaining liquid into the colon through the illeocecal valve. At this point the liquid, formerly
nutrient rich chyme, is now made up of waste particles feces.
Through peristalsis, the muscles of the colon and the
abdomen advance the liquid feces through the colon and
compress the fecal matter into stools. During this process the
colon extracts water from liquid feces as it is passed over the
surface of the lumen (the interior) of the colon. The water is
absorbed by the lumen, leaving the larger waste particles to
be further tumbled along and formed into stools. This is somewhat similar to spraying down
a sink or a side walk with water. The pressure and the water tumble the particles along.
Particles that are heavier than water form piles of debris as the water is drained away. This
debris is formed into stools.
Water and Dietary Fiber play critical roles in the formation of stools
and in Healthy Bowel Function. Water can move across the
intestinal mucosa of the lumen in both directions. While it is the job
of the colon to extract water from the liquid feces, the Insoluble
Fiber in the feces draws some of that water back into the stool from
the lumen as the stool is formed. These fibers can swell up to 20
times their original size. The fluid these fibers retain creates volume
and weight in the stool. Increased volume and weight stimulates
muscle contractions. When these muscle contractions occur, stools
move more quickly through the colon. Optimal movement of stool
through the colon is referred to as Speedy Stool Transit Time.
Movement that is too fast results in diarrhea, and movement that istoo slow results in

constipation. Through fermentation, healthy intestinal bacteria convert the Soluble


Fiber present in the chyme, into a gel that becomes incorporated throughout the fecal mass
as the stool is formed. This gel creates stools that are soft, flexible and easy to pass. Gel
that is not incorporated into the stool nourishes the lining of the colon and nourishes the
growth of healthy bacteria. A Healthy Colon Lininglubricates the passage of stools. This also
contributes to speedy stool transit time.
Muscular activity, fluids, dietary fiber, bacteria, a
healthy colon lining and speedy stool transit time
work together to produce stools of good texture,
volume, and weight that are soft, flexible and
easy to pass without straining. A prompt response
to the Defecation Reflex ensures this outcome.

Dietary Fiber
Fiber is the material that gives plants structure, texture and support. Dietary Fiber refers to
these fibers in edible plant forms. These fibers are complex carbohydrates with little caloric
value. Dietary fiber passes through the gastro intestinal tract mostly undigested. Dietary
fiber, plays an important role in health maintenance and disease prevention.
Dietary fiber reduces cholesterol, reduces the risk of heart disease, provides relief from
constipation and contributes to bowel health. Because it softens stools, fiber can also help
reduce the pain associated with hemorrhoids and anal fissures. Because fiber can create a
feeling of fullness, it may also be helpful with controlling
appetite. Constipation, Impactions and Diarrhea can be prevented by adequate intake of
dietary fiber. Though some what controversial, dietary fiber may also help to reduce the risk
of colon and rectal cancer. Some studies have associated a high fiber diet that is also low in
saturated fat and cholesterol with a reduction in the risk of certain cancers (colon, rectal and
breast), diabetes (better control of blood sugar), digestive disorders (diverticulosis) and
heart disease. Because many foods that are high in fiber are also high in antioxidants,
phytochemicals and other substances that may offer protection against disease, researchers
are uncertain that it is fiber specifically that is responsible for these reduced health risks.
There are many forms of dietary fiber. Though much is known
about Insoluble andSoluble fiber, the functions of all types of dietary fiber are not fully
known. Most plant foods contain some of each kind of fiber. A high-fiber diet will contain
many forms of fiber but it is most often described as a diet that is high in the insoluble and
soluble forms of fiber. A high-fiber diet contains about 20-35 grams of fiber per
day. Animal products such as milk, eggs and meat do not contain fiber. Refer to the Dietary
Fiber Chart for some helpful information about the fiber content of foods. How can I include
more fiber in my diet?
Dietary fiber helps to normalize bowel function. Though insoluble and soluble fiber each
have very different effects on bowel function, they work together in the production of well
formed stools and in the creation of healthy bowel function. Individuals on a high-fiber

diet usually store their feces for less than 18 hours (less than one day). Most Americans,
eating a conventional diet typically store their feces for 3 days. A conventional American diet
is usually one that is high in animal fat (meat, dairy products, and eggs), refined foods
(white sugar, white flour), sweets (rich desserts, candy), and convenience foods. A
conventional American diet is also low in dietary fiber. As a result, many Americans
experience constipation because they have poorly functioning bowels. To achieve Healthy
Bowel Function both insoluble and soluble fiber must be included in the diet.
Consuming both soluble and insoluble fiber in adequate quantities improves bowel health
by:
1.
2.
3.
4.
5.
6.

