Constipation treatment may be approached using laxatives – but they typically only offer temporary relief. A constipation cure IS possible through a comprehensive natural approach that emphasizes dietary and lifestyle changes, while identifying the CAUSE of your constipation.
Learn more about the differences between a conventional medical approach to constipation relief and a naturopathic approach to natural constipation relief below.
The first place to begin is with Constipation Assessment and Diagnosis. This may sound silly. You’re thinking:
I know I’m constipated – why do I need assessment and diagnosis?!
Even if this step is skipped, your MD or ND should AT LEAST evaluate for any Alarm Features before suggesting treatment. This is to make sure that more serious conditions don’t go unidentified or untreated. If any Alarm Features are present , you will likely be referred for a colonoscopy (to rule out Inflammatory Bowel Disease, Colorectal Cancer) or to the ER (if a Bowel Obstruction is suspected).
But don’t panic – having one of these signs doesn’t mean you have a serious condition – it just means we want to rule it out before we proceed. Learn more about Alarm Features here.
FIRST STEPS: Initial Treatment of Constipation – With NO Alarm Features
Conventional Approach To Constipation Cure
If no alarm features are present, your MD/gastroenterologist will likely recommend:
- Evaluation of any medications that may be implicated, and determination of whether they may be withdrawn or substituted
- Screening bloodwork to rule out an underlying condition such as hypercalcemia, diabetes or hypothyroidism
- Eating a high-fibre diet
- Drinking more fluids
- Increasing dietary intake if calories had previously been restricted
- Getting regular moderate exercise
- Dedicating time for bowel movements and avoiding postponement of bowel movements when an urge for defecation is felt
- Taking bulk laxatives (may be better for those who have occasional loose stool between bouts of constipation) or stool softeners (may be preferred for those with very hard stools and a lot of straining)
Naturopathic Approach To Constipation Cure
As a Naturopathic Doctor, my advice to patients (without alarm features) is similar to that of MDs. But there are some key differences that may translate to more support than you would get in a conventional setting. Additionally, my choice of therapeutic agents differs somewhat, and may include additional options shown in studies to be effective. Relying on medications for constipation relief is avoided where possible.
Key Differences in a Naturopathic Approach to Constipation Cure:
- I provide detailed dietary recommendations and education. Counseling goes beyond a brief mention or simple handout, and aims to assist individuals in translating those recommendations onto their plate.
- Dietary counseling may include: the difference between soluble and insoluble fibre, colonic foods, resistant starches, prebiotic & probiotic foods, and amounts & types of fluids/beverages to consume to support healthy and normal bowel function.
- Dietary advice will also be specific, and differ depending on whether constipation is primary or secondary, and what underlying cause may be implicated. While prunes may be as effective as psyllium (a bulk laxative), there are other options that can be even more effective!
- Lifestyle counseling may include: appropriate types and amounts of exercise to support regular bowel habits, skills and tools to enhance relaxation (an essential component of defecation), tools like posture and abdominal massage that may be beneficial.
- Routines & Habits are discussed, and suggestions are made about how to create routines that will support healthy bowel habits. Sometimes, we will brainstorm together to find creative solutions in this area.
- If patients have a significantly restricted caloric intake owing to a history of disordered eating, I work with them concurrent to other therapeutic approaches that they are accessing via a psychologist or psychotherapist specializing in that area.
- If bulking agents or laxatives are indicated, I select the ones seen to provide the most benefit with the least side effects. Supplemental fibre, prebiotics, and specific strains of probiotics are considered, and again are tailored specifically to the individual and any underlying cause of their constipation.
Ready to tackle YOUR constipation?
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NEXT STEPS: Initial Treatment Did NOT Provide a Constipation Cure
No constipation relief. You’re STILL constipated 🙁
If you didn’t get constipation relief from initial dietary & lifestyle measures, further assessment is advised. At this point, your MD or ND should rule out Dyssynergic Defacation.
Do You Have Dyssenergia?
