What Is Constipation? The Definitive Guide (Incl. Symptoms)

Have you ever sat on the toilet to only get crickets?  And, for consecutive days?

Have you ever felt you have to go, but nothing happens . . . Even after a PUSH or some STRAIN, your bowel movement then . . . eventually. . . happens?

And when it does, it’s lumpy, hard little stools, and/or we may even feel a sense of incomplete evacuation. Still after, not feeling completely comfortable.

If so, you most likely have experienced constipation.

How Common is Constipation?

Some people may have absolutely no idea what it’s like to have regular, healthy bowel movements (BMs).

Constipation is a very common digestive health symptom that has a significant personal effect on the quality of life for individuals physical and mental health and plays a remarkable economic effect (11).

Mild or acute constipation commonly goes undiagnosed and those experiencing the discomforts and health implications often suffer in silence until the issue may become chronic constipation (CC) (2).

Fortunately, the majority of those who suffer from CC do not have a life-threatening disorder (13). Occasionally, severe cases of constipation may be a sign of a more serious health issue(s) and require medical attention (13).

Symptoms are extremely common. In fact, constipation makes up a range of 2% to 34% of the general adult population, approximately 16% in adults overall and 33% in adults older than 60 years (10, 13).

The lack of consistency in prevalence statistics is attributed to the varying dietary habits, socioeconomic status, regional differences, race, society, and cultural norms studied (10).

Constipation is prevalent in nearly 15% of the North American population, or 42 million in the United States alone (3).

These figures represent 4-56 million physician visits each year in the United States (3), resulting in a total (direct and indirect) cost of $1.7 billion (6). According to a prospective study, the mean annual cost for treatment of chronic constipation per patient was $7,522.00 (6).

What is constipation?

The first problem with the inconsistency of understanding and defining constipation is that the word constipation has different meanings to different people.

Constipation means different things to different people

With the four main characteristics of BMs (frequency, stool form, ease of defecation, and bowel evacuation) noted above, constipation has been defined by a wide range of different terminology and definitions created by symptoms, objective measurements, or both (6).

Constipation may mean different symptoms to different people. For example for some, it’s how often they use the bathroom -- infrequent bowel movements. Whereas for others, it could be hard stools, defined by pushing or straining. It could mean the individual feels they have not completely emptied their bowels and still feel the sensation of needing to go.

Also even if you don’t feel constipated now, you still should be aware of these signs and symptoms if you’ve had a history of constipation, straining to defecate, drop little nuggets or separate hard lumps every now and then, or sometimes go a day without a movement (14). And lastly, even if you have diarrhea, you surprisingly may be still constipated. Here's the thing, some of the most severe cases of constipation present with diarrhea (14).

Think of bowel movements like kids sliding down a playground slide. Healthy bowel habits flow in a coordinated and predictable fashion from your colon into your rectum. This can be similar to a playground slide, when each child starts at the top of the slide and waits for the next child to finish sliding down before it’s their turn to go -- coordinated and in a timely fashion.

In the case of constipated bowels, basically what happens is the stool is stuck somewhere in your colon and the stool gets harder and more impacted the longer it's in your system. In this situation, stools build up behind it, like sliding down a busy playground slide -- if a child were to stay at the bottom of the slide, the kids behind would bump into each other at the end and pile up , maybe even jump off over the slide if it got too crowded.

Severe constipation works the same, with the impacted stool stuck somewhere in your colon, the solid stool piles up but the liquid stool behind can still sneak through the cracks to evacuate and come out loose, giving the individual diarrhea while constipated. Therefore, severe constipation can even manifest into loose bowel movements and in this case, it can be very confusing for both the patient and doctor when classifying constipation symptoms (14). This is called constipation with overflow diarrhea (14).

So then, how do we define the multi-symptomatic characteristics of constipation for individuals?

Transient constipation vs acute constipation vs chronic constipation

Constipation usually happens due to changes in our daily routine like diet, travel, stress, lack of exercise, etc. (15) Therefore, it’s a transient problem that responds quickly or spontaneously resolves itself with dietary and lifestyle interventions like diet changes, short-term laxatives or fiber supplementation (15). 

With more ongoing symptoms, you may have acute constipation. This can be sudden and occurs between 2 weeks to 3 months (15). Acute constipation can be more serious and can result from drug usage (opioids), hospitalization for surgery (such as orthopedic), immobilization (from injury or stroke), fecal impaction, or obstruction (stricture or cancer) (15).

On the other hand, chronic constipation (CC) lasts at least 3 months or more. CC can be very challenging to treat due to its multiple underlying primary or secondary causes (15). One quarter to half of all sufferers may or may not respond well to general constipation therapies, while some treatments can even worsen constipation symptoms and/or discomfort, which we’ll discuss later in this guide. (15) 

What is the clinical definition of chronic constipation?