Stimulating muscle contraction & bowel contraction.


Toning the intestinal muscles.
Producing soft stools of good texture and volume.
Speeding overall stool transit time.
Decreasing high colonic pressure.
Increasing (restoring) the diameter of the large intestine.

Elements of Healthy Bowel Function


1. Strong Abdominal And Intestinal Muscles
The job of the colon is to extract water from the chyme (waste matter) that enters the colon
so that stools can be formed and eliminated. The colon accomplishes this task with the aid
of the intestinal and abdominal muscles. These muscles contract and relax in a wave like
motion (peristaltic activity) to express water from the chyme, to form the stools and to
move the stools down to the rectal sack. These muscles are toned around well formed
stools. They are also toned and strengthened by five minutes of simple daily exercise. When
these muscles become weak, stool moves slowly through the colon. This is known as slow
intestinal motility. Stool that remains too long in the colon becomes dry, hard, and difficult
to pass as the colon continues to extract water from the stool. This leads to straining while
trying to eliminate stool. Straining during elimination can lead to the development of
diverticuli, or pouches in the colon. These diverticuli can trap waste matter and clumps of
dry stool, which can become infected, inflamed and cause bleeding. This is a serious
condition called Diverticulosis.

How can I strengthen my intestinal muscles?


Avoid laxative use. Do five minutes of simple daily exercise such as walking, leg
lifts, or climbing stairs will help to support the strength of your intestinal and
abdominal muscles. Physical therapy including leg lifts and knee bends can help
tone the muscles of individuals who are confined to bed. Additionally, intestinal
muscles are exercised and toned around well formed stools that a high fiber diet
can produce. High fiber Fruit-Eze, all natural fruit blend, can be easily
incorporated into the diet to help you to produce well formed stools that will help
you to increase and maintain your intestinal muscle tone.

What contributes to slow intestinal motility?

Lack of daily exercise reduces muscle tone.

Excessive bed rest due to illness or depression reduces muscle tone.

A low fiber diet reduces muscle tone. Poorly formed stools do not regularly maximize
the extension and contraction of colon muscles.

Hyperosmotic Laxative and Stimulant Laxative use reduces muscle tone. Poorly
formed stools do not maximize the extension and contraction of colon muscles.Avoid
laxative use unless directed otherwise by your doctor.

Fiber Laxative use can slow down intestinal motility. If not taken with adequate
amounts of water, blockages can form. Avoid laxative use unless directed otherwise
by your doctor.

Medications that relax muscles can also relax the intestinal muscles.

Medications that reduce pain interfere with signals to the brain that control the
normal peristaltic (muscular) activity of the colon.

Chronic diarrhea reduces muscle tone. Poorly formed stools do not regularly
maximize the extension and contraction of colon muscles.

Certain diseases are characterized by low intestinal motility.

Surgery can cause a temporary paralysis of the intestines.

The process of aging may include reduced intestinal motility for some individuals.

2. A Healthy Colon Lining


A healthy colon lining is critical to bowel health. A healthy colon lining lubricates the passage
of stool through the colon. A smooth passage, means that the waste is eliminated quickly. A
healthy colon lining protects delicate nerve endings in the colon that send messages about
the colon to the brain. When protected, these messages are reliably transmitted. A healthy
colon lining promotes healthy bacterial growth. Healthy bacteria helps to further break down
waste and generates more lubrication in the process. Healthy bacteria also cleanses the
colon and protects it against infection. Fluids and dietary fiber help to create a healthy colon
lining. Overtime, without adequate fluids and dietary fiber, the colon lining will deteriorate
contributing to constipation and growth of harmful bacteria. This can lead to impactions and
infections.

How can I improve the lining of my colon?