If 6-8 weeks of effort left you still wondering how to relieve constipation, the diagnosis of Dyssynergic Defacation should be considered – especially if you experience:
- A sensation of anal blockage
- Frequent straining at stool
- A need to manually assist defecation
To review, Dyssynergic Defecation is the inappropriate or inadequate contraction and relaxation of the pelvic floor muscles, resulting in the failed expulsion of stool.
If dyssynergia is the cause, a constipation cure is still possible. Physiotherapy of the pelvic floor along with biofeedback have been shown to be effective for many people. A 2017 review of the literature concluded that randomized controlled trials show major improvement of constipation symptoms in 70-80% of patients, and long-term studies have shown it to be effective at maintaining improvement for 55-82% of patients after a year.
Biofeedback works to improve coordination of abdominal and anorectal muscles, and may be used concurrently with:
- Diaphragmatic muscle training
- Simulated defecation training
- Pelvic floor muscle training
Initial Treatment Didn’t Help AND You DON’T Have Dyssenergia
What if you DON’T have signs of Dyssenergia AND didn’t respond to Initial Treatment Guidelines after 6-8 weeks?
You’re still left wondering how to get rid of constipation!
Is there a constipation cure for you?!
If you work with a Medical Doctor, you will undoubtedly be prescribed some type of laxative as a constipation cure. Guidelines suggest that if you fall into this category (no response after 6-8 weeks of treatment, and no suspicion of dyssynergia), an osmotic type of laxative should be considered.
A conventional approach tends to favour PEG – polyethylene glycol, while a naturopathic approach favours lactulose or magnesium. But there is actually a LONG list of types of laxatives available. And different laxatives may be more effective depending on what type of constipation you have.
See all the options below for both CONVENTIONAL and NATUROPATHIC types of laxatives used. I additionally provide warnings associated with some types of laxatives along with bottom line assessments of the “Pros & Cons” associated with different types of laxatives.
Types of Laxatives
Conventional Constipation Treatment – Laxatives
There are 7 main types of laxative agents recommended by MDs, which include:
1. Bulk Forming Laxatives that are methylcellulose-based (Citrucel) or psyllium-based (Metamucil). These work by adding bulk via fibre and helping stool to retain more water, making them easier to pass. These are often a first choice for patients with primary constipation (especially those who have occasional bouts of diarrhea between episodes of constipation), as they are often effective and without the side effects associated with other types of laxatives.
2. Stool Softeners with docusate sodium (Colace, Dulcolax) soften stool, or with PEG – polyethylene glycol agents (Restoralax, Miralax) both soften stool and also have an osmotic effect. Stool softeners may be preferred in patients with primary constipation who complain of hard stool and straining at stool.
3. Lubricant Laxatives like mineral oil. A study published in 2005 explored the benefits and risks of different constipation treatment approaches, and showed that side effects of lubricant laxatives may include “lipid pneumonia (resulting from aspiration), malabsorption of fat-soluble vitamins, foreign-body reactions in tissue, and anal seepage.” Anal seepage. (Insert emoticon of choice here.)
4. Saline Laxatives or Enemas containing sodium, phosphate and/or magnesium (Fleet enemas, milk of magnesia, magnesium citrate). These products work by drawing water into the colon in an effort to soften stools and make them easier to pass. After a number of reports of adverse effects and DEATHS related to their use, the FDA issued a warning against them. WARNING: For individuals with kidney or heart/vascular conditions, magnesium & other saline type laxatives (see below) are advised against. Note too, that overdose (more than the recommended single dose or total doses per day) run the same risks owing to excessive absorption of sodium, phosphate or magnesium, including: electrolyte imbalance, dehydration, or volume overload – each of which can be dangerous or even deadly.
5. Stimulant Laxatives offer immediate relief by stimulating bowel muscles to speed the movement of stool through the gut. These include herbs like aloe and cascara or senna (Senokot, Ex-Lax), bisacodyl (Dulcolax), or castor oil. WARNING: These products are marketed for “occasional constipation” – but are often erroneously used or abused by sufferers of chronic or unrelenting constipation. Over time, stimulant laxatives may decrease your colon’s ability to contract strongly – worsening constipation and resulting in dependence upon them. They also may cause cramps and diarrhea. Speeding transit time may lead to dehydration, electrolyte imbalance or impaired absorption of nutrients like calcium and vitamin D. Castor oil is a purgative – which means it can induce vomiting and diarrhea – and, for the same reasons above, is NOT recommended for oral use (though it’s still commonly tried).
