Since starting the Forgotten Side of Medicine, I’ve received quite a few correspondences from readers asking me to write about constipation. This I believe, is reflective of how widespread but rarely discussed constipation is, especially as one becomes older¹ (where it often becomes a primary concern of everyday life).

Likewise, the primary diagnosis for constipation is “chronic idiopathic constipation” (CIC). Idiopathic, for reference, means “no one knows why” which is remarkable given that existing studies find² between 9% to 20% of adults (averaging at 14%) have CIC. This figure in turn, varies greatly by country:

In tandem, there is no clear consensus on how to treat CIC (e.g., if you review the treatment guidelines,³ you will see they vary greatly depending on which country they were made in). Likewise, the majority of patients do not even discuss their condition with their doctors:

“Overall, 4,702 participants had experienced constipation (24.0% met the Rome IV CIC criteria).⁴ Among all respondents with previous constipation, 37.6% discussed their symptoms with a clinician (primary care provider 87.6%, gastroenterologist 26.0%, and urgent care/emergency room physician 7.7%).

We found that the locus of control — the extent to which individuals believe they can control events that affect them — is associated with healthcare seeking for constipation. Namely, those with a lower locus of control (i.e., who believe symptoms are driven by others, chance, or fate) are more likely to consult with providers regarding their symptoms.

However, individuals experiencing this maladaptive cognition may be resistant to both undergoing indicated diagnostic testing and accepting and adhering to treatments, thereby undercutting treatment success and reducing patient satisfaction.”

Additionally, many who seek out medical help end up getting colonoscopy, a procedure which carries real risks and has no benefit here:

“Among those who sought care, 54% reported previous diagnostic testing.⁵ Colonoscopy was the most commonly performed test; 46% of health seekers specifically underwent the procedure to evaluate their constipation.

Although we did not ask the respondents about alarm features or have access to their medical records to confirm the ‘true’ indication for the procedure, this suggests potential overuse of endoscopy in the evaluation of constipation. This is an issue because the diagnostic yield of colonoscopy for constipation is limited.

Pepin and Ladabaum noted that in 234 individuals undergoing lower endoscopy solely for constipation, no cancers were found, and only 3% had advanced lesions. The American Society for Gastrointestinal Endoscopy states that colonoscopy should not be performed in the initial evaluation of constipated patients without alarm features or suspicion of organic disease.

The high usage of endoscopy and other tests seen in our study, in combination with the high prevalence of constipation, further reinforces the significant impact of constipation on population health and healthcare costs and emphasizes that efforts to reduce unnecessary testing are needed.”

In short, there is a surprising gap of knowledge in this area, which I believe is best demonstrated by how many times I’ve been asked to admit a patient to a hospital who was essentially just severely constipated.

Note: The current research shows constipation hospitalizes 92,000 Americans each year⁶ and results in 1.3 million visits to American emergency rooms,⁷ which again illustrates our society’s lack of knowledge in this area, especially as the rate of this is increasing (e.g., from 2006 to 2011, there was a 42 percent rise in ER visits for constipation).⁸

The Effects of Constipation

While it is relatively unlikely one will be hospitalized for constipation, the condition nonetheless has a significant effect on quality of life, as it is stressful to be unable to defecate when you attempt to and often quite uncomfortable once too much has built up inside you. Conversely, after a large bowel movement (especially if they've been constipated), individuals often feel much better and clear-headed.

Constipation frequently results in significant issues. Most commonly, we recognize its connection to the fact that the pressure created by strained bowel movements can lead to hemorrhoids, rectal prolapse, and anal fissures. However, it can also lead to less appreciated issues including:

The Dangers of Laxatives

Since most constipation is labeled as "idiopathic" treatments are typically symptom based. Unfortunately, while laxatives are relatively benign if used occasionally, over time, they can impair the normal function of the GI tract and create a situation where one requires chronic laxative use.

Note: Clinicians have also reported instances where laxatives destroyed the normal functioning of the colon which then required part of the colon to be surgically removed.¹²

One of the most commonly used laxatives (MiraLAX) can create issues because a surprising number of people have sensitivities or allergies to polyethylene glycol. When individuals have delayed bowel transit time (anyone who is constipated), they are more likely to systemically absorb MiraLAX and experience toxicity from it.

As such, it is critical to identify the actual cause of constipation rather than just trying to perpetually treat the symptoms.

