Constipation? I Have Two Questions

“There’s Nothing Like a good Bowel Movement” made the point that chronic constipation is all too common and distressing among seniors. In the past, doctors defined constipation as having fewer than 3 bowel movements a week. Anything else was considered “normal”…hmmm…really?? Obviously, the patient was much more uncomfortable than the physician. We now evaluate constipation more broadly, starting with the patient’s perspective. Here are two important questions:

Question 1: What bothers the patient the most? Different answers mean different problems.

A. It’s very painful to have a bowel movement.

Sometimes only small pieces of stool come out.

What causes this?:

Pain is a sign of injury. It could be due to a tear or abnormal narrowing in the anal canal. Highly inflamed hemorrhoids are painful.  Hemorrhoid surgery can cause scar tissue with narrowing of the opening. Pain can also be due to blockage of the canal by a large hard stool. With straining the pressure increases so much that it causes pain. A thorough rectal examination is needed when pain is the main issue.

B. The poop is: “right inside, I can feel it.

But it doesn’t come out.” In this situation, the patient may also suffer from irregularity. Sometimes there is discomfort. But overall, the quantity of stool is not the issue. The main problem is that it doesn’t come out. Sometimes patients strain. Other times the stool comes out without straining but some of it just stays inside.

What causes this? The muscles and nerves in the rectum and anus are weak and uncoordinated. As a result, feces is not pushed out. This happens in

  • neurologic conditions such as Parkinson’s Disease or spinal cord damage. Nerves do not coordinate the muscles well.
  • long term overuse of laxatives or enemas. Nerves and muscles are damaged.
  • Chronic fecal impaction. Over a long period, the canal becomes dilated and weak.

C. There’s just not enough poop.

The stools are too infrequent or too small. This happens due to any of the following:

  • daily fiber and fluid intake are low
  • overall food intake is very poor
  • food and stool move too slowly through the GI tract. More water is removed and stools shrink. They clump together and result in fewer bowel movements.
  • Stool is “held back”. A person resists having a bowel movement. Feces accumulates inside until it is too big to hold back.

Cycles of constipation and diarrhea:

Some patients go back and forth between frequent and infrequent bowel movements. This is a different problem from “not enough stool”. It can be caused by irritable bowel syndrome. Inflammatory bowel disease is a less common and serious disease. Emotions can also result in irregular bowel movements. Excess use of laxatives can have this result.  Laxatives empty out the colon. Then, there is no bowel production for days. This prompts the patients to use laxatives again and repeat the cycle.  Alternating frequency of bowel movements is not an age-related problem. It usually starts earlier in life.

Question 2: What does the stool look like?

As silly as it sounds, geriatricians specialize in stools. When families say that a patient is constipated, I ask what the stool looks like. Sometimes caregivers don’t know. However, it’s an important question. For instance, a  person can have infrequent but large and soft bowel movements. Adding more fiber and a stool softener will not improve this type of constipation. So, what can the appearance of stool tell you? Let’s start with size and consistency:

A. Small medium or large?

  • Small stools mean that there is not enough fiber and fluid in the stool.
  • Medium sized but infrequent bowel movements. This is due to clumping of small slow-moving stools.
  • Large infrequent bowel movements. Stool is being kept inside until it is large.

B. Hard, medium or mushy/liquid?

  • Hard stools are dry.
  • Stools that are neither hard nor liquid are optimal.
  • Mushy or small amounts of liquid bowel movement. This can be due to watery stool leaking through an obstruction.

C. What’s the importance of color?

Constipation is seldom associated with a change in color. Colorful foods that are partially digested can cause a temporary change of color. Medicines can change the color of stool due to the formulation by the drug company. Iron and some other drugs cause black stools.

Bleeding can result in red, dark, or black stools. Any significant and persistent unexplained change in color is unusual. These situations need medical attention.



Answers to the questions about size and consistency are helpful. They give hints about what is causing the constipation. Constipation is usually due to a combination of the following problems:

Medications play a role in up to 40% of  constipation problems. Narcotics are very constipating. Some common hypertension medicines also cause the problem. Drugs used in combination can have the same result. These medicines slow down movement of food and waste through the GI tract. More water is removed causing drying.

Stool appearance: Small and hard. Stools can clump together to form larger infrequent lumps.

A diet low in fiber and fluids. This results in stools that are smaller and dry.
Stool appearance: Small and hard. Stools can clump together to form larger infrequent lumps.

Chronic diseases, such as diabetes, hypothyroidism, and kidney disease, decrease GI motility. This  results in more removal of water.
Stool appearance: Small and hard. Stools can clump together to form larger infrequent lumps.

Neurologic conditions, such as Parkinson’s Disease and spinal cord damage, can cause multiple problems. These include decreased GI motility and rectal incoordination.
Stool appearance: Variable. Small or large, hard, or soft. Sometimes incontinent.

Overuse of laxatives results in overproduction of stool followed by days of no stool.
Stool appearance: Loose stool followed by no stool or small amounts of liquid stool.

Disability is a much overlooked and major cause of constipation. Disability can be due to stroke, dementia, depression, or any advanced illness. The disabled person often needs help getting to the bathroom. In addition, the person needs to be stable and relaxed when sitting. Mental, physical, or emotional impairment can result in inability to coordinate a bowel movement. Sometimes there are accidents. Distress results in efforts to hold back bowel movements.  More and more waste is backed up until it is too much to hold back.

People with severe frailty may also not eat and take enough fluids.  Sometimes people eat less to avoid having bowel movements.

Families can be unaware of these issues if the patient does not talk about it.

Stool appearance:  Variable. Small or large, hard, or soft. Sometimes incontinent.

Fecal impaction is sometimes the end result of the above problems. Stool accumulates. The rectum and anal canal gradually enlarge and become less responsive. This results in ineffective pushing of waste. The large amount of stool can cause discomfort. Once some of the stool is evacuated, the pressure inside the canal decreases. Discomfort improves.

Stool appearance: large or small; soft or hard.  Sometimes incontinent. Sometimes prolonged periods of no evacuation followed by a very large amount. Stools are small when only the overflow comes out.

If there is severe plugging, semi-liquid stool seeps out. This is called paradoxical “diarrhea”. (I have seen antidiarrhea medicines ordered when liquid stool comes out. This is the incorrect thing to do and makes the impaction worse!!)

What about Aging?  Constipation is more common in seniors but aging of the intestines plays a minor role. Medicines, diet, chronic diseases, and immobility are more important factors. Everyone’s GI tract is slightly different. Some GI tracts have more wear and tear over time due to chronic dietary and lifestyle habits.

How are Geriatricians Different?

Medical specialty evaluations for memory problems are done by neurologists, psychiatrists, and geriatricians. I was often asked: “How are the consultations different?”  Memory testing is standard in each of these specialties. Geriatricians frequently have a good understanding of local resources.

But I also had a simpler answer about how geriatricians are different. 😊 The geriatrician is the only specialist who is likely to do a rectal examination. Stool may be stuck in the rectum.

I hope this article helps people figure out what chronic constipation is due to. The next step is to make the problem go away. That’s next. 😊

Warmest Aloha,

[email protected]

PS: Acute constipation is different from chronic constipation. A change in bowel pattern and stool size requires medical attention.

Posted in Caregiving, Dr. Warren, Geriatrics with Aloha and tagged , , , , , .


    • Hi Frances,
      I hope you’re well. Thanks so much for your comment. Yes, i’ve seen constipation mismanaged too often. I actually have an opinion that many providers don’t: With careful effort, constipation can be well managed and life is better. Aloha

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