6. Osmotic Laxatives stimulate the intestines to draw water into them, producing watery stool that is easier to pass. The effect may take hours or days to produce depending on the dose (this is often what’s used as bowel prep for colonoscopy or surgery). These laxatives include milk of magnesia, magnesium citrate, sorbitol, polyethylene glycol (GoLYTELY, GlycoLax, and MiraLax), and lactulose. WARNING: Osmotic laxatives can cause problems for some individuals, like: bloating, nausea, cramps, gas, diarrhea, and dehydration. The elderly may be more sensitive to these side effects, and those with a history of bowel obstruction should consult with their doctor prior to use.
7. Suppositories containing docusate (Microenema), bisacodyl (Dulcolax Suppository) or sodium phosphate (Fleet Enema), are inserted rectally, and employ some of the same mechanisms describes above. These products tend to give more rapid relief (within 15-60 minutes), but are intended for occasional NOT regular use. WARNING: Enemas & suppositories can sometimes cause local irritation or burning, and often result in crampy discomfort leading to watery diarrhea. Regular use can lead to dehydration or electrolyte imbalance.
General Notes On Laxative Overuse & Abuse
Laxatives are sometimes abused as weight loss tools. Not only are they ultimately ineffective in this regard, but all the dangers listed above must be considered, including death. Overuse of laxatives (especially stimulant ones) may lead to dependence and worsening of constipation. Children, infants & pregnant women should focus on dietary & lifestyle modifications rather than laxatives to relieve constipation, as they are more susceptible to the associated dangers. Elderly are frequently prescribed laxatives – often related to medications they are taking that contribute to constipation – despite being at higher risk.
Naturopathic Constipation Treatment – Laxatives
Naturopathic Doctors sometimes employ laxatives in their treatment approach too. Here are the ones most frequently recommended.
1. Osmotic Type – Lactulose is often effective, but must be administered by an experienced practitioner, and should be gradually increased to the therapeutic dosage over several weeks to minimize the adverse symptoms of increased gas, bloating and discomfort. These symptoms are typically temporary, and should abate within 7 days of initiating treatment.
Lactulose has an effect that is somewhat gentler than that of PEG laxatives (perhaps because it’s effect isn’t purely osmotic, but also related to its role as a prebiotic), and when increased gradually, the side effects are typically minimized or avoided. While a Cochrane Review of studies to date comparing the effectiveness of lactulose and PEG, gave PEG a small edge in effectiveness against constipation, lactulose has other benefits to be considered.
Lactulose is effective at improving transit time through the colon (the amount of time from ingestion of food until it passes as stool), and as such, should be considered in those with primary constipation due to slow transit time. Normally, it should take about 18-24 hours between ingestion of food and it’s elimination via the stool. Those with slow transit time may additionally have bloating, distension, trapped gas or very odourous gas.
Another far-reaching benefit of lactulose is it’s role as a prebiotic – acting as a fuel source for healthy and desirable bacteria in the gut. Lactulose has been shown in studies to: be of benefit after antibiotic treatment (nourishing the surviving “friendly” bacteria), treat SIBO (Small Intestinal Bacterial Overgrowth) & normalize the balance of bugs in the gut, decrease intestinal permeability (“Leaky Gut”), and protect against damage from toxins in the gut.
Bottom Line: While PEG laxatives may be slightly more effective overall in treating constipation, this effect is measured when used alone. When lactulose is combined with other naturopathic approaches, it may be just as effective and provide additional benefits that reach beyond the digestive system. This makes it a worthwhile option to try.
2. Saline Type – Magnesium is an essential nutrient with myriad functions. It works in tandem with calcium to control muscle contractility and relaxation. Thus, magnesium is required for healthy heart function, and any condition associated with muscle spasms or cramps such as leg and muscle cramps, eye twitching, headaches from muscle tension, menstrual cramps and constipation.
