Constipation: When Not Even The Words Will Come Out

The Other Hard Parts About Hard Stools

“This is so embarrassing, Doctor Mary. I feel bad to waste your time here. It’s just that I have a problem. I eat a healthy diet and the internet says be sure I drink enough water, and I try. It says to drink an ounce for every kilogram, but I can’t because it makes me feel nauseous and bloated and it doesn’t help at all. I go to the gym regularly and I don’t do any better on the days I go to the gym versus stay home. What can I do? It’s making me miserable! I can’t believe I have to talk about this!”

Clare turns bright red and looks at the floor. She has a half-laughing, half-crying kind of expression on her face. Poor Clare is so embarrassed that she’s failed to identify what’s bothering her. All I have are clues that it involves water, exercise, and diet - and that’s about as generic and universal as you can get for health advice. Most things get better if you improve exercise, diet, and hydration. She hadn’t given any information in booking her appointment - which was supposed to be routine check on her anxiety meds - or in being roomed for her appointment. It’s pretty common for patients to want to address some issue other than the one their appointment is for, but they usually don’t leave me guessing what that issue is.

I sit silently for a moment, hoping that Clare will continue talking, but she just looks at me expectantly.

Something under the underwear seems likely. My best guesses are urinary incontinence or constipation. Usually, people with constipation will mention pain and people with urinary incontinence will mention the restrictions on their life or the expense of supplies. She hasn’t mentioned either.

To get her to say more, I go for a question that assumes nothing: “How long have you had this problem?”

“About two months. I kept trying what the internet said, and that didn’t work, but I knew I had this med check coming up.”

I try again: “Did the internet say anything besides to drink more water and exercise?”

“Not really. They talked about some over-the-counters and herbal stuff I could take, but I didn’t want to take anything because of my anxiety med. I thought it might conflict.”

There are probably herbals for urinary incontinence, but I am unaware of any over-the-counters. So, I’m going to go with constipation. To confirm that, I try a question that could be relevant to anything, but is specific to constipation: “About how often are you going?”

“Every few days.”

Aha! Now I know it’s constipation!

“I get cramps, and then sometimes a little bit will come out, or sometimes none at all. I keep getting my hopes up that I’ll feel okay, and I keep being disappointed. I used to be so regular. I didn’t have any problems, but now all of a sudden, I sure do.”

Thank heavens! I know the topic of conversation now. One of the communication problems here is that Clare is uncomfortable saying any of the necessary words. English has lots of words for poop, but they are all either childish, crude, or technical: the three contexts in which we talk about poop. I need to model the vocabulary for Clare. I usually use the word “poop” with patients, and sometimes “stool.” Most people can become comfortable with those. Hopefully, after hearing me say these a few times, Clare will become comfortable using the words.

“Any idea what changed to cause your constipation?”

“No, I keep wracking my brain. I didn’t change my diet. I’ve always eaten a high fiber diet, but I’ve even added in more and tried some over-the-counter fiber pills and it’s not helped any. I haven’t changed my meds. I haven’t added any vitamins or supplements except the ones I’ve tried to get stuff moving! Like I said, I increased my exercise and water. My periods stopped 3 or 4 years ago, and I’m still with the same guy and we have sex every once in a while and it doesn’t make any difference. I get really bloated sometimes, too. I look like I’m pregnant because sometimes I have so much gas!”

There’s some interesting information there, mostly just for ruling things out. Sometimes menopause can be associated with constipation. The underlying cause may be that. She’s still in the window where hormones would be okay. We won’t start there, but it’s something she could try.

Bloating can be an embarrassing and uncomfortable symptom on its own or with constipation. I’ll be giving her some basic GI information in a few minutes that may help with that, but first, I want to be sure there’s nothing concerning going on. Sometimes constipation can be a symptom of a serious underlying condition, although usually it’s not. I don’t want to miss something life-threatening, so we’ll start ruling those things out.

“Any blood in your stool?”

“No! I would have come right in for that!”

“Or mucous?”

“Nope.”

“Do you have to wake up to stool?”

“Nope.”

“Nausea or vomiting?”

“Yes, the nausea is the worst symptom!”

I glance at her chart. “You had your screening colonoscopy three years ago.” One possible but rare cause of constipation is colon cancer. If she were not up to date on her colon cancer screening, I would have taken this opportunity to encourage doing so.

“I’m not desperate enough that I want to do the prep yet. If this doesn’t get better soon, though, I might be begging for one!”

“I don’t think you need one at this point, Clare. I bet we can get you going again without a colon prep.”