Avoid diuretic s and laxatives. To improve the health of your colon lining, drink
adequate amounts of Fluids each day and consume Dietary Fiber at each meal.
Fluids are critical to the proper functioning of all the organs especially those that
eliminate waste. Water is the main ingredient in the mucus that lines the colon.
Since we eliminate fluids each time we eliminate waste, these fluids need to be
replaced in order to maintain proper organ function. Dietary Fiber is broken
down into a gel that helps to lubricate the colon. This gel becomes incorporated
in the stool mass and helps to keep it soft and flexible. This gel nourishes
healthy bacterial growth which further breaks down the gel into fatty acids.
Fatty acids act like a natural laxative in the colon. Together, fluids and fiber help
to produce stools of good texture and volume that are easily passed without
straining. Delicious high fiber Fruit-Eze, all natural fruit blend, can be easily
incorporated into the diet to improve the lining of your colon and to help you to
produce stools of good texture that are easy to pass.

What contributes to the destruction of the colon lining?

A low fiber diet will starve the healthy bacteria of nourishment they require to
survive, and reduce the amount of lubrication that they contribute to the colon.

Not getting enough fluids will reduce the amount of mucous the colon can produce to
lubricate and protect the colon lining and to foster healthy bacterial growth.

Hyperosmotic Laxative and Stimulant Laxative use can dehydrate the body rapidly
deteriorating the colon lining. Long term use can destroy the colon lining and actually
contribute to constipation and constipation leading to impaction. Avoid laxative use
unless directed otherwise by your doctor.

Fiber Laxative use can dehydrate the body overtime slowly deteriorating the colon
lining and contributing constipation and the risk of impaction. Avoid laxative use
unless directed otherwise by your doctor.

The stress of dehydration can deteriorate not only the colon lining but also the
tissues of the colon itself.

Certain Medications, such as antibiotics, can kill healthy colonic bacteria needed to
cleanse the colon and protect the colon from infection.

Intestinal infections can damage the colon lining and scar the colon tissue in the area
of the infection.

3. Speedy Stool Transit Time


Stool transit time is the length of time it takes for the chyme (waste matter) to pass
through the colon until it is eliminated during a bowel movement. A speedy stool transit
time is desirable because it helps to produce well formed stools that are neither too hard or
too soft. With speedy stool transit time, just the right amount of water is extracted from the
chyme in the formation of the stool as it passes through the colon. Toned muscles and

adequate fluid and fiber intake work together to create a speedy stool transit time. Without
them, constipation will result.

How Can I Improve My Stool Transit Time?


Avoid diuretics and laxatives. Strengthening abdominal and intestinal
muscles will improve intestinal motility. Drinking adequate amounts of
Fluids and eating Dietary Fiber at each meal helps to consistently produce
soft and flexible stools of good volume and texture. The intestinal muscles
are exercised around these well formed stools. Together, routine exercise
along with fluid intake and dietary fiber intake, ease the movement of the
stool through the colon and help to maintain intestinal tone and a speedy
stool transit time. Delicious high fiber Fruit-Eze, all natural fruit blend, can
be easily incorporated into the diet to increase your stool transit time.

What contributes to reduction in stool transit time?

A low fiber diet reduces stool transit time. Stools of poor quality do not pass easily
through the colon.

Dehydration reduces the volume of mucus the colon can produce and this reduces
stool transit time. Mucus provides lubrication that eases the passage of stool through
the colon and fosters healthy bacterial growth.

Hyperosmotic Laxative and Stimulant Laxative use can destroy the colon lining and
muscle tone of the colon resulting in reduced stool transit time. Avoid laxative use
unless directed otherwise by your doctor.

Fiber Laxative use can slow down intestinal motility and cause dehydration. If not
taken with adequate amounts of water, full or partial blockages (impactions) can
form that will slow down or restrict stool transit. Avoid laxative use unless directed
otherwise by your doctor.

Lack of exercise and excessive bed rest reduces muscle tone and stool transit time.

Damage to nerves in the colon from injury, infections, surgery or stroke can reduce
stool transit time.

Medications that relax muscles can also relax the intestinal muscles reducing stool
transit time.

Medications that reduce pain can interfere with signals to the brain that control the
normal peristaltic (muscular) activity of the colon and reduce stool transit time.

Certain diseases are characterized by low intestinal motility.

Surgery can cause a temporary paralysis of the intestines reducing stool transit time.

Intestinal infections can reduce stool transit time.

Constipation and impactions reduce stool transit time.

The process of aging may include reduced stool transit time for some individuals.

