Constipation: What Causes It, How to Get Relief Fast and When It Is a Sign of Something More Serious

What actually counts as constipation?

Constipation is not going a day without opening your bowels. Doctors define it as passing stools fewer than three times a week, passing hard, dry stools, having to strain hard, or feeling that your bowel has not fully emptied. Anything from three times a day to three times a week is normal for many people. What matters is that the stool is soft and passes without a struggle.

Constipation becomes chronic when these symptoms last three months or more. It is very common. A review that pooled 45 studies covering more than 261,000 people worldwide found that about 14% of adults have chronic constipation. It was roughly twice as common in women, and it became more common with age and with lower income.

In Saudi Arabia, a study of 543 people in Riyadh and Qassim found a much lower figure of 4.4% using a strict scoring system. Most of the gap between studies comes from how constipation is defined. What stands out in the Saudi study is that the two factors most strongly linked to constipation were constant stress and not drinking enough water, both very familiar in daily life here.

Most constipation is functional, meaning the bowel itself is healthy but moves slowly, or the way you open your bowels is not working well. Less often it is a sign of another condition, such as an underactive thyroid, diabetes or a problem in the bowel itself, and this page will show you how to tell the difference.

What your stool shape tells you: the Bristol stool chart

Doctors around the world use the Bristol Stool Chart to describe stool shape in a consistent way, because shape says more about how fast food moves through your gut than the number of visits does. The longer stool stays in the colon, the more water the colon absorbs from it, so it becomes harder and smaller.

Types 1 and 2 mean constipation: small, hard pellets like nuts, or a lumpy sausage. Types 3 and 4 are the ideal, a soft, smooth sausage shape. Types 5 to 7 are on the loose side and move towards diarrhoea.

You may find that you go every day but your stool is type 1, and that is constipation even though you are regular. The opposite also happens: you go every second day but the stool is soft and easy to pass, which is perfectly normal and does not need a laxative. So look at the shape before you worry about the number.

Common causes of constipation in the Middle East

The first cause is food. White bread, white rice, pastries and sweets form the base of many family meals, and all of them are low in fibre. Fibre is the part of plant food that is not digested, so it stays in the bowel, holds on to water and gives stool bulk and softness. The irony is that traditional regional cooking is rich in fibre: ful, lentils, chickpeas, bulgur, freekeh, molokhia, cooked vegetables, figs and dates. They have simply lost ground to fast food and white bread.

The second cause is too little water. In the heat the body loses a lot of fluid through sweat, so the colon pulls as much water as it can out of the stool. Many people drink only tea and coffee, or wait until they feel thirsty, and during Ramadan the whole timing of eating and drinking changes. On top of this come too little movement, long hours sitting at work or in the car, and putting off the toilet because the facilities at work, school or on the road are not clean.

The third cause, often overlooked, is medicines. Painkillers containing codeine are sold without a prescription in some countries and are among the strongest causes of constipation, as is tramadol. Iron tablets are prescribed very widely to women and in pregnancy. An analysis of 43 trials involving 6,831 adults found that ferrous sulfate roughly doubled the risk of digestive side effects, including constipation, compared with a placebo. If your constipation started after a new medicine, tell your doctor, and do not stop a prescribed medicine on your own, because there is usually an alternative or a fix.

How to relieve constipation quickly and safely

The first and most important step is fibre. A systematic review of seven randomised trials in adults with chronic constipation found that 77% of those given fibre supplements improved, compared with 44% given a placebo, and fibre increased how often people went and made stools softer. Fibre also caused more wind, so add it gradually over two or three weeks: brown bread instead of white, a bowl of lentils or ful, a few figs or prunes, and vegetables with every meal.

Fibre without water can make things worse, because it needs water to swell and soften the stool. Keep drinking water through the day, and drink more on hot days. Movement moves the bowel too. A half-hour walk every day helps many people, particularly those who spend the day sitting.

Make use of a natural reflex called the gastrocolic reflex. The colon usually becomes more active after eating, especially after breakfast and a morning cup of tea or coffee. Set aside ten minutes after breakfast to sit on the toilet without rushing and without your phone, and never ignore the urge when it comes. Putting it off again and again teaches the bowel to ignore the signal.

Many people recommend a small footstool to raise the knees above the hips, or using a squat toilet. The evidence is weaker than its popularity suggests. In a 2023 Australian trial of 41 patients with constipation, a footstool did change body posture, but it did not make passing a test balloon any easier and patients felt no difference. Try it if you like, as it does no harm, but do not rely on it alone.

Types of laxatives and which one suits you

If changes to food and habits are not enough, laxatives are a reasonable short-term option, but they are not all alike. A pharmacist or doctor can help you choose the right type, especially if you are pregnant, older, living with a long-term condition or taking other medicines.

Bulk-forming laxatives, such as psyllium husk, also sold as ispaghula, are concentrated fibre that works like fibre in food and needs plenty of water with it. Osmotic laxatives, such as lactulose and macrogol, draw water into the bowel to soften the stool, and they are among the laxatives doctors prescribe most often for ongoing constipation. Stimulant laxatives, such as senna and bisacodyl, push the bowel muscles directly and work within hours, and they are suited to short-term use only.