I continue scanning, “Your weight is the same.”

“I feel like I’m heavier, even though I think I’m eating a little bit less, but that’s all probably just because my stomach is so bloated!”

“Yes, probably.”

I continue, “Any changes to your skin? Or hair?” If she says yes, she might have thyroid problems. In that case, I’d inquire about other symptoms such as being cold.

“Nope.”

“And nothing else going on? The rest of you is fine?”

“Yep. The rest of me is just like usual.”

“Okay, before we work more on your constipation, I need to cover the bases on the official reason you’re here, which is to check up on how you’re doing with your anxiety meds.” I go through a checklist with Clare. Fortunately, everything is going well and all I need to do is to issue more refills. Even with that good fortune, I’ll have trouble fitting Clare’s constipation issue into the time allotted for this appointment.

As I finish typing in Clare’s refills, I turn the topic back to constipation.

“Okay, let me poke around and see what’s going on with your constipation.”

I gesture to the table, and she hops up. I pull out the footrest, and Clare lies back and, without my asking, pulls her t-shirt up to her chest.

I put my stethoscope on her belly. A few quiet gurgles, nothing helpful, but also not alarming.

If someone is constipated, I can often feel their colon. I go looking for it. I start in the right lower quadrant and go in the path in which stool makes its way around the abdomen, looking for tenderness or masses. Her right lower quadrant is non-tender. Her right upper quadrant is non-tender. I have her take a deep breath and feel for her liver edge, which I do not feel. This can be normal. The important thing I find is that the area is non-tender, which is what I needed to know. I’m not interested in her liver or gallbladder today, so I do not linger. I move on to her left upper quadrant. Clare tells me it’s a bit tender there.

“Do you get cramps in this area?”

“Not usually. Usually it’s a little below there.” She pokes around a bit lower on her abdomen.

Patients frequently will interrupt my exam to do their own exam, as Clare is doing now. It’s rarely helpful, but it doesn’t usually take very long, so I let them finish. It is, after all, their body.

“Here!” she says triumphantly, “Here is where it’s usually sore and it’s more sore there today.”

“Okay. I’ll get there in a second.” I continue my exploration of her left upper quadrant. I am feeling for tenderness or masses.

“Ow!” Clare tells me.

I have found the trailing edge of her stool.

“Sorry.”

“No, you have to find the sore spots to figure out what’s going on.”

She’s not wrong. I inch my way slowly down to her left lower quadrant.

“This is all your colon, filled up with stool. I’m sure this is not a surprise to you, but this is why you’re not comfortable.”

Sometimes, when I say obvious things my patients will laugh - which Clare does. I continue towards the midline of her abdomen. There, her colon dives away from the surface and I cannot follow it.

I go to the right lower quadrant, which is not tender at all, and poke my index finger in as far as it goes comfortably, then suddenly pull it out.

“Did it hurt more going in or when I pulled it out?”

This is a quick test for irritation of the connective tissue in the abdomen. If it hurts when the abdomen is jarred, as when I pull my finger out quickly, there may be something seriously wrong, in which case I would send the patient to the emergency department to get some imaging. I am not expecting this to be the case, but the test is free, takes no more than 10 seconds, and to miss something serious would be unforgivable.

No problem with the in-and-out poke.

“I’d like to do a quick rectal exam.”

Clare wrinkles up her nose. I go into reassurance mode.

“I do these all the time. My fingers are not very thick. I’ll be gentle. It gives me a lot of information.”

I can’t tell if she’s just embarrassed at having me examine her there or if she’s afraid it will hurt. Of course, especially if someone has had violence done to them through their anus, a rectal exam may be traumatic and I won’t do it. There are medical contexts where this kind of exam might be necessary, but my office is not one of them. As Clare seems to have no serious objection to the exam itself, but, like many patients, feels guilty that I need to do the exam, I figure this is Clare’s issue. Rectal exams are just part of the job. I’ve done at least a thousand of them. They’re not a big deal to me, or most any other physician.

“There are two ways we can do it. I can step out while you put a gown on, or we can just slip your pants down around your ankles. Whichever you prefer.”

I learned in med school and residency to always make a patient gown up, but years of taking care of minimally mobile people have taught me that slipping one’s pants down works just fine. Once I started offering it to able-bodied patients, they all preferred it.

“I don’t have to change? I shake my head no.

As I predicted, Clare says, “Let’s just get it over with.”

“Okay. You stay lying there. Just pull your pants and underwear down to your ankles.