. Normal Functioning Defecation Reflex


A normal functioning defecation reflex produces a muscular contraction
that serves as a signal to the body that it is time to move the bowels
and eliminate stools. Prompt response to the defecation reflex by going
to the bathroom when it is activated, prevents stool from drying out and
becoming difficult to pass. The defecation reflex may be triggered about
45 minutes to an hour upon rising from sleep, after drinking a hot
beverage, or after eating a meal. The defecation reflex will disengage
after about 15 minutes of being ignored. Like any other muscle that is
not used, it will breakdown and fail to function if continuously ignored.
When the defecation reflex is ignored, constipation will result as the
stool that is retained in the colon becomes dried out, hard and difficult
to pass. Retained waste can stretch out the rectal sack. A stretched out
rectal sack requires more and more stool to fill the rectal sack before
the reflex will be activated. This causes even more stool to dry out as it
collects behind the previously retained stool.

How can I improve My defecation reflex?


Avoid diuretics and laxatives. A prompt response to the
defecation reflex by eliminating the bowel will help to
prevent stool from drying out and will keep this reflex
working properly. To prevent breakdown of this reflex, do
not ignore the defecation reflex for longer than a few
minutes. Pay attention to bowel movement stirrings that
occur from day to day. For instance, some people will
routinely have the urge to move their bowel in the morning
after waking up or after having breakfast. If this is true for
you, make the time to allow it to happen. If you have lost
use of the defecation reflex or you suspect that it is more
normal for you to move your bowels more frequently,
consult with your doctor. It is possible to Retrain The Bowel
with a few changes in lifestyle and diet. Drinking adequate
amounts of Fluids and consuming Dietary Fiber at each meal
helps to consistently produce soft and flexible stools of good
volume and texture. These stools are easily passed when
the defecation reflex is stimulated. High fiber Fruit-Eze, all
natural fruit blend, can be easily incorporated into the diet
to help recover, improve and maintain the defecation reflex.

Some of our customers report recovery of their defecation


reflex after a few weeks of using all Natural Fruit-Eze fruit
blend.

What contributes to the destruction of the defecation


reflex?

Routinely ignoring the defecation reflex will cause it to break


down and fail to function properly.

Hyperosmotic Laxative and Stimulant Laxative use destroys the


defecation reflex as the urgent eliminations of the stool prevents
normal stimulation and operation of the defecation reflex. Avoid
laxative use unless directed otherwise by your doctor.

Withholding stool to avoid a bowel movement breaks down the


stimulant and response action of the reflex and stretches out the
rectal sack. A stretched out sack requires more stool to collect
before the reflex will be stimulated again.

Fear of painful defecation due to hemorrhoids or anal fissures


can cause some people to withhold stools and delay the
stimulation and response action of the defecation reflex. This will
also stretch out the rectal sack and break down the reflex.

Medications that relax muscles can also relax the defecation


reflex.

Medications that reduce pain can interfere with signals to the


brain that stimulate the defecation reflex.

Surgery can cause a temporary paralysis of the intestines and


the defecation reflex.

The process of aging may include breakdown of the defecation


reflex for some individuals.

Constipation is a common problem. It means either going to the toilet less


often than usual to empty the bowels, or passing hard or painful poo (also
called faeces, stools or motions). Constipation may be caused by not
eating enough fibre, or not drinking enough fluids. It can also be a sideeffect of certain medicines, or related to an underlying medical condition.
In many cases, the cause is not clear. Laxatives are a group of medicines
that can treat constipation. Ideally, laxatives should only be used for short
periods of time until symptoms ease.

Note: there is a separate leaflet called Constipation in Children.

What is constipation?

Constipation is common. If you are constipated it causes one or more of the following:

Poo (faeces, stools or motions) becomes hard, and difficult or painful to pass.
The time between toilet trips increases compared with your usual pattern. (Note:
there is a large range of normal bowel habit. Some people normally go to the toilet
to pass stools 2-3 times per day. For others, 2-3 times per week is normal. It is
a change from your usual pattern that may mean that you are constipated.)
Sometimes, crampy pains occur in the lower part of your tummy (abdomen) You
may also feel bloated and feel sick if you have severe constipation.

Related articles

Constipation in Children
Laxatives
Common Problems in Pregnancy

What are the causes of constipation?


Known causes include the following:

Not eating enough fibre (roughage) is a common cause. The average person

in the UK eats about 12 grams of fibre each day. But, 18 grams per day is
recommended by the British Nutrition Foundation. Fibre is the part of plant food
that is not digested. It remains in your gut. It adds bulk to the poo (faeces, stools or
motions), and helps your bowels to work well. Foods high in fibre include: fruit,
vegetables, cereals and wholemeal bread.
Not drinking much may make constipation worse. Stools are usually soft and

easily passed if you eat enough fibre, and drink enough fluid. However, some
people need more fibre and/or fluid than others in order to avoid constipation.
Some special slimming diets are low in fibre, and may cause constipation.

