The Role of Constipation in Hemorrhoids
What is Constipation?
Constipation refers to the condition of your bowel when you are passing feces more slowly than you usually would.
Everyone has a normal rate at which they poo, which doctors might refer to as a ‘normal bowel habit’.
Normal here is a very vague term - it’s whatever is usual for you.
Some people go once a day, some a little more, some a little less, there’s no ‘correct’ value you need to adhere to! But if, for whatever reason, your bowel isn’t working at its usual rate, you can get backed up. This is the definition of constipation.
Causes of Constipation
Constipation all depends on how our bowels are working, which depends on a number of factors: -
Muscle tone and nerve supply can contribute to constipation
Your bowel moves whatever is inside it through its length by a muscular action called peristalsis. It’s quite a vigorous action, and it’s the same one that’s used when you swallow.
Your intestines can be considered in five major parts - your mouth is the first, then the throat or oesophagus, then the stomach, then the small bowel and then the large bowel.
The throat and stomach have very vigorous peristaltic action, kneading the bowel contents around, back and forth, allowing them to mix with secretions that cause digestion.
Muscles don’t fire without getting nerve impulses, and the body controls all this muscular action without conscious effort, using the autonomic nervous system (that’s the part that looks after things like heart rate, blood supply and breathing).
Equally, if there’s anything affecting the muscles, then it doesn’t matter how many nerve impulses arrive, not much will happen.
Diet and drugs can affect muscles and nerves, and hence can cause constipation and diarrhea
Although many diseases can affect either of these systems, the most common way you will affect muscles and nerves in your gut is with drugs, either deliberately when you are taking prescribed ones or without realizing it when you eat or drink certain foods.
Chillies contain a chemical that can irritate the lining of the bowel, for example, and the body responds by flushing the bowel contents through - I’m sure that’s not news to anyone who likes strong curry - diarrhea.
One of the key classes of drugs that slow down the nerve impulses to the intestine are Opiates - the class of painkillers that includes morphine and codeine. These are a major cause of constipation, particularly in patients who use them regularly for chronic pain.
Your diet is a much more important factor for most cases of constipation.
The speed with which your food passes through you can lead to constipation or diarrhea
One of the chief purposes of your lower intestine is to recover all the fluid your body has been pouring into your food in order to dissolve and digest it.
Something like 9 litres of fluid enter your intestines a day, some from the water you drink and the food you eat, but mostly from fluids, acids and enzyme-rich secretions from the organs of digestion.
Of that, only about 150 ml is lost in the feces - your kidneys deal with most of the watery waste, and the body is very cautious about losing more than it needs to.
So the lower bowel is extremely good at sucking water out of whatever is passing through it.
If the bowel isn’t moving food through as quickly (for whatever reason, drugs, disease or low dietary fibre), then the lower bowel has more time to soak up water from the waste matter. And it leaves hard, pebbly lumps behind, drained of all fluid.
These are hard and can be painful to pass.
If the fecal matter stays in there long enough, being squashed from behind by the arrival of more feces, it could even form what is called a ‘faecolith’ (which is Latin, approximately, for ‘poo stone’).
The converse is true - if everything is rushing through the bowel, there will be more water left behind, and that’s when you get diarrhoea.
Foods that control speed and water retention in feces
Fibre is important for two reasons.
The more you drink, the more there is for the body to use.
If you don’t drink enough, your body will slow the passage of stool through the bowel to make sure it can suck out every last drop, which will eventually result in constipation.
You should aim to drink 1.5-2 litres of water a day, more in a hot climate, and most of us don’t simply because it takes a bit of effort to do that!
The role of Exercise in avoiding constipation
Finally, the exercise you do stimulates the movement of food through your gut as the muscles around the abdomen contract, helping move the food down and providing extra pressure inside the abdomen to help things on their way.
Sitting down all day deprives you of this extra helping hand and slows things up, increasing the liklihood of constipation.
Age and Constipation
The older we get, the less active we tend to be, and this, combined with the slightly weaker muscle tone that comes with age, leaves us open to more constipation as we grow older.
Am I constipated?
According to the textbook I’ve just checked up in, ‘Constipation is such a major problem in the general population that it need not be considered a disease’.
Fair enough, it’s not really a disease in itself, although it can be a symptom of an underlying disease. And almost all of us will get constipated at one time or another. But it’s still something to watch out for.
Basically, if your own normal bowel habit has changed so that you are voiding feces less frequently than you usually would, you can refer to that as constipation. If you are having a bowel movement less than three times a week, you are probably constipated.
Constipation can also manifest itself with some or all of the following symptoms: -
More severe constipation can also cause your stomach to bloat up and feel hard to the touch; you may feel sick or headachy, and if you’ve been constipated for long enough, you may actually get diarrhoea as the fluids from behind the log jam of feces overflow.
Doctors love making scientific sounding scales and charts to measure things on, and one of my favourite bits is the Bristol Stool Chart. It’s a seven point scale that lets you categorise exactly what your bowels are producing, if you’re so inclined, and here it is, copied from its Wikipedia entry: -
Delightfully graphic, isn’t it? If your stools resemble numbers one or two, you probably have constipation.
Constipation and Hemorrhoids
So what’s the link here? Well, it’s basically that if you are constipated, you are likely to end up straining to pass your hard, uncomfortable stools, which themselves may now be so hard that they have quite rough edges.
If you already have hemorrhoids, you may be wincing at the very thought of going through that, and it’s fair to say that constipation will certainly be uncomfortable for a piles sufferer and may well make things worse.
But constipation can even be a cause of hemorrhoids.
