My Doctor Online The Permanente Medical Group

Symptoms

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Symptoms of constipation include:

• Difficulty defecating or straining to pass stools
• A sense that the bowels are not completely empty after a bowel movement
• Hard stools
• Low frequency of stools (usually fewer than 3 bowel movements in a week)
• Cramping and pain in the rectum caused by trying to pass hard dry stools
• Bloating and nausea

Call us if any of these symptoms occur:

• Constipation that persists. Call us if it persists for several days following home treatment or if you are unable to have a bowel movement without using laxatives.
• Painful or bleeding hemorrhoids. Hemorrhoids are painful swollen veins in the lower part of the rectum or around the anus. Hemorrhoids are signified by small amounts of bright red blood that appears on the stools. This is caused by tearing as the stools are pushed through the anus.
• Blood in your stools. Contact us immediately if you experience heavy rectal bleeding, if the blood is reddish brown or black, or if it persists after constipation has improved. Blood in your stools may be a sign of a serious condition.
• Fecal incontinence  (loss of bowel control). If your stool is lodged in the rectum, you may experience leakage of mucus and fluid around the stool leading to fecal incontinence. This may be experienced as alternating diarrhea and constipation.
• Sharp abdominal pain.
• Stools that have become pencil-thin or extremely thin.
• Unexplained weight loss.

Diagnosis

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To determine the cause and the best treatment for your kind of constipation, your history is very important. Here are some things that may be a factor:

About your bowel movements:

• How long have you been constipated?
• How frequent are your bowel movements?
• What is the consistency of the stool?
• How difficult is it to pass the stool?
• Do your bowels feel empty after the bowel movement passes?
• Have you seen blood with your bowel movements, mixed with the stool or in the toilet?

About medications:

• What medications and supplements are you taking?
• Have you started new medications or changed the dosage recently?

About your lifestyle:

• What is your level of physical activity?
• Are you under any unusual stress?

About your emotional health:

• Have you recently been bothered by feeling down, depressed, or hopeless?
• Do you often feel anxious or overwhelmed by worries?

We will also discuss your dietary habits since some foods (like dairy products) may cause constipation and others (like fiber) may help the bowels to move.

We will make the diagnosis based on your symptoms and a physical examination. We may order tests or studies. The tests we perform depend on the severity of your constipation and what we are able to glean during your screening. Most people do not need extensive testing.

If your symptoms are severe or persistent, we may check your abdomen, anus, and rectum as well as the muscles that support the anus and rectum.

Causes and Risk Factors

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Constipation occurs in the colon (large intestine). As you digest your food, it moves through the colon where water is absorbed and waste products (stools) form. Muscle contractions then push the solid stool toward the rectum. If the colon absorbs too much water or if the colon's muscle contractions are slow, the stool moves too slowly, becoming hard, dry, and difficult to eliminate.

We know that:

• More women than men are affected by constipation for reasons that are not known.
• People 65 years old or older are more likely to experience constipation because they are more sedentary and may have other conditions that may cause or be related to constipation.
• People with depression, severe anxiety, eating disorders, or obsessive-compulsive disorder, or those who have experienced physical or sexual abuse have more problems with constipation.

Sometimes constipation is caused by taking certain medications, is associated with an illness, or is a symptom of a disease. If this is the case, we will conduct a thorough diagnosis and work with you to design a treatment plan that will help.

Common causes are:

• Diets low in fiber
• Not enough physical activity
• Ignoring the body's signals to have a bowel movement
• Overuse of laxatives
• Certain medications
• Pregnancy 
• Illnesses such as irritable bowel syndrome, stroke, underactive thyroid, diabetes, Parkinson's disease, injuries to the spinal cord, and colorectal cancer

Treatment

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For most people, treatment is straightforward. Your treatment will include:

• Education on how to improve your bowel function
• Dietary advice on good sources of fiber
• Advice on when and which laxatives to use

Constipation can usually be treated at home, but if symptoms like blood in your stools or sharp abdominal pain persist or seem to be getting worse, please contact me.

Lifestyle Changes and Management

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Improve your diet

• A high-fiber diet is key to having healthy bowels. If you are not eating a high-fiber diet now, it is best to increase your intake of fiber gradually over several weeks to avoid cramping and bloating as your colon gets used to processing the fiber.
• Drink 8 glasses of water a day to allow the fiber to work to keep your stools soft.
• Plan to eat 20 to 35 grams of fiber daily. Read the labels on the foods that you buy. Generally, whole grains are better than refined grains. Whole fruits and vegetables contain more fiber than juices made from them.

