What Is Constipation?

Constipation is when you have infrequent bowel movements and stool that may be hard, dry, and difficult to pass. You may also have stomach cramps, bloating, and nausea when you are constipated.

What Causes Constipation?

Cancer treatments such as chemotherapy can cause constipation. Certain medicines (such as pain medicines), changes in diet, not drinking enough fluids, and being less active may also cause constipation.

Ways to Prevent or Treat Constipation

There are steps you can take to prevent constipation. It is easier to prevent constipation than to treat its complications which may include fecal impaction or bowel obstruction.

Take these steps to prevent or treat constipation:

• Eat high-fiber foods. Adding bran to foods such as cereals or smoothies is an easy way to get more fiber in your diet. Ask your health care team how many grams of fiber you should have each day. If you have had an intestinal obstruction or intestinal surgery, you should not eat a high-fiber diet.
• Drink plenty of liquids. Most people need to drink at least 8 cups of liquid each day. You may need more based on your treatment, medications you are taking, or other health factors. Drinking warm or hot liquids may also help.
• Try to be active every day. Ask your health care team about exercises that you can do. Most people can do light exercise, even in a bed or chair. Other people choose to walk or ride an exercise bike for 15 to 30 minutes each day.
• Learn about medicine. Use only medicines and treatments for constipation that are prescribed by your doctor, since some may lead to bleeding, infection, or other harmful side effects in people being treated for cancer. Keep a record of your bowel movements to share with your doctor or nurse.

Talking with Your Health Care Team about Constipation

Prepare for your visit by making a list of questions to ask. Consider adding these questions to your list:

• What problems should I call you about?
• What information should I keep track of and share with you? (For example, you may be asked to keep track of your bowel movements, meals that you have, and exercise that you do each day.)
• How much liquid should I drink each day?
• What steps can I take to feel better?
• Would you give me the name of a registered dietitian who can tell me about foods that might help?
• Should I take medicine for constipation? If so, what medicine should I take? What medicine should I avoid?

With constipation, bowel movements are difficult or don’t happen as often as usual.

Constipation is the slow movement of stool through the large intestine. The longer it takes for the stool to move through the large intestine, the more it loses fluid and the drier and harder it becomes. The patient may be unable to have a bowel movement, have to push harder to have a bowel movement, or have fewer than their usual number of bowel movements.

Certain medicines, changes in diet, not drinking enough fluids, and being less active are common causes of constipation.

Constipation is a common problem for cancer patients. Cancer patients may become constipated by any of the usual factors that cause constipation in healthy people. These include older age, changes in diet and fluid intake, and not getting enough exercise. In addition to these common causes of constipation, there are other causes in cancer patients.

Other causes of constipation include:

• Medicines
  • Opioids and other pain medicines. This is one of the main causes of constipation in cancer patients.
  • Chemotherapy.
  • Medicines for anxiety and depression.
  • Antacids.
  • Diuretics (drugs that increase the amount of urine made by the body).
  • Supplements such as iron and calcium.
  • Sleep medicines.
  • Drugs used for anesthesia (to cause loss of feeling for surgery or other procedures).
• Diet
  • Not drinking enough water or other fluids. This is a common problem for cancer patients.
  • Not eating enough food, especially high-fiber food.
• Bowel movement habits
  • Not going to the bathroom when the need for a bowel movement is felt.
  • Using laxatives and/or enemas too often.
• Conditions that prevent activity and exercise
  • Spinal cord injury or pressure on the spinal cord from a tumor or other cause.
  • Broken bones.
  • Fatigue.
  • Weakness.
  • Long periods of bed rest or not being active.
  • Heart problems.
  • Breathing problems.
  • Anxiety.
  • Depression.
• Intestinal disorders
  • Irritable colon.
  • Diverticulitis (inflammation of small pouches in the colon called diverticula).
  • Tumor in the intestine.
• Muscle and nerve disorders
  • Brain tumors.
  • Spinal cord injury or pressure on the spinal cord from a tumor or other cause.
  • Paralysis (loss of ability to move) of both legs.
  • Stroke or other disorders that cause paralysis of part of the body.
  • Peripheral neuropathy (pain, numbness, tingling) of feet.
  • Weakness of the diaphragm (the breathing muscle below the lungs) or abdominal muscles. This makes it hard to push to have a bowel movement.
• Changes in body metabolism
  • Having a low level of thyroid hormone, potassium, or sodium in the blood.
  • Having too much nitrogen or calcium in the blood.
• Environment
  • Having to go farther to get to a bathroom.
  • Needing help to go to the bathroom.
  • Being in unfamiliar places.
  • Having little or no privacy.
  • Feeling rushed.
  • Living in extreme heat that causes dehydration.
  • Needing to use a bedpan or bedside commode.
• Narrow colon
  • Scars from radiation therapy or surgery.
  • Pressure from a growing tumor.

