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Non Pharmacological Treatments for Constipation

June 27, 2021

Blocked up. Stuffed. Bloated. Impacted even. Whatever term you use, being constipated is a terrible and often embarrassing. It’s hard to talk about these problems because of the stigma surrounding our bowel habits.

But waste management, so to speak, is essential to good gut health. Since the 2/3rds of the internet and 86.4% of Los Angeles hates Western Medicine, I figured I’d offer a few tips that don’t involve pharmaceuticals to help move things long. This is particularly true because constipation is way more common that you might imagine.

Disclaimer: As always, these tips are for general education only. Please consult your provider before making any major (or even minor) health decisions. Common sense and safety should prevail.

Second disclaimer: These suggestions are relatively safe, may be effective (YMMV), but are poorly evidenced based. Many of these are not studied (who’s going to do an RCT on water as an intervention for constipation?) but are either bio-plausible, have numerous anecdotal reports, or small studies on them. Having said that, this list is a best attempt to meet patients who have a hesitation about pills and want to do things naturally, even if I don’t necessarily agree with this perspective at times.

A word before we start.

First know what you’re experiencing.

Constipation is a bit subjective of a term. What does that word even mean? Most commonly, when my patients complain of constipation they usually refer to one of three problems (or perhaps all of the above): 1) infrequent stools 2) painful or hard stools 3) straining with passage of stools.

As for the first problem, the rule of 3’s is what I commonly cite. For the vast majority of the population, up to three bowel movements per day or once every three days is considered “normal.” This has been evidenced in prior literature surveying patients as well as based on an understanding of the rhythms of gastrointestinal motility.

“But Dr Modi, I always have 2.5 bowel movements per day!”(what on earth is half a half bowel movement ?) “I don’t feel right if I don’t.”

That may be entirely true and, of course, you know your habits better than anyone else (until we develop smart toilets that track this for us). However, I do want to provide some reassurance to you, dear reader, that not having a movement for one to two days doesn’t spell dire trouble. I’d add extra emphasis of this warning to my elderly patients who tend to be particularly concerned with their bowel workings in my experience. This anxiety, sometimes unfounded, can actually worsen bowel health. Not sure how? Read my primer on gut health and emotions here.

Ok, with that said, let’s begin (again)

1. Fiber

Fiber, fiber, fiber. I say these things and invariably, the eye rolls and sighs commence.

Sometimes the best secrets are in plain sight, much like the Byrd electric scooters littering up most of America’s sidewalks.

If there is one micronutrient that is critical to overall gut health it is fiber. I’ve written before about the various types of fibers out there. Frankly, nearly all Americans (including myself) are deficient in fibers (all kinds).

It is almost impossible to have regular, “normal” bowel movement without fiber. Plain and simple. People should be shooting for roughly 30 g per day (more if you’re a man or larger/taller).

Honestly, I’ve seen near miraculous cures to a whole host of intestinal ailments when I get patients to take a fiber supplement. (Any bulk forming fiber supplement will do although psyllium husk is my go to). So please give it a shot. You’ll also reduce your risk of hemorrhoidal bleeding, an unfortunate complication of constipation.

Now, bear in mind, in otherwise healthy individuals, fiber alone is unlikely to make a dramatic difference. In other words, we might say fiber is necessary but not sufficient for appropriate bowel movements.

Please don’t eat an entire bushel of apples in one setting otherwise you’ll have massive GI upset. Start slow and ramp up as your body acclimates.

How might you know if low fiber is the root of your bathroom stall struggles? One way is to look at your stool before you flush it. It’s not as gross as it sounds (we are preoccupied with nutrition in the US, our so called inputs, but pay almost no attention to outputs). Pellet or “rabbit like” stools are a tip off.

2. Water

In all honesty, water is not that effective as solution to constipation. And please don’t start on your pink Himalayan sea salt, electrolyte vitamin enriched Alkaline Yak Water. In fact, prefer my pH balanced water from Chilean Llamas.

The majority of your entire body is water so it’s a good bet you need to be drinking some. More if you’re an athlete, a busy professional/parent or elderly – the latter two groups often fail to drink enough water because of sheer business or diminished thirst sensation, respectively.

Consider water like a roth IRA. It is valuable as a long term intervention but not useful for any immediate cash flow/bowel regularity needs.

Keep this mind: Compound interest has value in your health and not just your finances. In fact, most situations (but not all things) can be enhanced by small, consistent daily investments (like human relationships, physical exercise, and your Netflix queue). More often than not, this is the source of true health as opposed to the latest “biohack.”