Conventional Causes of Constipation

When evaluating the root cause of constipation, it is critical never to forget that constipation can also be a symptom of a more serious illness.

For example, when a tumor grows in the colon, it progressively blocks transit through the colon, which in turn leads to the feces becoming narrower and narrower (along with abnormal weight loss, anemia, and rectal bleeding). Because of this, if you notice that it is gradually happening, it is worth getting a preliminary test to see if you may have cancer (there are simple and complex ways to test the stools for colon cancer).¹³

Note: Red meat (especially for those who do not eat it frequently) and beet juice can also make the stools turn red.

Other diseases that can frequently cause constipation include:

Proposed mechanisms include brain-gut axis dysfunction, increased pelvic floor muscle tension due to anxiety, altered gut microbiota in anxiety, and hormonal pathways affected by stress — and my leading hypothesis — sympathetic activation directly reducing bowel transit.¹⁷ Because of this, mind-body practices that relax the body can sometimes be quite helpful, as is psychological support.

Note: The natural treatments for anxiety are discussed here and those for depression here.

Additionally, many medications, particularly opioids, can cause constipation, with potential offenders also including antacids, anticholinergics, antidepressants, antihistamines, antipsychotics, calcium channel blockers, certain blood pressure medications, and NSAIDs. Because of this, if you develop constipation after starting a new prescription, it is always important to see if that drug is linked to impaired bowel movements.

Note: Iron and calcium supplements can sometimes cause constipation (e.g., iron supplements cause constipation for approximately 10% of users¹⁸).

Other Causes of Constipation

Unfortunately, in most cases, the cause of constipation remains unknown, and typically the advice given is to "eat more fiber," which while sometimes helpful often is not. Additionally, in some cases, the benefits of fiber are not due to their stool bulking activity but rather that they directly stimulate peristalsis.

Presently, I believe there are a few major contributors to the epidemic of constipation we face that are largely overlooked.

Squatting

Something many people don't realize is that the modern toilet is a relatively new invention, and that prior to it, rather than sitting, humans squatted to go to the bathroom.³⁰ Additionally, sitting toilets are primarily a Western creation, so as one goes to many other societies, squatting toilets are much more common (although they are gradually being phased out as a sitting toilet is seen as a sign of affluence). For example, toilets like these are commonly seen throughout Asia.

Note: One of the interesting things about this design is how much less water it uses (whereas by contrast, standard toilets account for approximately 30% of the average home's indoor water use).³¹

Unfortunately, due to our anatomy, this positional change is much more problematic than we realize as it compresses the rectum and hence makes it much harder to force feces through it.

In turn, many find that if they squat while defecating, this significantly eases bowel movements (e.g., I periodically hear this story from patients who went to Asia and had to use squat toilets there). Sadly, however, like many other harmful modern cultural practices (e.g., there are a variety of issues with wearing bras such as it causing breast cancer), the importance of the position we defecate in is rarely recognized.

Conclusion

One of the things I find the most unfortunate about the constipation subject is that due to it being “inappropriate” to discuss, many patients simply don’t bring it up. Because of this, despite being a widespread problem in our society, little is still known about constipation and many unwise approaches are used to manage it.

I hence believe the subject deserves much more attention than it gets, and again and again I’ve seen just how significantly a person’s quality of life can improve once their bowels start functioning again. In many cases, the fix isn’t complicated — but finding what actually works requires stepping outside the standard model and taking the time to look at the full picture.

The good news is that once you start connecting these dots and supporting your body's natural processes — most people can get their digestive system back on track without becoming dependent on pills. It just takes looking at the whole picture instead of treating constipation like it's some mysterious, unsolvable problem when the answers are often hiding in plain sight or simply doing what our ancestors used to.

Author’s Note: This is an abridged version of a longer article about the causes and treatments of constipation which goes into greater detail on the natural therapies for constipation. That article and its additional references can be read here.

A Note from Dr. Mercola About the Author

A Midwestern Doctor (AMD) is a board-certified physician from the Midwest and a longtime reader of Mercola.com. I appreciate AMD's exceptional insight on a wide range of topics and am grateful to share it. I also respect AMD’s desire to remain anonymous since AMD is still on the front lines treating patients. To find more of AMD's work, be sure to check out The Forgotten Side of Medicine on Substack.