The rectum is the last 12cm of your lower bowel, and has the anal sphincter at the bottom of it. Around this is a mass of spongy blood vessels, the hemorrhoidal cushions.
As a normal reflex, once there’s about 100mL of matter inside the rectum, you’ll feel the urge to defecate.
There’s then a complex set of muscular contractions (which are under a degree of voluntary control, once you’re potty trained) that relax the anal sphincter while the walls of the rectum gently contract. At the same time, the cushions get inflated with blood, and that also helps squeeze the contents of the rectum out.
One of the mechanisms that inflates the cushions is when you increase the pressure inside the abdomen by contracting the muscles in it - by straining.
Veins in particular are quite elastic in their structure, rather like balloons, and just like a balloon, you can push them past their tolerances.
Inflate a vein too much and rather than bursting, it is more likely to overstretch so it can’t return to its original size (just as a balloon does after the first time you blow it up. Balloons aren’t as tough as veins!), and that’s partly what a hemorrhoid is.
So you can see that if you’re constipated, and spending a lot of extra time on the toilet straining to move your bowels, you’re putting extra strain on these cushions full of veins. And that’s one of the causes of hemorrhoids.
As our muscles weaken as we get older, the more likely we are to get constipated and be straining, and therefore the more likely we are to get hemorrhoids.
In short, constipation causes hemorrhoids too.
The Treatments for Constipation
Well, the good news is that it’s very easy to treat constipation.
Exercise and Water to prevent constipation and to treat it.
Get plenty of regular exercise, at least twenty-thirty minutes of an exercise that makes you break a gentle sweat and at least three times a week, and even just getting up and having a quick walk about once an hour if you have a very sedentary job.
Make sure you are drinking at least 1.5 litres every day, and have a look at your diet to make sure there’s enough fibre in it.
Laxatives - be warned - are a constipation treatment to be careful about
If you’re doing all that already, or if you aren’t able to, maybe you are thinking about a laxative.
Don’t rush into taking these - almost all constipation should be treatable without the need for laxatives, and they are definitely not to be used as a quick fix!
Like all medicines, you should understand what they are and what they do before leaping into taking them.
But sometimes, they can be the best option, especially if your constipation is caused by another medicine you have to take regularly.
Even then, do try the advice above as well if at all possible.
Types of Laxatives that people use for constipation, and their pros and cons.
There are roughly five different categories that laxatives fall into, and I’m listing them in the order you should try them in. It’s not an exhaustive list, but you should be able to find out what class any laxative you’re thinking of trying fits into.
Treating constipation with bulking agents
Bulking agents (e.g. sterculia, ispaghula hulks) act like extra dietary fibre, giving the bowel wall something to push against and keeping extra water in the stool.
These should be your first port of call if you want to use laxatives - they work in a very natural way.
Bear in mind, though, that isn’t the same as saying they are mild drugs. I once snacked on an entire box of dried apricots rather absent mindedly, and the result was very far from gentle, I can assure you!
Treating constipation with Stool softeners
Stool softeners (e.g. docusate) work by making your stools more permeable to fat and water, so more fat and water stays in them making them softer and easier to pass.
But your body can quickly get tolerant of these, so they’re unlikely to be much use for a long term solution.
Treating constipation with Stimulants
Stimulants (e.g. bisacodyl, senna) are a little more powerful in their action, and work by either increasing the muscle tone in the bowel or by lightly irritating the membranes like the curry I mentioned earlier to produce an increased rate of flow through the bowel.
They can make you feel crampy and uncomfortable, as you might expect.
There is a risk with long term use in that that they can actually result in a partially paralysed bowel - you body will always try and maintain a balance, and if you’re stimultating the bowel artificially, you can get to a point where the muscles are just worn out!
This is a risk, though, not a certainty, but you shouldn’t take stimulant laxatives without medical advice.
Treating constipation with Osmotics/hydrating agents
Osmotics/hydrating agents (e.g. Magnesium salts, saline solutions) work by reducing how much water the bowel can absorb from its contents.
More water in the stool equals softer, more easily passed motions and less constipation, but could also alter the balance of water in your body with unpredictable results.
Treating constipation with Lubricants
Lubricants (e.g. mineral oils) work exactly as you might expect, by helping the stool slide out.
Some are administered via the top end, some as enemas from the bottom end, and they aren’t something I’d advise for home use unless you are very sure of what you are doing.
Use of laxatives for constipation in general
Many patients also find relief from suppositories versions of some of these laxatives - that’s a pill form of the tablet that is inserted into the rectum and allowed to dissolve into the bloodstream there.
There are other risks with the long term use of laxatives including renal failure, irritable bowel syndrome and pancreatitis. All small risks, but I mention them here to stress that laxatives are not to be taken lightly. Try other options first, and laxatives if they don’t work!
For the frail with constipation
Extremely severe constipation in someone too frail to respond well to any of these treatments can even be manually evacuated by a trained nurse, although that’s unusual except in someone very weak and unable to care for themselves.
Summary of Constipation and it's Treatment
I hope you can see that there is a clear relation between constipation and hemorrhoids, and that ensuring you have healthy, regular bowel movements that are normal for you is important for your health.
It’s always a bit embarrassing to talk about your bowel habit - that’s why there are so many coy ways of referring to it - but it is an important factor in looking after yourself and your hemorrhoids, and doesn’t take too much effort to sort out if you are otherwise healthy.
Look at your lifestyle today and see what you could improve on now.
Research and write by James Hogg,(BSc Oxon, MBBS & BA Hons), Doctor of Medicine, minor editing by Donald Urquhart.
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