3. Changes in your Diet

Here’s one you may not have anticipated but any abrupt or major shift in your diet can often induce a malabsorptive effect that can led to the “runs.” Don’t believe me? Ask anyone of your health nut friends what happened the last time they broke their diet and ate ice cream. Or people who suddenly go gung ho on the keto diet because some burpee loving CrossFitter told them too.

The ability to digest and absorb foods is beyond the scope of this article but suffice to say, it depends on a critical balance of gut bacteria, digestive enzymes, and appropriate functioning of the intestinal lining. This is all calibrated over time to handle most people’s typical diet (which, in the US, is dramatically limited to the same rotating staple of foods much like a radio station that always plays the same Top 40 tracks.)

So any abrupt shift in food intake often has people rushing to the bathroom.

Now, of course, this is not a long term or scalable solution but I figure I’d put it all out there and let you decide.

4. Exercise

When was the last time you took a walk? Went to the gym? Swam? Entered a competitive cartwheel competition?

Yeah, I thought so.

The body is designed to move in its parts as well as a whole. Life is movement. This is a truism even on a cellular level.

The unique effects of regular exercise (“sub maximal” efforts) on constipation in the general (read: non athlete population) is unclear, of only because regular exercisers tend to engage in other health behaviors.

We do know that intense exercise can trigger diarrhea probably via local intestinal hemodynamic shifts. These effects have been most pronounced in runners and endurance athletes.

Overall, we do know that long term consistent exercise is useful in regulating gi motility so I do think this is a worthy investment.

5. Sleep

I’ve discussed ad nauseaum about the benefits of sleep. But to recap: sleep-wake cycles and timing of defecation are intricately linked and alterations in one will naturally affect the other.

Some people have alleles in their clock genes that may make them more susceptible to these effects. We know that gut bacteria themselves have their internal circadian rhythms that determine their migration in the gut, adherence to the mucosal wall, production of byproducts and metabolism of short chain fatty acids.

Dysbiosis is may be one of the reasons people always seem to get constipated when flying, as mice studies seem to suggest when manipulating their perception of time zones.

In summary, sleep deeply and consistently.

6. Squatty Potty

The puborectalis muscle is essentially a sling around the end of the colon in a horseshoe fashion. It is tonically contracted to help maintain continence by cinching the rectum like a valve. When it is relaxed, so is the kinking of the anorectum and ease of passage of stool is facilitated.

The angulation of the hips when using the restroom, ie in a squat as opposed to traditional sit position, may ‘loosen’ this muscle by decreasing the sharpness of the angulation. In developing countries where portable toilets are unfortunately still lacking, people often squat to the ground and naturally create this process. However, the traditional toilet doesn’t elevate the legs high enough to do this.

Thus for people who have passage problems, namely straining, a squatty potty or foot stool when using the restroom won’t be such a bad idea.

Is the stool going to cure you of hemorrhoids and all manners of ano-rectal dysfunction? Probably not, so don’t fall for the marketing hype.

While we are on this topic, the ability to squat is a foundational movement and if you struggle with it for any reason then I would suggest a few sessions with a physical therapist. A healthy individual, even someone’s elderly, should be able to sit and rise from a sitting and squatting position without assistance.

Now, a brief interlude about baby wipes:

Increasingly, their use has been common to help people clean up after a bowel movement. In fact, the argument goes, you can’t be clean after defecating without using it.

To quote noted physician will.i.am of the Black Eye Peas:

“You ain’t got no baby wipes? … Here’s proof on why people should have baby wipes. Get some chocolate, wipe it on a wooden floor, and then try to get it up with some dry towels. You’re going to get chocolate in the cracks. That’s why you gotta get them baby wipes.” -Interview with Elle 2011

Frankly, I disagree. If you need baby wipes to have a bowel movement and feel clean, then you’re probably not using enough fiber.

Moreover, we are seeing an epidemic of patients coming into the clinic with anal abrasions, irritation and even dermatitis. The anoderm is incredibly sensitive and the various steroids (hydrocortisone), numbing agents (like lidocaine) and astringents in these compounds can cause discoloration, erosive changes to the epithelium and even pain/bleeding in some rare instances.

Plus, these packages are not biodegradable and are collecting in landfills, polluting the earth. So do the planet and your a@@ a favor, and minimize their use.