In an effort to better define CC, physicians define and diagnose CC with Rome III Criteria which was established in 2000 and later updated in 2016 stating:

Modified Rome III Diagnostic criteria for functional constipation

Must include at least two or more of the following symptoms for the past 3 months with symptom onset at least 6 months before diagnosis: less than 3 bowel movements a week  Straining for more than 25% of bowel movements Lumpy or hard stools for at least 25% of bowel movements Sensation of incomplete evacuation for more than 25% of bowel movements Sensation of anorectal obstruction or blockage for more than 25% of bowel movements Manual manoeuvres to facilitate more than 25% of bowel movements (eg, digital evacuation, support of the pelvic floor) Loose stools are not present without use of laxatives Insufficient criteria for the diagnosis of IBS with constipation No organic disorder responsible for chronic constipation symptoms is present

(15)

The issue with Rome III criteria is that it may be too confusing or detailed for a primary care setting diagnosis (4). Because of this, most constipated patients do not fulfill the specifics of the Rome criteria and are only captured in ⅓rds of self-reported CC patients in observational studies (4). 

What does constipation feel like?

Therefore, there is a large percentage of people who feel that they have constipation yet don’t describe their complaints using any symptoms physicians typically use to define constipation (3).

Often complaints of constipation have little to do with how often they're going and more to do with how it feels (3). For some people constipation could be experiencing hard or lumpy stool which may be difficult to pass and/or requires pushing and straining to have a BM.

For others, it could mean their BM doesn’t completely evaluate after using the restroom, feeling as if they still ‘need to go’. While it could be a feeling of an anorectal obstruction or using manual maneuvers to pass stools. And lastly for some, they could have a combination of these constipation symptoms (3).

Some patients, “constipation” may be their perception or expectation of what it is to have ‘normal’ bowel habits (3). For example, an individual might think that if they don’t have a bowel movement on a daily basis then there is an issue. This leads to unnecessary concern or even abuse of supplements and laxatives if they do not achieve this ‘normal’ frequency.

Then they consider themselves constipated despite the absence of straining, hard stools, or feelings of incomplete evacuation, which physicians generally use to define constipation (3). 

But on the contrary, if one does not have a bowel movement but every third day for example and it is not hard stools, does not require any straining, and the stool evacuates completely, then this may be considered completely ‘normal’ bowel habits for this individual.

This indicates that the reliance on the Rome criteria alone in research studies will likely miss a large population who may believe they have constipation whether or not they have any objective symptoms to confirm the diagnosis (3). An estimate of 14.8% prevalence, comparable to estimates from other countries, suggests that 63 million North Americans meet the constipation Rome criteria (3).

However, another study estimates a 27% prevalence of self-reported constipation, suggesting that an additional 50 million North Americans report that they have constipation without meeting Rome criteria (3).

To avoid further confusion around terminology it is important to first and foremost establish what symptoms the individual is experiencing and use broader definitions for symptoms most commonly expressed (5). 

What does constipation look like?

As seen above in the Bristol stool chart, visual indicators are defined by stool types 1(severe constipation) and 2 (mild constipation). This is when stools may come out to be hard little nuggets, like nuts or sausage shaped but hard and lumpy and both being difficult to pass.

Summary

• Transient constipation usually happens due to changes in our daily routine like diet, travel, stress, lack of exercise, etc. and responds quickly or spontaneously resolves itself with dietary and lifestyle interventions
• Acute constipation can be more serious, resulting from medications, hospitalizations, immobilization, fecal impaction or obstruction and can occur between 2 weeks to 3 months.
• Chronic constipation (CC) lasts at least 3 months or more and can be very challenging to treat due to its multiple underlying primary or secondary causes. CC sufferers may not respond well to general therapies, while some treatments can even worsen constipation symptoms.
• Constipation can mean different things to different people so in an effort to define constipation, Rome III criteria was created:
• CC must include two of the following:
• Less than 3 bowel movements per week
• Straining more than 25% of the time
• Hard stools more than 25% of the time
• Incomplete evacuation or sense of blockage more than 25% of the time
• Need to use manual maneuvers to pass bowel movement at least 25% of the time
• Loose stools are rarely present without use of laxatives
• There are insufficient criteria for IBS-C
• This criteria must be fulfilled for the past 3 months with symptom onset at least 6 months before diagnosis
• There is a need to use broader definitions to define constipation for commonly used descriptions of constipation symptoms
• CC typically looks like stool types 1 and types 2 on the BSFS