I get my gloves out of the box. I want to be sure she knows what’s coming.

“I’ll get some cold goo and then I will slide a finger inside your anus. Okay?”

“Ugh,” Clare responds, “I’m sorry you have to do this.”

There’s my answer for her hesitancy.

“It’s not a big deal. They’re just bodies. Everybody has one.”

She’s undone the waist of her pants and shimmied them past her hips and down to her ankles.

“Okay, just relax your knees apart like a frog.”

“You doing okay?” Just like with paps, I check in frequently.

“Yep,” Clare responds.

I learned in medical school to use a drape over the lower abdomen when doing a rectal exam, but it always gets in the way. Unless I am sensing a lot of discomfort from the woman, I skip the drape and go for getting it over with quickly and using a tiny bit less paper.

“Okay, you’ll feel me touching you, cold goo, lots of pressure,” and I slide a finger into Clare’s anus. I’ve already had a quick look at the outside, looking for hemorrhoids, fissures, masses, sores, etc. Internally, I want to know if there is stool in there, if so, what the stool is like, if the area is tender, if there is a mass. Often, I can stimulate the colon to start working by doing a gentle exam.

If there is anything unusual about the rectal tone, if the muscle seems to be squeezing me more tightly than usual or not as tightly, I will ask the patient to squeeze or relax and see what happens. Sometimes I ask the patient to push like she’s having a bowel movement to make sure that the wall of her vagina stays in place, but I don’t think that’s a super useful maneuver because very few women are willing to relax their anus while lying on their back on an exam table with a person between their legs. I rarely use it.

In Clare, I find some stool present, it’s formed and in small, hard pebbles. I stretch my fingers to feel all the way to her first rectal fold. I cannot feel circumferentially around the whole fold, but I can feel much of it.

“I feel that,” Clare tells me. “That feels weird.”

“Yep. It feels normal to me, but it’s your colon.” People frequently say it feels weird to be examined internally and I want her to know this is normal. The double meaning of “feels” gives me a way to say it all that seems clever, but is still clear.

I sllide my finger out and remove my right glove, then hand her the box of tissues. I look away while she cleans herself up. When she seems ready, I push the footrest in. If my patient is not as physically able as Clare is, I will slide their clothes up for them and help them sit up.

“You can sit in the chair if you wish.” She takes the opportunity to get off the exam table and onto a chair.

There are a lot of things I want to tell Clare about. My two biggest concerns are that she may be dehydrated and is eating the wrong type of fiber. Pebbly stools indicate dehydration, and bloating suggests issues with fiber. I also worry that my diagnosis is going to be “things don’t work as well as they used to; let’s fix what we can and see if there’s anything else going on,” and that is not a satisfying diagnosis, but we’ll get there and see how satisfying Clare finds it.

“Your GI system is basically just a long, muscular tube with some valves in it.”

This is not quite true, but as a first approximation, it is helpful. We’ve learned in recent years that our guts are not just a passive tube that carries food from one end of the body to the other. There is a complex interplay between sections of the tube and even betweeen the contents of the tube and the tube itself, to say nothing of the rest of the body. And so much is unknown or guessed at.

“In fact, you can think of your whole body, from the point of view of your GI system as just a pipe with arms and legs dangling off. One end is the mouth, and the other is the anus. The system is all twisty-turny like a three-dimensional version of the line for airport security, but it functions much like a river with everything flowing downstream. If you dam the river up at the end, things will overflow at the beginning.”

“Oh, I see! That’s why I feel kind of sick. It makes sense. If stuff is not moving forward, you can’t put more in.”

“Exactly.

“Each part of the tube has a different function and different things that can go wrong, but we’re going to think only about the last part of the tube, the colon, because that’s where I think things have gone wrong for you.

“The main functions of the colon are to serve as a reservoir for stool - a place to store it until we’re at a convenient place to have a bowel movement - and to remove fluid as the stool passes through. The colon has other functions as well. One, which we have learned a little about in recent years, is to serve as housing for the bacteria that produce compounds our bodies need. The bacteria digest what’s left of the food when it gets to the colon and make vitamins and other compounds that our body uses. These get absorbed from the colon along with the extra water in the stool.

“For whatever reason, Clare, your colon has slowed down very much and is removing too much water from your stool. There are some things you can do to keep more water in your stool, and these will help the stool move along and lessen your constipation. It’s not totally clear which is the chicken and which is the egg. Does having more water in your stools make them move more easily, or does having them move faster give the colon less time to absorb the water and make them move faster? Either way, more fluid in your stools is associated with the poop moving along, so that is part of why the standard advice is be sure to drink enough water.