An assessment is done to help plan treatment.

The assessment includes a physical exam and questions about the patient's usual bowel movements and how they have changed.

The following tests and procedures may be done to help find the cause of the constipation:

• Physical exam: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. The doctor will check for bowel sounds and swollen, painful abdomen.
• Digital rectal exam (DRE): An exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual. In women, the vagina may also be examined.
• Fecal occult blood test: A test to check stool for blood that can only be seen with a microscope. Small samples of stool are placed on special cards and returned to the doctor or laboratory for testing.

• Proctoscopy: A procedure to look inside the rectum and anus to check for abnormal areas, using a proctoscope. A proctoscope is a thin, tube-like instrument with a light and a lens for viewing the inside of the rectum and anus. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer.
• Colonoscopy: A procedure to look inside the rectum and colon for polyps, abnormal areas, or cancer. A colonoscope is inserted through the rectum into the colon. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.

• Abdominal x-ray: An x-ray of the organs inside the abdomen. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.

There is no “normal” number of bowel movements for a cancer patient. Each person is different. You will be asked about bowel routines, food, and medicines:

• How often do you have a bowel movement? When and how much?
• When was your last bowel movement? What was it like (how much, hard or soft, color)?
• Was there any blood in your stool?
• Has your stomach hurt or have you had any cramps, nausea, vomiting, gas, or feeling of fullness near the rectum?
• Do you use laxatives or enemas regularly?
• What do you usually do to relieve constipation? Does this usually work?
• What kind of food do you eat?
• How much and what type of fluids do you drink each day?
• What medicines are you taking? How much and how often?
• Is this constipation a recent change in your normal habits?
• How many times a day do you pass gas?

For patients who have colostomies, care of the colostomy will be discussed.

Treating constipation is important to make the patient comfortable and to prevent more serious problems.

It's easier to prevent constipation than to relieve it. The health care team will work with the patient to prevent constipation. Patients who take opioids may need to start taking laxatives right away to prevent constipation.

Constipation can be very uncomfortable and cause distress. If left untreated, constipation may lead to fecal impaction. This is a serious condition in which stool will not pass out of the colon or rectum. It's important to treat constipation to prevent fecal impaction.

Prevention and treatment are not the same for every patient. Do the following to prevent and treat constipation:

• Keep a record of all bowel movements.
• Drink eight 8-ounce glasses of fluid each day. Patients who have certain conditions, such as kidney or heart disease, may need to drink less.
• Get regular exercise. Patients who cannot walk may do abdominal exercises in bed or move from the bed to a chair.
• Increase the amount of fiber in the diet by eating more of the following:
  • Fruits, such as raisins, prunes, peaches, and apples.
  • Vegetables, such as squash, broccoli, carrots, and celery.
  • Whole grain cereals, whole grain breads, and bran.
  It's important to drink more fluids when eating more high-fiber foods, to avoid making constipation worse. Patients who have had a small or large intestinal obstruction or have had intestinal surgery (for example, a colostomy) should not eat a high-fiber diet.
• Drink a warm or hot drink about one half-hour before the usual time for a bowel movement.
• Find privacy and quiet when it is time for a bowel movement.
• Use the toilet or a bedside commode instead of a bedpan.
• Take only medicines that are prescribed by the doctor. Medicines for constipation may include bulking agents, laxatives, stool softeners, and drugs that cause the intestine to empty.
• Use suppositories or enemas only if ordered by the doctor. In some cancer patients, these treatments may lead to bleeding, infection, or other harmful side effects.