7. Coffee

As anyone who has been to Starbucks will tell you, coffee can be a potent laxative. Coffee increases recto-sigmoid motor activity within 4 min after ingestion in some people. This has been seen in both caffeinated and decaffeinated drinks. Similar effects have been found in patients who drink/ingest so called Bulletproof coffee, which in its traditional forms has a high amount of butter and MCT, which can induce a mild malabsorption.

8. Plums/prunes

As your grandma Bessie (bless her!) probably can attest to, prune juices are key to her daily movement. They are rich in insoluble fiber and sorbitol and so can give you the assist you’re looking for. Consider adding it to your smoothie, oatmeal, or the like.

Pro tip: consider warming up your prune juice for a get more intestinal bang for your buck.

9. Magnesium

Magnesium is a mineral that is a potent laxative. In fact, magnesium citrate is a common cathartic prescribed by GI’s in anticipation of a colonoscopy.

Keep in mind that magnesium comes in many salts, include glycinate, citrate, orotate, taurate, oxide etc. These all have different health effects (some forms have been used for arrhythmias or asthma because of its neuro-depressants and bronchical effects respectively).

As a side but not unrelated note: I will mention that soil depletion through modern farming techniques have dramatically lowered key levels of vitamins and minerals including magnesium in many fruits and vegetables. While I don’t feel that all individuals should supplement magnesium, this is a discussion point worth having with your primary provider given the numerous metabolic reactions that have magnesium as a cofactor and there is comparatively little risk for overdosing on magnesium.

10. Massage/ yoga poses

There have been a few studies looking at these complementary health practices as they relate to constipation. By and large, the data is minimal but generally these therapies won’t hurt. There is more substantive data that gut related distress is improved with these practices – which is a win IMHO.

Some yoga practitioners argue that gut directed massage and aryuvedic abdominal contractions can assist in bowel movements. While that remains speculative in my book, it may be worth exploring.

11. Meditation

Meditation in and of itself, won’t cure much. But what mindfulness practice does it to truly pay attention, which you quickly realize few of us ever do and do consistently. Can you just be with your experience of life in this moment? If you can, then you can begin to lower the stress in your life that may be contributing to your overall gut dysfunction.

12. Herbs 

This category is a bit of a grab bag. There are very few rigorous studies attesting to the benefits of these herbs.

Cascara sagrada (Rhamnus purshiana, also known as sacred bark or California buckthorn) are hydroxyanthraquinone glycosides found in the dried bark of the plant and along with senna, are common agents in herbal weight loss or “detox” teas (although, of course, they do neither).

I’ve had a variety of patients over the years attest to the benefit of some of the following agents. Try at your own risk: YMMV.

Rhubarb
Cascara sagrada
Flaxseed oil
Triphala (aryuvedic)
Aloe vera
Persimmon

13. Diabetic Candy

“What?!” you might say. Hear me out. Diabetic or sugar free candy often has erythritol or xylitol – sugar alcohols that have minimal blood sugar impact but still provide that sweet sweet hit of flavor we all so desperately want.

The side effect of these sugar alcohols is that they can often cause cramping, bloating, and yes loose stools. In fact, it is precisely because they are poorly absorbed by the gut that these things happen.

True story, as a medical student on a fitness craze, I decided to try and circumvent my diet by binge eating a bunch of “sugar free” Reese Peanut Butter cups.

I paid the price later in my bathroom. That painful lesson may be your salvation soon.

14. Biofeedback Therapy and Pelvic Floor Therapy

Some people clench when they should relax, sort of like trying to squeeze toothpaste when the cap is still on. No amount of effort will be successful if this is your strategy.

This problem, termed dyssynergia, is at the root of a lot of constipation. Biofeedback, if done correctly and consistently, is remarkably effective in getting patients to improve their bowel habits by allowing them to see their muscle activity with EMG readouts on a screen.

Related to this is the larger concept of the pelvic floor, which forms the base of your GI tract and also incorporates reproductive and urinary organs like the prostate, bladder, vagina. This entire area is covered in a thick wrap of not only muscles but connective tissue and fascia. When adhesions, imbalances, strength weaknesses and laxity of tendons and ligaments emerge, this floor becomes weak and can contribute to a whole host of below the belt issues. This commonly seen in pregnant women who strain considerably during labor, but also part of our larger sedentary lifestyles that has us putting disproportionate pressure on our ano-rectum, which was not designed to handle it.

“Cleaning up” this area with myofascial work in conjunction with a good, responsible pelvic floor physical therapist may help not just constipation but chronic pain, erectile dysfunction and more.

