Constipation refers to infrequent or hard stools, or difficulty passing stools. Constipation may involve pain during the passage of a bowel movement, inability to pass a bowel movement after straining or pushing for more than 10 minutes, or no bowel movements after more than 3 days. Infants who are still exclusively breastfed may go 7 days without a stool.

Normal patterns of bowel elimination vary widely from person to person and you may not have a bowel movement every day. While some healthy people have consistently soft or near-runny stools, others have consistently firm stools, but no difficulty passing them.

When the stool is hard, infrequent, and requires significant effort to pass, you have constipation. The passage of large, wide stools may tear the mucosal membrane of the anus, especially in children. This can cause bleeding and the possibility of an anal fissure.

Constipation is most often caused by a low-fiber diet, lack of physical activity, not drinking enough water, or delay in going to the bathroom when you have the urge to defecate. Stress and travel can also contribute to constipation or other changes in bowel habits.

Other times, diseases of the bowel (such as irritable bowel syndrome), pregnancy, certain medical conditions (like an underactive thyroid or cystic fibrosis), mental health problems, neurological diseases, or medications may be the reason for your constipation. More serious causes, like colon cancer, are much less common.

Constipation in children often occurs if they hold back bowel movements when they aren't ready for toilet training or are afraid of it.

Children and adults should get enough fiber in their diet. Vegetables, fresh fruits, dried fruits, and whole wheat, bran, or oatmeal cereals are excellent sources of fiber. To reap the benefits of fiber, drink plenty of fluids to help pass the stool.

For infants with constipation:

• Over 2 months old -- try 2-4 ounces of fruit juice (grape, pear, apple, cherry, or prune) twice a day.
• Over 4 months old -- if the baby has begun solid foods, try baby foods with high-fiber content (peas, beans, apricots, prunes, peaches, pears, plums, spinach) twice a day.

Regular exercise is also important in establishing regular bowel movements. If you are confined to a wheelchair or bed, change position frequently and perform abdominal contraction exercises and leg raises. A physical therapist can recommend exercises appropriate for your physical abilities.

Stool softeners (such as those containing docusate sodium) may help. Additionally, bulk laxatives such as psyllium may help add fluid and bulk to the stool. Suppositories or gentle laxatives, such as milk of magnesia liquid, may establish regular bowel movements. Enemas or laxatives should be reserved for severe cases only. These methods should be used only if fiber, fluids, and stool softeners do not provide enough relief.

DO NOT give laxatives or enemas to children without first asking your doctor.

Call your doctor if you have:

• Sudden constipation with abdominal cramps and an inability to pass gas or stool (DO NOT take any laxatives -- call immediately!)
• Sharp or severe abdominal pain, especially if you're also bloated
• Blood in your stool
• Constipation alternating with diarrhea
• Thin, pencil-like stools
• Rectal pain
• Unexplained weight loss
• Been using laxatives for several weeks or self care is not working

Call if:

• An infant younger than 2 months is constipated
• An infant (except those exclusively breastfed) goes 3 days without a stool -- call immediately if the child is vomiting or irritable
• A child is holding back bowel movements in order to resist toilet training

Your doctor will perform a physical examination, which may include a rectal exam, and ask questions such as:

• How long have you had constipation?
• How many days between two bowel movements?
• Is it worse when you are stressed?
• What is the color, shape, and consistency of the stools?
• Is there any bleeding with bowel movements?
• Do you have any abdominal pain?
• What surgeries or injuries have you had?
• What medications do you take?
• Do you drink coffee or drink alcohol? Do you smoke?
• What other symptoms are also present?

The following tests may help diagnose the cause of constipation:

• Anorectal manometry (pressure measurements of the anus and rectum)
• Barium enema
• Blood tests such as a CBC, PT, or PTT
• Colonoscopy
• Proctosigmoidoscopy (an examination of the lower bowel)
• Stool studies
• Upper GI series
• X-rays of the abdomen

Avoiding constipation altogether is easier than treating it, but involves the same lifestyle measures:

• Eat lots of fiber.
• Drink plenty of fluids each day (at least 8 glasses of water per day).
• Exercise regularly.
• Go to the bathroom when you have the urge. Don't wait.

National Digestive Diseases Information Clearinghouse. Constipation page. Available at: http://digestive.niddk.nih.gov/ddiseases/pubs/constipation/index.htm. Accessed March 23, 2005.

Bleser S, Brunton S, Carmichael B, Older K, Rasch R, Steele J. Management of chronic constipation: Recommendations from a consensus panel. J Fam Pract. 2005 Aug;54(8):691-8.

Rao SS. Constipation: evaluation and treatment. Gastroenterol Clin North Am. 2003; 32(2): 659-683.