Some medicines can cause constipation as a side-effect. Examples

are painkillers(particularly those with codeine, such as co-codamol, or very strong


painkillers, such as morphine), some antacids, some antidepressants
(including amitriptyline) and iron tablets, but there are many others. See the list of
possible side-effects on the leaflet that comes with any medicine that you may be
taking. Tell a doctor if you suspect a medicine is making you constipated. A change
of medication may be possible.
Various medical conditions can cause constipation. For example,

an underactive thyroid, irritable bowel syndrome, some gut disorders, and


conditions that cause poor mobility, particularly in the elderly.
Pregnancy. About 1 in 5 pregnant women will become constipated. It is due to
the hormonal changes of pregnancy that slow down the gut movements. In later
pregnancy, it can simply be due to the baby taking up a lot of room in the tummy
and the bowels being pushed to one side.

Unknown cause (idiopathic)


Some people have a good diet, drink a lot of fluid, do not have a disease or take any
medication that can cause constipation, but still become constipated. Their bowels are
said to be underactive. This is quite common and is sometimes called functional
constipation or primary constipation. Most cases occur in women. This condition tends
to start in childhood or in early adulthood, and persists throughout life.

Do I need any tests?


Tests are not usually needed to diagnose constipation, because symptoms are often
typical.
However, tests may be advised if you have any of the following:

If regular constipation is a new symptom, and there is no apparent cause, such

as a change in diet, lifestyle, or medication. This is known as a 'change in bowel


habit' and should be investigated if it lasts for more than about six weeks.
If symptoms are very severe and not helped with laxative medication.
If other symptoms develop. More worrying symptoms include passing blood from
your bowel; weight loss; bouts of diarrhoea; night-time symptoms; a family history
of colon cancer or inflammatory bowel disease (Crohn's disease or ulcerative
colitis); or other unexplained symptoms in addition to constipation.

What can I do to ease and to prevent constipation?


These measures are often grouped together and called lifestyle advice.

Eat foods that contain plenty of fibre

Fibre (roughage) is the part of plant food that is not digested. It stays in your gut and is
passed in the poo (faeces, stools or motions). Fibre adds bulk and some softness to the
stools. High-fibre foods include the following:

Wholemeal or whole-wheat bread, biscuits and flour.


Fruit and vegetables. Aim to eat at least five portions of a variety of fruit and

vegetables each day. One portion is: one large fruit such as an apple, pear, banana,
orange, or a large slice of melon or pineapple; OR two smaller fruits such as plums,
satsumas, etc; OR one cup of small fruits such as grapes, strawberries, raspberries,
cherries, etc; OR one tablespoon of dried fruit; OR a normal portion of any
vegetable (about two tablespoons); OR one dessert bowl of salad.
Wholegrain breakfast cereals such as All-Bran, Bran Flakes, Weetabix,

Shredded Wheat and muesli. A simple thing like changing your regular breakfast
cereal can make a big difference to the amount of fibre you eat each day.
Brown rice, and wholemeal spaghetti and other wholemeal pasta.

Although the effects of a high-fibre diet may be seen in a few days, it may take as long
as four weeks. You may find that if you eat more fibre (or take fibre supplements - see
below), you may have some bloating and wind at first. This is often temporary. As your
gut becomes used to extra fibre, the bloating or wind tends to settle over a few weeks.
Therefore, if you are not used to a high-fibre diet, it is best to increase the amount of
fibre gradually.
Note: have lots to drink when you eat a high-fibre diet or fibre supplements. Drink at
least two litres (about 8-10 cups) per day. This is to prevent a blockage of the gut, which
is a rare complication of eating a lot of fibre without adequate fluid. See below in the
section 'Bulk-forming laxatives' for an explanation.
A separate leaflet in this series, called Fibre and Fibre Supplements, gives more details
on high-fibre foods.

Related blogs

Piles just a pain in the backside?


Irritable Bowel Syndrome just puff and wind?