Suppositories and enemas are used when hard stool has collected in the rectum, and they should not become a habit. If you find you need a laxative for more than two weeks in a row, that is in itself a reason to see a doctor, not a reason to take more.

Why you should not rely on senna or herbal laxative teas

Herbal shops and pharmacies sell blends and tea bags marketed as natural slimming teas or colon cleansers, and many of them contain senna or similar leaves. Because they are natural, people assume they are safe to use every day, but they are true stimulant laxatives with all of the effects that come with that.

Long-term use can cause painful cramps and diarrhoea that drains water and potassium from the body, which is dangerous in the heat, in older people and in anyone taking heart medicines or water tablets. Many people find they need more and more over time to get the same effect, and end up in a cycle that is hard to break. The weight loss promised on slimming tea packets is lost water, not fat.

The hidden danger is that the laxative masks the symptom. Someone who drinks a herbal tea every night may not notice that their bowel habit has changed, or that the constipation is getting worse, and so may be late finding a cause that needs treatment. If you use senna regularly, read our detailed article on senna and laxative safety, and talk to your doctor about a safer alternative.

When is constipation a sign of bowel cancer or another illness?

Most constipation is not serious, but some signs mean you should not just treat it at home. The most important is a new change in bowel habit that lasts more than a few weeks, especially after the age of 50. That might be constipation you never had before, constipation alternating with diarrhoea, or stools that are narrower than usual.

Blood in the stool should never be ignored, even if you think it is from piles. Piles are common with constipation, but only a doctor can confirm that the blood is coming from them and not from the bowel. The same applies to black, tar-like stools, losing weight without trying, iron deficiency anaemia in a man or in a woman after menopause, and having a close relative who has had bowel cancer.

In these cases a doctor may ask for a stool test for hidden blood (FIT) or a colonoscopy, a camera test of the bowel. Colonoscopy may not be easy to get in every city, but the FIT test is now offered by many private laboratories and gives a useful first indication. The doctor may also check thyroid function (TSH), blood sugar and calcium, because these are treatable causes.

There is also an emergency you should know about. If your belly becomes badly swollen and painful, you are passing no stool and no wind, and you start vomiting, this may be a blocked bowel. Go to the emergency department straight away.

Constipation in children

Constipation is one of the most common reasons children see a doctor, and it usually starts at one of three points: moving from breast milk to solid food or formula, toilet training, and starting school, when a child refuses to use the school toilets. A child has one painful hard stool, starts holding on for fear of the pain, the stool builds up and gets harder, and the cycle begins.

Signs of holding include standing stiffly, crossing the legs or hiding in a corner. Soft stool may leak and soil the underwear, which parents often mistake for diarrhoea or carelessness, when it is really leakage around a hard mass of stool. Do not punish a child for this, as they cannot control it.

Guidelines from the European and North American societies for paediatric gastroenterology recommend a normal amount of fibre and fluid for the child's age, regular sitting on the toilet after meals, and osmotic laxatives such as macrogol as the first choice when medicine is needed. Do not give your child a stimulant laxative, a herbal tea or an enema on your own, because the type and dose are decided by the doctor based on age and weight.

Take your child to a doctor promptly if constipation started in the first weeks of life, if the first stool after birth came more than 48 hours late, or if there is a swollen belly with vomiting, blood in the stool, or poor growth or weight gain.

Constipation in pregnancy

Many pregnant women get constipated, for several reasons that add up. The hormone progesterone slows the bowel, the growing womb presses on it, and the iron tablets prescribed to most pregnant women in the region make stools harder. Nausea in the early months can also cut down how much you eat and drink.

A 2024 review from the American Gastroenterological Association notes that treatment options in pregnancy include dietary fibre, lactulose and polyethylene glycol laxatives such as macrogol. Always start with fibre, water and gentle walking, and check with your doctor or pharmacist before taking any laxative.

Avoid castor oil and herbal laxative blends in pregnancy, as some can trigger contractions of the womb. If iron tablets are the cause, do not stop them yourself. Ask your doctor about a different form of iron or a different way of taking it. Constipation in pregnancy also makes piles more likely, so treating it early protects you from them.

Sources

• Suares NC, Ford AC: Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis, The American journal of gastroenterology, 2011
• Alhassan M, Alhassan A, Alfarhood A et al: Prevalence of constipation among central region population, Riyadh and Qassim provinces, Saudi Arabia, 2018-2019, Journal of family medicine and primary care, 2019
• Christodoulides S, Dimidi E, Fragkos KC et al: Systematic review with meta-analysis: effect of fibre supplementation on chronic idiopathic constipation in adults, Alimentary pharmacology & therapeutics, 2016
• Tolkien Z, Stecher L, Mander AP et al: Ferrous sulfate supplementation causes significant gastrointestinal side-effects in adults: a systematic review and meta-analysis, PloS one, 2015
• Trieu RQ, Prott G, Sequeira C et al: Using a footstool does not aid simulated defecation in undifferentiated constipation: A randomized trial, Neurogastroenterology and motility, 2023
• Tabbers MM, DiLorenzo C, Berger MY et al: Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN, Journal of pediatric gastroenterology and nutrition, 2014
• Kothari S, Afshar Y, Friedman LS et al: AGA Clinical Practice Update on Pregnancy-Related Gastrointestinal and Liver Disease: Expert Review, Gastroenterology, 2024