Magnesium helps to ensure smooth nervous system communication. In addition to this, it is required for the production and balance of several brain chemicals including serotonin, dopamine and melatonin. Magnesium is therefore employed in states of nervous tension, anxiety, to aid sleep and balance sugar and chocolate cravings. This nervous system connection may also relate to digestion & elimination.
How to relieve constipation?
A diet rich in magnesium may improve frequency & quality of stool. But supplemental magnesium may be required in moderate to severe constipation to illicit a laxative effect initially.
Some healthy food sources of magnesium include: whole grains, legumes such as black-eyed peas and kidney beans, molasses, nuts including almonds, hazelnuts & pecans as well as fresh produce such as Swiss chard, spinach & other leafy greens, bananas and avocados. Some mineral waters are higher in magnesium than others, and while they do not provide HUGE amounts, this study showed the effectiveness of Hepar brand mineral water at reducing symptoms of functional constipation.
WARNING: For individuals with kidney or heart/vascular conditions, magnesium & other saline type laxatives (see below) are advised against. Note too, that overdose (more than the recommended single dose or total doses per day) run the same risks owing to excessive absorption of sodium, phosphate or magnesium, including: electrolyte imbalance, dehydration, or volume overload – each of which can be dangerous or even deadly.
Bottom Line: Because of the potential dangers associated with saline type laxatives, long-term reliance on supplemental magnesium as a laxative is less desirable than dietary & lifestyle changes & other approaches wherever possible & effective. Including magnesium-rich food regularly in the diet is a safer option, especially for thise with any history of kidney or cardiovascular problems.
3. Bulk Forming Type – Ground Flax Seeds
While a diet high in mixed types of fibre, other sources of soluble fibre (like psyllium or chia), and prunes may be effective tools, studies have demonstrated that ground flax seed is MOST effective at relieving & preventing constipation. Soluble fibre means that it can absorb many times it’s weight in water, and becomes “mucilaginous” when mixed with water – meaning a texture that is moist and lubricative. These qualities help to bulk, moisten/soften and lubricate stool, aiding in its easy passage. Again, bulk forming agents may be ideal for those with primary constipation who exhibit occasional diarrhea between episodes of constipation.
Individuals may need to start with a smaller amount of ground flax seeds, and gradually increase the dose over time with guidance. WARNING: Additional water or fluids should be taken concurrently, or else ground flax can worsen constipation rather than help it.
4. Stimulant Type – Topical Castor Oil
In a review of the uses, efficacy and mechanism of action of topical castor oil, the following was found: while the mechanism of action is not fully understood, a study of elderly subjects with chronic constipation showed that the use of castor oil packs did not necessarily impact frequency of bowel movements, but did significantly improve quality of stool and sensation of complete evacuation of stool, and also decreased the need to strain at stool. All positive outcomes. WARNING: A test patch on a small area of skin should be done first to make sure there is no irritation or allergic reaction to the oil. While topical use of castor oil may produce the same side effects as oral use or other stimulant laxatives, the effects tend to be milder.
NEXT STEPS: No Constipation Cure With Initial Guidelines OR Osmotic Laxatives
Further Considerations For Unresponsive Constipation
Patients with chronic constipation that is unresponsive to the above therapies should have physiologic testing, which may include:
- colonic transit studies
- anorectal manometry
- balloon expulsion studies
- colonic manometry
In this population, oral stimulant laxatives may be considered – but the above considerations and warnings must be applied.
Enemas, suppositories, and digital maneuvers are not desirable in the management of chronic constipation.
FINAL STEPS: Surgery
Surgery For Constipation
Patients with persistent constipation that is unrelenting and unresponsive to medical treatment may be referred for consideration of surgery, including colectomy and cecostomy. Surgery would be considered a last resort for constipation relief or constipation cure.
These procedures are only considered as options of how to relieve constipation, in those with severe colonic neuropathy (damage/dysfunction of the nerves controlling the colon) who have healthy motility in the stomach and small intestine.
Otherwise, surgery is not seen to be beneficial for constipation relief.