Have plenty to drink


Aim to drink at least two litres (about 8-10 cups) of fluid per day. You will pass much of
the fluid as urine, but some is passed out in the gut and softens the stools. Most sorts of
drink will do, but alcoholic drinks can be dehydrating and may not be so good. As a
start, try just drinking a glass of water 3-4 times a day in addition to what you normally
drink.

Sorbitol
Sorbitol is a naturally occurring sugar. It is not digested very well and draws water into
the gut, which has an effect of softening the stools. In effect, it acts like a natural
osmotic laxative (osmotic laxatives are explained later). So, you may wish to include
some foods that contain sorbitol in your diet. Fruits (and their juices) that have a high
sorbitol content include apples, apricots, gooseberries, grapes (and raisins), peaches,
pears, plums, prunes, raspberries and strawberries. The concentration of sorbitol is
about 5-10 times higher in dried fruit. Dried or semi-dried fruits make good snacks and
are easily packed for transport - for example, in a packed lunch.

Exercise regularly, if possible


Keeping your body active helps to keep your gut moving. It is well known that disabled
people, and bed-bound people (even if just temporarily whilst admitted to hospital) are
more likely to get constipated.

Toileting routines
Do not ignore the feeling of needing the toilet. Some people suppress this feeling if they
are busy. It may result in a backlog of stools which is difficult to pass later. When you go
to the toilet, it should be unhurried, with enough time to ensure that you can empty
your bowel.
When mobility is limited - for example, in people who are frail or who have dementia - it
is important for carers to see that they have sufficient help to get to the toilet at the
time they need to go; also, that they have a regular, unhurried toilet routine, with
privacy. As a rule, it is best to try going to the toilet first thing in the morning or about
30 minutes after a meal. This is because the movement (propulsion) of stools through
the lower bowel is greatest in the mornings and after meals (due to the gastrocolic
reflex).
Positioning on the toilet is also important, especially for elderly people with constipation.
Western-style toilets actually make things more difficult - squatting is probably the best
position in which to pass stools. Putting a small footstool under your feet is a simple way
to change your toilet position to aid the passage of stools. Relax, lean forward and rest
your elbows on your thighs. You should not strain and hold your breath to pass stools.

What are the treatments for constipation?

Treatment with a laxative is needed only if the lifestyle measures above do not work
well. It is still worth persisting with these methods, even if you end up needing to use
laxatives.
For short-term uncomplicated constipation, you may even choose to treat yourself
(without visiting the GP), by buying laxatives in the pharmacy or supermarket. In shortterm constipation, laxatives can be stopped once the poo (faeces, stools or motions)
becomes soft and easily passed again. You should probably visit your GP if you are
struggling to manage short-term constipation yourself, or if you have longer-term
(chronic, or persistent) constipation. All the different types of laxative are available on
prescription.
Chronic (persistent) constipation can be more difficult to treat. Laxatives are usually
needed for longer periods (sometimes even indefinitely) and they should not be stopped
abruptly. Chronic constipation is sometimes complicated by a backlog of hard faeces
building up in the bowel (faecal loading) or even partially blocking it (impaction). If
loading and impaction occur they need to be treated first, often with much higher doses
of laxatives. Then a normal maintenance dose of laxatives is used to keep the bowels
moving.
There are four main groups of laxatives that work in different ways:

Bulk-forming laxatives.
Stimulant laxatives.
Osmotic laxatives.
Faecal (stool) softener laxatives.

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Bulk-forming laxatives
Sometimes these are known as fibre supplements. These increase the bulk of your
stools in a similar way to fibre. They can have some effect within 12-24 hours but their
full effect may take several days to develop.

Unprocessed bran is a cheap fibre supplement. If you take bran, it is best to build
up the amount gradually. Start with two teaspoons a day, and double the amount
every five days until you reach about about 1-3 tablespoons per day. You can
sprinkle bran on breakfast cereals, or mix it with fruit juices, milk, stews, soups,
crumbles, pastries, scones, etc.

Other fibre supplements include ispaghula (psyllium), methylcellulose, sterculia,


wheat dextrin, inulin fibre, and whole linseeds (soaked in water).

There are various branded products that contain these ingredients. Examples are:

Fibrelief, Fybogel, Isogel, Ispagel Orange and Regulan - these all contain
ispaghula.
Celevac - contains methylcellulose.
Normacol and Normacol Plus - both contain sterculia.

