Constipation is arguably the most common digestive complaint in the developed world. It affects approximately 16% of all adults globally, rising to 33% in those over 60. Yet despite its prevalence, it's chronically undertreated — partly because people are embarrassed to mention it, and partly because there's so much conflicting advice out there. Prune juice, coffee enemas, herbal teas, detox cleanses... the noise is deafening. Let's cut through it with what the science actually says.
📋 What Constipation Actually Is (And Isn't)
Medically, we use the Rome IV criteria to define functional constipation. You need to have at least two of the following symptoms for the last three months, with onset at least six months ago:
Notice that frequency alone doesn't define constipation. If you go every other day but your stool is soft, easy to pass, and you feel complete — that's not constipation. Conversely, if you go daily but strain painfully with hard pellets, that is constipation.
🔍 Common Causes: Finding Your Root Issue
Effective treatment starts with identifying the cause. Here are the major categories:
1. Dietary factors: Low fiber intake is the most common cause worldwide. The average Western adult consumes only 12–15 g of fiber daily — roughly half the recommended amount. Inadequate water intake compounds the problem, as fiber needs water to bulk up stool effectively.
2. Sedentary lifestyle: Physical inactivity slows colonic transit. The colon responds to movement — contractions in your skeletal muscles stimulate peristalsis through mechanical and neural pathways.
3. Medications: Opioids are the most notorious (opioid-induced constipation affects 40–80% of patients). Other common offenders include calcium channel blockers, iron supplements, anticholinergics, antidepressants (tricyclics and SSRIs), and aluminum-containing antacids.
4. Pelvic floor dysfunction (dyssynergic defecation): In up to 40% of chronic constipation patients, the problem isn't slow transit — it's paradoxical contraction of the pelvic floor muscles during attempted defecation. Instead of relaxing to allow stool to pass, the muscles tighten. This is often missed and requires specialized testing (anorectal manometry) to diagnose.
🌾 Fiber: Your Most Powerful Tool (Used Correctly)
Not all fiber is created equal. Understanding the difference between soluble and insoluble fiber will help you choose the right approach.
Soluble fiber (psyllium, oats, beans, apples, flaxseed) dissolves in water to form a gel-like substance. It softens stool, increases bulk, and is gentler on the GI tract. Psyllium husk is the most studied supplement and is recommended as first-line therapy by every major gastroenterology guideline.
Insoluble fiber (wheat bran, whole grains, vegetable skins, nuts) doesn't dissolve — it adds bulk and accelerates transit through the colon. However, in patients with slow-transit constipation, large amounts of insoluble fiber can worsen bloating and discomfort without improving symptoms.
Start low, go slow. Increase fiber by 5 grams per week to your target of 25–30 g/day. Rapid increases cause bloating, cramping, and gas as your gut microbiome adjusts. Always pair fiber with increased water intake — at least one extra glass of water for every additional 5 g of fiber. If you experience significant bloating, favor soluble fiber (psyllium) over insoluble fiber (bran).
💊 Laxatives: A Practical Guide
When lifestyle measures alone aren't enough, laxatives are the next step. Here's the hierarchy I follow in practice:
🪑 Toilet Posture: The Squatting Advantage
Here's a simple change that can make a dramatic difference: elevate your feet while sitting on the toilet.
When you sit on a standard toilet with feet flat on the floor, your anorectal angle is approximately 90 degrees. The puborectalis muscle — which wraps around the rectum like a sling — maintains a kink that helps with continence but makes evacuation harder.
When you elevate your knees above your hips (using a footstool, stacked books, or a commercial product like the Squatty Potty), the anorectal angle opens to approximately 120–130 degrees. This relaxes the puborectalis muscle, straightens the rectal canal, and allows stool to pass with significantly less straining.
A 2019 study in the Journal of Clinical Gastroenterology found that using a toilet footstool reduced straining by 50%, reduced time spent on the toilet by 30%, and improved the sensation of complete evacuation. It's free, safe, and takes effect immediately.
🧠 Biofeedback Therapy: For When Muscles Are the Problem
If you have dyssynergic defecation — where your pelvic floor muscles contract instead of relaxing during attempted bowel movements — no amount of fiber or laxatives will fully solve the problem. This is where biofeedback therapy comes in.
Biofeedback uses sensors placed in or near the rectum to provide real-time visual or auditory feedback about your pelvic floor muscle activity. Over 4–6 sessions, a specialized therapist teaches you to consciously coordinate relaxation of the pelvic floor with abdominal pushing. Success rates range from 70–80%, and results are durable — most patients maintain improvement years later.
- New-onset constipation after age 50 — warrants colorectal cancer screening.
- Blood in stool or on toilet paper — don't assume hemorrhoids without evaluation.
- Unintentional weight loss accompanying constipation.
- Severe abdominal pain or distension — could indicate obstruction.
- Family history of colorectal cancer or inflammatory bowel disease.
- No bowel movement for 7+ days — consider impaction, especially in elderly or opioid-using patients.
📝 Your Anti-Constipation Action Plan
Constipation is not a character flaw, a sign of laziness, or something you should just "tough out." It's a medical condition with well-understood mechanisms and effective treatments. If lifestyle changes aren't enough, don't give up — escalate. Your gastroenterologist has a deep toolkit, and together you can find what works for your body.