“This is hard in your case because you’re already feeling overly full and drinking more water worsens that. Just do the best you can. Minimize coffee, tea - anything with caffeine - as they increase the amount of water that leaves via urine. Carbonated beverages may be worse for your nausea, or they may be better. You’ll need to experiment with that. Drink small amounts all the time. That should help get more water into your GI system.

“To try to keep the water in the stool, we’ll add some fiber. One of the ways in which fiber works to help you poop is by hanging on to fluid that is in the stool. Taking more fiber can be helpful for softening your stool, as long as you are drinking enough water. If you’re not drinking enough water to hydrate the fiber, it has the opposite effect and makes your stool even more like concrete.

“The other thing fiber does is feed the bacteria in your gut. Some combinations of bacteria and fiber cause the bacteria to make a lot of gas. When that happens, you end up with bloating. Some fibers tend to good for the bacteria that create gas. These are called soluble fibers. The other kind are insoluble fibers, and they result in less gas. You might want to avoid soluble fibers and increase your insoluble fiber so that you bloat less.

“On the other hand, if you don’t have enough soluble fiber, that can cause problems, because some of the beneficial bacteria need it. If the bacteria get unhappy, you can have problems. The gas may be an unfortunate side effect you have to put up with.”

“Which hand is it, then?”

“Everybody’s got their favored hand and there are lots of opinions out there about it. I am inclined to think that once you know the difference between soluble and insoluble fiber, you just have to try it out until you get a balance that keeps you comfortable. You can play with both the total amount of soluble and insoluble fiber and the ratio between them.”

“That’s so complicated!”

“It sure is! And we’re nowhere near done with the levers you have access to that can change your stool. Plenty of foods have soluble and insoluble fiber. I’ll let you look those up. ‘Psyllium husk’ is the generic name for a common soluble fiber, and ‘cellulose’ or ‘polycarbofil’ are the common generic names for insoluble fiber. You can buy both in a capsule form so you know exactly how much you’re getting.

“Prunes are a good source of both soluble and insoluble fiber. They can also help your bones. The problem with them compared to fiber pills is that it’s harder to be exactly sure of what you’re getting. Their effects vary from prune to prune. They do, however, taste pretty good compared to fiber pills.”

“Good to know. My mother always tried to get me to eat prunes, and so I’ve never had one.”

“Isn’t that interesting? I wonder if your mother had problems with constipation.”

“I’m certainly not going to ask her! You can see how uncomfortable the whole topic is for me. I bet you can guess where I learned that from.”

“The apple - a good source of soluble fiber, by the way - does not fall far from the tree.” I pause briefly. “And the apple tree, properly processed, might be a good source of insoluble fiber.”

Clare rolls her eyes. “So, I should get some fiber tablets, a couple different kinds, and chew on an apple tree?”

“Exactly! The other thing you should get is PEG 3350. Look it up. It’s the craziest thing. Initially, we thought it worked by bringing water into the stool and making the stool softer so it could move along better, but it actually seems to work by stimulating contractions of the muscle that makes up the colon wall. It does not affect the bacteria that live in your colon, and it is not irritating to the lining of your colon. It’s really a wonder substance for a lot of people with constipation.

“None of these substances, by the way, should affect your anxiety medication. So, don’t worry about that. You’ll need to experiment with them to figure out what works best for you. I would say that each change you make, you should try to keep at it for at least four days so that you really get an idea of how well it’s working because things don’t change quickly in your guts. For example, say you start with one serving of PEG and four days later, you feel like your stool is too watery, you could try decreasing the PEG or adding in an insoluble fiber tablet and see how that works and then make the next change. A lot of it really is just trying and seeing what works for your body.”

“I feel like a guinea pig!”

“I guess. Everyone has a different body and a different collection of bacteria in that body. There’s no way to know what your body is going to do with a particular substance until we try it.

“Shall we make an appointment in a month to see how things are going? To see if you’re going, Clare?”

Clare agrees. I tell her to stop at the front desk and make the appointment. I hope there’s a slot where I’m available. I check my watch. I’ve gone five minutes over on this appointment. My patients are backing up. I wish I could hydrate or fiber my way to improve that.

*All patients are patient amalgams and any resemblance to a real person is accidental.

**Nothing in this esstory is or should be construed as medical advice.

If you have ever seen anything more cute and relaxing than Nettie, the snoring puppy, please let me know in the comments what it is.