A note of caution: fibre and bulk-forming laxatives partly work by absorbing water (a bit
like blotting paper). The combination of bulk-forming laxatives and fluid usually
produces soft, bulky stools which should be easy to pass out. When you eat a high-fibre
diet or take bulk-forming laxatives:

You should have plenty to drink. At least two litres per day (8-10 cups). The stools

may become dry and difficult to pass if you do not have enough to drink. Very
rarely, lots of fibre or bulk-forming laxatives and not enough fluid can cause an
obstruction in the gut.
You may notice an increase in wind (flatulence) and tummy (abdominal) bloating.
This is normal and tends to settle down after a few weeks as the gut becomes used
to the increase in fibre (or bulk-forming laxative).

Occasionally, bulk-forming laxatives can make symptoms worse if you have very severe
constipation. This is because they may cause abdominal bloating and discomfort
without doing much to clear a lot of faeces which are stuck further down the gut. See a
doctor if you feel that bulk-forming laxatives are making your symptoms worse.

Stimulant laxatives
These stimulate the nerves in the large bowel (the colon and rectum, sometimes also
called the large intestine). This then causes the muscle in the wall of the large bowel to
squeeze harder than usual. This pushes the stools along and out. Their effect is usually
within 8-12 hours. A bedtime dose is recommended so you are likely to feel the urge to
go to the toilet sometime the following morning. Stimulant laxative suppositories act
more quickly (within 20-60 minutes). Possible side-effects from stimulant laxatives
include abdominal cramps, and long-term use can lead to a bowel that is less active on
its own (without laxatives). This can be thought of as a 'lazy bowel'.
Stimulant laxatives include bisacodyl, dantron, docusate, glycerol, senna and sodium
picosulfate. These medicines can be prescribed on a prescription in the unbranded
(generic) form. Commercially branded versions (proprietary brands) contain the same

ingredients, but are generally only available for purchase over-the-counter. Examples
include:

Dulcolax - contains bisacodyl.


Dioctyl, Docusol and Norgalax Micro-enema - all contain docusate.
Manevac and Senokot - are both brands that contain senna. Senokot
tablets are not available on prescription. Manevac also contains the bulk-forming
laxative ispaghula.
Dulcolax Perles - contain sodium picosulfate.

Osmotic laxatives
These work by retaining fluid in the large bowel by osmosis (so less fluid is absorbed
into the bloodstream from the large bowel). There are two types - lactulose and a group
called macrogols (also called polyethylene glycols). Lactulose can be bought over-thecounter as Duphalac, Lactugal and Regulose. Movicol, Movicol-Half and
Movicol Paediatric Plain all contain macrogols and are available on prescription.
Lactulose can take up to two days to have any effect so it is not suitable for the rapid
relief of constipation. Possible side-effects of lactulose include abdominal pain and
bloating. Some people find the taste of lactulose unpleasant. Macrogols act much faster,
and can also be used in high doses to clear faecal loading or impaction. Stronger
osmotic laxatives (such as magnesium salts and phosphate enemas) can be used to
clear the bowel quickly and in situations such as before bowel surgery.

Faecal softeners
These work by wetting and softening the faeces. The most commonly used is docusate
sodium (which also has a weak stimulant action too). Bulk-forming laxatives also have
some faecal-softening properties. Arachis (peanut) oil enemas are occasionally used to
soften impacted faeces in the rectum (the lowest part of the colon, just before the back
passage (anus)).
Liquid paraffin used to be commonly used as a faecal softener. However, it is now not
recommended, as it may cause side-effects such as seeping from the anus and irritation
of the skin, and it can interfere with the absorption of some vitamins from the gut.

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Which laxative should I use and for how long?
The one recommended by your doctor or pharmacist will depend on factors such as
your own preference, the symptoms of constipation that you have, possible unwanted
effects, your other medical conditions, and cost. However, as a general rule:

Treatment with a bulk-forming laxative is usually tried first.


If poo (faeces, stools or motions) remains hard despite using a bulk-forming

laxative, then an osmotic laxative tends to be tried, or used in addition to a bulkforming laxative.
If stools are soft but you still find them difficult to pass then a stimulant laxative

may be added in.


High doses of the macrogol osmotic laxatives are used to treat faecal loading and
impaction - this should be under the supervision and advice of a doctor.

You should use a laxative only for a short time, when necessary, to get over a bout of
constipation. Once the constipation eases, you should normally stop the laxative. Some
people get into the habit of taking a laxative each day 'to keep the bowels regular' or to
prevent constipation. This is not advised, especially for laxatives which are not bulkforming.

