Summary: Constipation and Natural Remedies for Constipation
- To help treat and prevent constipation, patients should be advised to start a high-fiber diet which should include 20 to 25 grams of fiber per day. Increase fiber in the form of fruits and vegetables throughout the day.
- Encourage exercise daily and use physical therapy if necessary. See aerobic exercise and resistance training sections in Preventive Health Advisor for further information.
- Unless fluid restriction is necessary, increase water intake throughout the day to change urine color from yellow to slight hint of yellow shade with each urination. Water intake should be at least 1-2 liters daily.
- Bowel movement regularity is generally established naturally by the body at the same time daily. Patients should be encouraged to attempt bowel movements at approximately the same time every day and establish timed toilet training. Patients should be educated to attempt a bowel movement at least twice a day, 30 minutes after meals, and should not strain more than five minutes.
Initial laxative choice:
- Initial laxative choice should include the bulk forming fiber supplements psyllium ( Metamucil®), glucomannan, calcium polycarbophil (FiberCon®), methylcellulose (Citrucel®), wheat dextran (Benefiber®), or bran. 50-100 grams of prunes have been shown to be more effective than psyllium for stool frequency and consistency (14,15), but psyllium has excellent evidence for reduction of bleeding from hemorrhoids(3), as well has been established as more effective for hypertension, diabetes, and weight loss.
- If response to these fiber laxatives fail, the next choice is an osmotic laxative, polyethylene glycol (Miralax) preferred at a dose of 17-34 grams in liquid of choice daily. Other osmotic laxatives include sorbitol and lactulose. Sorbitol is better tolerated than lactulose, is less expensive and is similarly efficacious. Magnesium citrate is also a reasonable second choice.
- The next choice would be a stimulant laxative such as senna or bisacodyl.
- A stool softener may benefit patients which typically experience hard impacted stool or hard pellet-type stool.
- Suppositories with glycerin or enemas with tap water or sodium phosphate would be the next choice.
Psyllium husk fiber:
- Psyllium husk is a naturally derived fiber which may be used to reliably and routinely add enough fiber to the diet over simply increasing high fiber foods to produce constipation relief. Psyllium may also be used to produce more immediate results until dietary habits with higher fiber intake are established.
- Psyllium husk added more water to stools, was a more effective stool softener, and was a better laxative at a dose of 5.1 g twice daily than docusate sodium (Colace brand) at a dose 100 mg twice daily (1).
- Psyllium husk may also be as effective as other stimulant laxatives but the use of this fiber results in less adverse effects (2).
- Compared to placebo, 7 grams of psyllium fiber mixed with water three times daily before meals reduced the pain and bleeding associated with hemorrhoids in outpatients with symptomatic first and second degree hemorrhoids after 6 weeks and with less hemorrhoid bleeding (8% vs 44%) and also had less pain when going to the bathroom (4% vs 32%) (3).
- Constipation relief, measure by stool frequency and weight, was reported in 63% of participants taking 6.5 g/day of psyllium plus 1.5 g/day of senna compared to 48% taking 7.2g/day of psyllium alone (4). Therefore, psyllium and senna taken together is likely more effective than either agent taken alone when a stronger laxative effect is needed.
Glucomannan, a water-soluble dietary fiber:
- Glucomannan increased daily and weekly bowel movements by 0.5 times per day and 3 more times per week for 3 gr/day, by 0.9 times per day and 6 more times per week for 4 gr/day with no change for the placebo group (7).
- Glucomannan treated 45% of chronically constipated children successfully and reduced abdominal pain at a dose of 100 mg/kg body weight daily (maximal 5 g/day) with 50 mL fluid/500 mg vs. 13% for matching placebo after 4 weeks (8).
Senna
- Senna is an effective natural plant based laxative which is effective for constipation (5).
- Senna is often considered a safe and mild benign laxative because it is derived from a plant source, but it can have many of the same harmful effects of prescription cathartic laxatives if taken long term.
- Patients should be aware that senna may reduce the absorption of drugs(11).
- According to van Gorkom BA et al, senna may not only result in dependence, but also may increase the risk of colon cancer by shortening crypts, increasing cell growth, and by reducing apoptosis (12,13).
- Laxative use following childbirth: Use of senna tablets immediately after giving birth resulted in treatment of constipation in 93%-96% of women.
Miralax for constipation:
- The most commonly recommended treatment for constipation is Polyethylene Glycol 3350, (Miralax brand) available over the counter which is an effective treatment for constipation without urgency, cramping, bloating and gas. It does not work by stimulation of bowel movements, but instead draws water into the colon to soften stool and produce evacuation in a comfortable manner. For further information, see: http://www.miralax.com/miralax/why-miralax/how-miralax-works.jspa .(10)
- Miralax is more effective than senna (6), and works by drawing water into the gastrointestinal tract, softens the stool, and promotes a natural bowel movement resulting in elimination rather than functioning as a stimulant.
- Irritable bowel syndrome (IBS) with constipation: IBS suffers who ate 2 kiwi fruit a day for 4weeks had less constipation with more frequent bowel movements and shorter colon transit time than a placebo group (9).