When constipation is caused by opioids, treatment may be drugs that stop the effects of the opioids or other medicines, stool softeners, enemas, and/or manual removal of stool.

Pain medications can slow bowels down and cause constipation. Here are a few things you can do to keep your bowel movements regular:

• Eat foods that contain good bacteria or probiotics.
• Eat prunes and products made from prunes. These foods can help soften your bowels.
• Eat foods that contain fiber. NOTE: Add fiber slowly into your diet if you do not already eat a diet high in fiber-rich foods. Include water (at least 6 glasses each day) otherwise you could develop gas, bloating, diarrhea, or constipation.

Probiotic foods

Foods that provide “good bacteria” or probiotics will help your digestive system work its best. These foods have typically been fermented or cultured. Some examples include:

• Yogurt with live cultures. Look for yogurt with:
  • Bifidobacteria. These strains of bacteria are abbreviated with a “B” on the nutrition label’s list of ingredients.
  • Lactobacillus. These strains of bacteria are abbreviated with an “L” on the nutrition label’s list of ingredients.
• Kefir (a yogurt beverage, found in the dairy section of the grocery store)
• Sauerkraut or kimchi (fermented cabbage)
• Miso or tempeh (fermented soy products)

Prunes

Prunes and prune products can soften bowels. Start by adding a small amount at each meal. For example, add 2 prunes with breakfast, a small glass of prune juice with lunch, and 2 prunes with your evening meal.

High Fiber Foods

Eat 2-4 cups of fruit each day.

• Choose fresh or frozen fruitinstead of juice, canned, or peeled fruit.
• Have fruit as a snack between meals, such as a banana, pear, or apple.
• Add fruit to cereals, salads, yogurt, or cottage cheese.

Eat 3 or more cups of vegetables each day.

• Choose fresh vegetables instead of canned.
• Use frozen vegetables (without sauce).
• Add lettuce, tomatoes and other vegetables to sandwiches.
• Use vegetables in a stir-fry or cut up fresh vegetables and enjoy with a low-fat dip.

Eat at least 3 ounces of whole grain each day.

• Choose whole grain cereals with 5 grams or more of fiber per serving.
• Choose whole grain breads with 3 grams or more of fiber per serving.
• The first ingredient in breads and cereals should be “whole grain” or “whole wheat.”
• Choose brown rice, wild rice, barley, or quinoa instead of white rice.
• Add oat or wheat bran when baking muffins, cookies, pancakes, waffles, or meatloaf.
• Add wheat germ to yogurt or hot cereal.

Eat at least ½ cup of dried beans, peas, potatoes with skin, or corn a few times a week.

• Dried beans can be a replacement in recipes for animal protein.
• Use cooked dry beans, peas, or corn in soups, stews, side dishes, dips, casseroles, salads, and pastas.
• Add dried beans, peas, or corn to tacos, burritos, or rice.
• Use cooked and cooled unpeeled potatoes or whole grain pasta to make salads.

Mix high fiber foods into your daily food choices.

• Add nuts or seeds to breakfast cereal, yogurt, salads, and desserts.
• Add a small handful of nuts or dried fruit to trail-mix for snack.
• Try a new flavor on your dinner plate: add avocado to salsa to make guacamole dip; grill or bake squash.
• Edamame (green soy beans) can be steamed, boiled, or eaten as a fiber rich appetizer.

Foods with added fiber are also available at grocery stores such as cereal, granola bars, pasta, yogurt, and high fiber soups.