Other treatments
Constipation is usually helped by the above treatments. Mostly, laxatives are taken by
mouth (orally). In some cases, it is preferable also to treat constipation by giving
medication via the back passage (anus).
Suppositories are pellet-shaped laxatives that are inserted into the the lowest part of
the colon (the rectum), via the anus. Glycerol suppositories act as a stimulant within the
rectum, encouraging the passing of poo (faeces, stools or motions). Sometimes, an
enema is needed in severe constipation. An enema is a liquid that is inserted into the
rectum and lower colon, via the anus. Enemas can be used to clear out the rectum in
severe constipation.

Other treatments may be advised by a specialist for people with severe constipation
who have not been helped by the treatments listed above.

Are there any complications of long-term (chronic)


constipation?
Short-term constipation or intermittent bouts of constipation are unlikely to cause any
long-term problems. Sometimes a split or tear in the anal skin (an anal fissure) can
occur with the passage of particularly big or hard poo (faeces, stools or motions). This is
very painful, and there may be a small amount of fresh red blood on the toilet paper.
Treatment of an anal fissure involves lifestyle measures (mentioned earlier) to keep the
stools soft, and perhaps laxatives too, to keep the stools really easy to pass. Local
anaesthetic ointment or glyceryl trinitrate (GTN) ointment can be prescribed by your GP
to ease the pain and help relax the muscles around the back passage (anus), to help the
fissure to heal.
Chronic constipation and long-term use of laxatives can mean that your bowel becomes
sluggish and 'lazy'. This means that the bowel doesn't work very well on its own,
without medication. Constipation then becomes a vicious cycle and even more chronic.
Try to avoid getting into this situation in the first place, and consult your GP for advice.
Some people with persistent and severe constipation do require regular laxatives.
Severe chronic constipation can result in faecal impaction. This is something that is
more likely in the elderly and infirm. Basically, a large mass of hard faeces blocks the
rectum. The mass is too big to pass and the rectum is stretched and enlarged, so the
muscles within it don't work so well to push faeces out. Sometimes people with this
problem think that they have diarrhoea. This is because liquid faeces, from above the
blockage, leak round the big lump of faeces, and out of the anus. This is known as
overflow diarrhoea. In this situation, you may also have faecal incontinence - that is, you
have no control over this liquid faeces leaking out. Faecal impaction with overflow
diarrhoea is likely if you have been getting progressively more constipated, and then get
liquid faeces, possibly explosive, and without much control. If a doctor or nurse
examines the anus, the hard faeces can often be felt, confirming the diagnosis. The
diagram below shows this process:

In order to treat impaction, higher doses of laxatives need to be used. Movicol is often
used, and sometimes enemas or suppositories. Temporarily, symptoms of diarrhoea
may worsen, but it is important to keep up with treatment, to clear the blockage. After
the large mass of faeces is cleared, laxatives are often needed for a while (or perhaps
even long-term or intermittently), to prevent the problem recurring.

Natural treatments for constipation


Prunes
Prunes (dried plums) have long been thought of as effective for constipation. However,
up until recently, there had been little scientific proof of this. But, a research trial
published in 2011 (cited at the end) lends support to the belief that prunes are good for
treating constipation.
In the trial, 40 adults with persistent constipation were studied as to the effect of prunes
versus ispaghula (psyllium) - a commonly used treatment for constipation. Briefly, on
average, 50 g of prunes (about six prunes) twice daily seemed to be better at easing
constipation than 11 g of ispaghula taken twice daily. This is just one small trial, but
does seem to confirm many people's belief that prunes are good for easing constipation.

The Beverley-Travis natural laxative mixture


This recipe (detailed below) was studied in a research trial that involved older people in
a care home. A treatment group was compared to a non-treatment group. The
conclusion of the study stated that "the Beverley-Travis natural laxative mixture, given

at a dosage of 2 tablespoons twice daily, is easy to use, cost-effective, and more


effective than daily prescribed laxatives at producing normal bowel movements". So, it
may be worth a try.

Recipe ingredients - one cup each of: raisins; pitted prunes; figs; dates;

currants; prune juice concentrate.


Directions - combine contents together in grinder or blender to a thickened

consistency. Store in refrigerator between uses.


Dose - two tablespoons twice a day. Increase or decrease dose according to
consistency and frequency of bowel movements.

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