Constipation: Why It Happens and What to Do, Step by Step

Constipation is among the most common and least discussed symptoms: around 15 % of adults deal with it regularly, more often women and older people. Because it is rarely talked about, the topic attracts a lot of improvisation — from years of herbal teas to "colon cleanses". In most cases a sequence of simple steps solves it, provided they are done in the right order and each is given enough time.

What counts as constipation#

Clinically it is defined by the Rome criteria: two or more features present over the past three months, with symptoms starting at least six months ago.

Feature	How it shows up
Frequency	Fewer than 3 spontaneous bowel movements per week
Consistency	Hard or lumpy stool — Bristol types 1–2
Straining	Effort needed in more than a quarter of movements
Incomplete emptying	Sense that the bowel hasn't fully emptied
Obstruction	Feeling of blockage in the rectum
Manual assistance	Needing to help manually

Importantly, there is no "once a day" requirement. A daily bowel movement is not a health metric, and going every three days without discomfort or straining is not a disease. Judge by consistency and ease, not the calendar.

Common causes#

Category	Examples
Diet and routine	Low fibre, low fluid, irregular meals, restrictive diets
Lifestyle	Inactivity, suppressing the urge, travel and changes of setting
Functional	Constipation-predominant IBS, dyssynergic defecation
Medications	Opioid analgesics, iron supplements, antidepressants, aluminium antacids, some antihypertensives
Endocrine and metabolic	Hypothyroidism, diabetes, hypercalcaemia
Neurological	Parkinson's disease, multiple sclerosis, spinal cord injury
Structural	Strictures, tumours, rectocele, severe haemorrhoids

Dyssynergic defecation deserves separate mention — a condition in which the pelvic floor muscles contract instead of relaxing during straining. It affects roughly a third of people with chronic constipation and barely responds to laxatives; biofeedback therapy with a specialist is what works. Suspect it when the main complaint is being unable to evacuate despite soft stool, along with a sensation of blockage.

A step-by-step plan#

Work down the list, giving each step two to four weeks. For most people the first three are enough.

Step 1. Fibre — gradually#

The target is 25–30 g a day, but the rate of increase determines whether fibre helps or just adds bloating. Add roughly 5 g per week.

For constipation the type matters more than the total. Soluble, viscous fibre — psyllium husk, oats, flaxseed — holds water and softens stool. This is the best-evidenced option in chronic constipation. Insoluble fibre — wheat bran — adds bulk and stimulates motility, but often worsens pain and bloating in people with IBS.

Source	Portion	Fibre
Psyllium husk	1 tbsp (5 g)	4 g, mostly soluble
Prunes	5–6 (50 g)	3 g plus sorbitol, a mild osmotic agent
Ground flaxseed	2 tbsp	4 g
Cooked beans	150 g	10 g
Porridge oats	60 g dry	6 g
Pear with skin	1 medium	5 g
Wholemeal bread	2 slices	4 g

Читайте также: Fibre: How Much You Need and How to Get It Without Bloating

Step 2. Fluid#

Fibre without water works against you: it swells, and without enough liquid it makes stool firmer, not softer. A reasonable target is around 30 ml per kg of body weight a day, counting all drinks and soups. Drinking beyond that "for the bowel" achieves nothing — in a well-hydrated person the surplus is simply excreted by the kidneys.

Читайте также: How Much Water Per Day: Real Numbers and Persistent Myths

Step 3. Movement and routine#

Physical activity speeds colonic transit — 30 minutes of walking a day is enough. Routine matters just as much: the gastrocolic reflex is strongest in the morning and 15–30 minutes after eating. A practical tactic is to set aside ten unhurried minutes after breakfast, without a phone, and never to suppress the urge when it comes. Habitually postponing "until I'm home" is one of the most common everyday causes of chronic constipation.

Posture helps too: raised knees (a footstool) straighten the anorectal angle and reduce the need to strain.

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Step 4. Laxatives#

If the basics haven't worked after four to six weeks, add medication. The order of choice matters.

Class	Examples	Notes
Bulk-forming	Psyllium, methylcellulose	First line, need adequate fluid
Osmotic	Macrogol (PEG), lactulose	Best evidence, suitable long term
Stimulant	Bisacodyl, sodium picosulfate, senna	Second line, short courses
Stool softeners	Docusate sodium	Limited effectiveness
Prokinetics and secretagogues	Prucalopride, lubiprostone	Prescribed for refractory constipation

The dependence myth applies mainly to stimulant laxatives taken daily for years. For macrogol and psyllium there is no evidence of dependence, and current guidelines explicitly permit long-term use. Far more harmful is enduring and straining for years: that drives haemorrhoids, anal fissures and pelvic floor descent.

Red flags#

Читайте также: Bloating: Why It Happens and What Actually Helps

The bottom line#

Constipation is defined by stool consistency and effort, not the calendar. Start by building fibre gradually to 25–30 g a day with an emphasis on soluble sources (psyllium, oats, prunes), drinking enough, walking daily, and keeping an unhurried morning routine without suppressing the urge. If four to six weeks of that isn't enough, add a macrogol osmotic laxative — safe for long-term use. And check your medication list: the cause is often sitting right there. With blood, weight loss, anaemia or new onset after 50, see a doctor first.