Fiber content in common foods:

Sample day's menu:

Medications

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If lifestyle changes and adding fiber to your diet have not helped, you may try using laxatives. There are two types: those made from natural ingredients or those that are over-the-counter medicines.

Bulk-forming laxatives (fiber supplements). These are made from natural products and are the safest type of laxative, but they may cause uncomfortable bloating. You can usually find them for sale in drugstores or natural food stores. If you can't eat 20 to 35 grams of fiber every day, they may be helpful. You can find many of them in wafers or pills. They are safe to take on a regular basis. They include:

• Calcium polycarbophil (FiberCon, Fiber-Lax, Mitrolan)
• Methycellulose (Citrucel)
• Psyllium (Konsyl, Metamucil, Perdiem)
• Wheat dextrin (Benefiber)

Saline and hyperosmolar laxatives. These are effective, but do not overuse them. They include:

• Milk of Magnesia is safe, but do not take this if you have chronic renal failure.
• Miralax or Lactulose is a very effective and safe over-the-counter laxative.
• Sorbitol.

Stimulant laxatives. These are effective but when overused can lower your potassium levels, which can be harmful to your health. They include:

• Senna (Senokot) 
• Ex-lax
• Castoria/castor oil
• Bisacodyl (Dulcolax, Correctol)

Avoid herbal laxatives that contain cascara sagrada (dried bark), as it can cause long-term damage to the bowel.

Prescription laxatives in addition to lifestyle changes and more dietary fiber can help your constipation.

Stool softeners (Colace). These help soften stool. They are safe and may be helpful for some people.

Flax seed. Seeds from the flax plant contain soluble fiber, like that found in oat bran, and they can be an effective laxative. They come whole or crushed and can be mixed with water or juice and taken by mouth.

Enema. We also may suggest using an enema, but please be aware of the following:

• Tap water enemas can lower your blood salts if they are overused.
• Enemas are convenient, but avoid them if you have heart or kidney problems.
• Let us know if you are using enemas. It is important not to overuse them.

Prevention

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To help prevent constipation:

• Eat a high-fiber diet and remember to add fiber to your diet gradually to help reduce gas and bloating.
• Limit low-fiber foods that are high in fat and sugar and low in fiber content, such as ice cream, cheese, and processed foods.
• Drink 8 glasses of water daily.
• Be more physically active. A walking program is a good start to help stimulate intestinal function.
• Go to the bathroom when you feel the urge to have a bowel movement.
• Try over-the-counter bulk-forming laxatives, also called fiber supplements.
• Take stimulant laxatives with caution because they can be habit-forming.

Prevention of constipation when using medication

Some medications such as narcotic pain medications and calcium channel blockers cause constipation in many people. We may recommend the following:

• Stool softener - docusate (100 to 250 mg) daily
• Senna
• Miralax

If you cannot take medication orally, use:

• Dulcolax suppository
• Saline enemas if you do not have heart or kidney problems

If these agents aren't working, talk to us about other prescription laxatives.

Your Care with Me

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Constipation can usually be treated at home, but if symptoms like blood in your stools or sharp abdominal pain persist or seem to be getting worse, please contact me. I am available online, by telephone, or in person. Depending on the situation and what is most convenient, please choose the best way to contact me. 

• For nonurgent questions or concerns, you can e-mail me using this site. You can also book an appointment online to see me in person.
• If your concerns are immediate, or you simply prefer to use the telephone, please call our Appointment and Advice line, which is available 24 hours a day, 7 days a week. Our advice nurses can give you immediate advice, and our telephone staff can send me a message or book an appointment with me or one of my colleagues, if I am not available.

Based on your symptoms, history, and any tests I may order, I will confirm your diagnosis.  We will discuss potential lifestyle changes, therapies, and treatment options that are right for you.

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How We Coordinate Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system which allows all of the doctors and clinicians involved in your care to stay current on your health status and to collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization.  We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments as needed. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures we will schedule an appointment with the radiology department. When the results are ready I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to a specialist

My specialty colleagues are readily available to assist me if I need additional advice about your condition. In some cases, I may contact them during your visit, so we can discuss your care together. If we decide you need a specialty appointment after that discussion, we can often schedule it the same day or soon thereafter.

If you are due for preventive screenings or tests

As part of our commitment to prevention, additional members of our health care team may contact you to come in for a visit or test.  We will contact you if you are overdue for cancer screenings or conditions which may require monitoring.

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Convenient Resources for You

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My goal is to provide high quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available 24/7 so that you can access and manage your care where and when it is most convenient. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions and schedule appointments.
• View your past visits and test results.
• View your preventive services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at our medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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