Chronic constipation: symptoms, causes, treatment and when to see a GP

The NHS says that making simple changes to your diet and lifestyle can help treat constipation, and that you may notice a difference within a few days, though sometimes it takes a few weeks. It says these measures are safe to try when you are pregnant.

NICE CKS says management of chronic constipation should include managing any underlying secondary causes and advising on reducing or stopping any medicine that may be contributing, advice on fibre, fluid intake and activity levels, managing any faecal loading or impaction first if present, and offering oral laxatives using a stepped approach.

The NICE CKS stepped approach is bulk-forming laxatives first-line, then adding or switching to an osmotic or stool-softening laxative, then adding a stimulant laxative if needed. It advises adjusting the dose gradually, aiming to produce soft, formed stools without straining at least three times per week, and considering a short-term trial of prucalopride if symptoms persist and prescribing criteria are met.

The NHS advises eating a healthy balanced diet and including fruits that contain sorbitol such as apples, apricots, grapes, raspberries and strawberries, drinking plenty of water and other fluids and avoiding alcohol, gradually increasing fibre, and adding wheat bran, oats or linseed.

For your toilet routine, it advises keeping to a regular time and place, giving yourself plenty of time, not delaying if you feel the urge, and resting your feet on a low stool while going to the toilet, with your knees above your hips if possible. A daily walk or run can also help you poo more regularly.

• Eat a balanced diet with gradually more fibre, such as wheat bran, oats or linseed.

• Drink plenty of water and other fluids and avoid alcohol.

• Keep to a regular toilet routine and do not ignore the urge to go.

• Rest your feet on a low stool with your knees above your hips.

• Be more active, for example a daily walk.

The NHS says it is likely to be constipation if you have not had a poo at least 3 times in the last week or are pooing less often than usual, your poo is unusually large or small and dry, hard or lumpy, you are straining or in pain when you poo, or you feel like you have not fully emptied your bowels. You may also have a stomach ache and feel bloated or sick.

NICE CKS adds that the Rome IV diagnostic criteria include spontaneous bowel movements fewer than three times a week. The NHS notes that constipation may be easily missed in older people or someone with dementia or a learning disability, so look out for behaviour changes such as confusion.

NICE CKS describes constipation as a symptom-based disorder in which defecation is unsatisfactory because of infrequent stools, difficulty passing stools or the sensation of incomplete emptying. Chronic constipation usually describes symptoms present for at least three months.

It distinguishes functional (primary or idiopathic) constipation, chronic constipation without a known cause, from secondary (organic) constipation, which is caused by a drug or underlying medical condition. Faecal loading or impaction describes retention of faeces to the extent that spontaneous evacuation is unlikely.

The NHS says the most common causes include not eating enough fibre, not drinking enough fluids, not moving enough, ignoring the urge to go to the toilet, changing your diet or daily routine, a side effect of medicine, and stress, anxiety or depression. Sometimes there is no obvious reason.

It says constipation is common during pregnancy and after giving birth and is more common if you are over 65. It can also be caused by a medical condition such as diverticular disease or bowel cancer, but this is rare.

The NHS says to see a GP if you are constipated and it is not getting better with treatment, you are regularly constipated or regularly bloated, have blood in your poo, have lost weight without trying, feel tired all the time, are taking medicine that is causing constipation such as opioid painkillers, notice sudden changes in your bowel habits, or have tummy pain.

It says to speak to the GP before you stop taking any prescribed medicine. NICE CKS says assessment should identify red flag symptoms or signs that may suggest a serious underlying cause such as colorectal cancer.

The NHS says long-term constipation can lead to faecal impaction, where poo has built up in the rectum. The main symptom is diarrhoea, which leaks through the build-up of solid poo.

It says faecal impaction may be treated with stronger laxatives prescribed by a GP, a suppository, a mini enema, or a healthcare professional removing some of the poo, which is not something you should do yourself.

The NHS page used here is about constipation in adults and points to separate information on constipation in babies and children. NICE CKS notes that constipation may occur at any age.

If your child has constipation that is not improving, see a GP, who can advise on treatment suited to children.

On the NHS, a pharmacist is often the first stop for laxative advice, and a GP can assess for causes and arrange blood tests. NICE CKS says referral to a gastroenterologist or colorectal surgeon should be arranged if a serious underlying cause is suspected, or if symptoms persist or recur despite optimal management in primary care, and that referral to a continence service or dietitian should be considered.

Private gastroenterology or colorectal consultations can offer faster specialist review and tests such as assessment for a defecatory disorder, but most people improve with first-line diet, lifestyle and laxative measures.