15. Water, lots of water

But Rusha, you already listed water. True, but I do want to point out a different phenomenon here – that of the gastro-colic reflex.

What actually causes someone to feel the urge to use the restroom is still a bit of a mystery, it is, in part, neurally mediated. There is a reflex that triggers bowel movements in the presence of stomach distention. If I had to speculate, it may have evolved because if our cavemen (and women and non binary gendered ancestors) had time to eat then they should probably defecate too, before they have to move on and not be prey for some other predator.

That neural arc can be used to your advantage. And it is most powerful in the morning (see more under sleep). So drink a lot of water after arising may allow you to take advantage of this reflex and get your colon to move.

16. Acupuncture

It sounds illogical that sticking multiple tiny needles into your body would help constipation but small placebo controlled studies actually document this to be the case. Further studies comparing it to sham acupuncture or random needle insertion (acupuncture is premised that certain energy meridians at precise locations in the body can be addressed through needles) are needed but I do think it is interesting to consider.

I don’t pretend to be an expert in this technique and the mechanisms of improvement but it may be worth trying, although for how long and how many sessions remains unclear.

17. Stopping Medications

Polypharmacy, or the use too many medications, is a big problem in US medicine. Patients are often just continued on medications without regularly assessing if they are still needed, partly because of the time rushed managed care environments of most medical visits. Definitions vary on how many medications and how long constitute polypharmacy but usually studies look at a => 5 during a hospital stay or for 90 days.

Aside from constipation, polypharmacy is also associated with adverse outcomes including mortality, falls, adverse drug reactions, and longer time in hospitals.

So if you are on a lot of pills, please talk to your provider and review your medication list. This is called “medication reconciliation” and is increasingly part of quality of care guidelines and reimbursement strategies per third party payors.

 

Sometimes releasing the brakes is more effective than pushing the gas (actually, on second thought, isn’t this always the case?).

What isn’t helping:

1. Not going when you have to go. Kids, in particular, can train themselves into ignoring these complaints until the urge diminishes but I see this problem in adults. If you do this repeatedly, over time the urge to go will be diminish in potency

2. Scrolling with instagram on the toilet seat

Although hard evidence is lacking on this topic, prolong sitting on the stool checking out the latest contouring videos is just placing prolonged pressure on your rectum and this increases your risk for ano-rectal dysfunction. It’s just more sitting in a sedentary world.

3. Stigmatizing yourself for any bowel problems

Bowel problems will never get the attention, press, celebrity advocacy, or funding they deserve because it’s embarrassing and too intimate. It’s not sexy or cool to have an ostomy or problems in the restroom. But defecation is a vital part of our health, and the longer we continue to shame people, even indirectly for their bowel problems, the longer people continue to suffer in silence. And that is definitely not ok.

4. Colonics. Colonics purport to be part of “ancient wisdom” that allows you to detox the body in a way that ironically is also “scientifically supported.” In reality, none of this true. The ancients may have done, but I don’t think it was wise. Colonics have been associated infections of the colon, rectal bleeding and even frank perforation in some rare cases. Moreover, the electrolyte and fluid shifts can be troublesome for a lot of people.

“But I feel better doc when I have them done!” That may or may not be true, but a healthy bowel regimen based on common sense diet, sleep and distress management does not require this.

Look, I get it, there’s literally a visceral relief that comes from the removal of waste and it augments widespread notions that abound in our society about detoxing, and removing waste.

And while we are at it, no you don’t have ’30 lbs of waste’ in your colon at any time or any whatever such ridiculous number is regularly quoted. I routinely have patients prep for colonoscopies with pharmaceutical grade laxatives and they usually lose no more than ~ 5-7 lbs max (usually less than that). Ok, nuf said, rumor debunked.

So I hope this helps. Constipation is a serious, common problem. It deserves to get way more attention, celebrity endorsements for cures, and research dollars than it currently receives and I sincerely hope this changes. But you don’t have to suffer in silence.

Bonus Tips:
Your Armamentarium for BM’s on the go:

1. vitamin a + d ointment
2. fiber packet (benefiber has supplements in easy to go pouches)
3. hand sanitizer
4. portable air fresheners
5. prep H wipes for those who have hemorrhoidal itching. Just try to minimize these and consult your doctor if you need them regularly (see above)
6. Calmoseptine lotion for itching
7. Laxatives if you need them
8. Your favorite type of coffee; instant packets or K cups (just don’t bring your coffee into the bathroom, that’s disgusting!)

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