Constipation is something I see regularly in clinic, and for many people, it has been part of their life for so long that they have simply accepted it as their "normal".

You may be opening your bowels only a few times each week, regularly straining, passing small hard stools, experiencing bloating or abdominal discomfort, or feeling as though you haven't completely emptied your bowels.

For some people, going to the toilet can become a lengthy daily routine.

But constipation is about much more than how many times you open your bowels each week.

Recently, I attended Microba's Solving Stubborn Constipation practitioner education event, which explored chronic constipation, Functional Constipation, IBS with constipation (IBS-C), gut transit, the microbiome and the wider consequences constipation can have on health and quality of life.

It was an important reminder of just how many people live with ongoing constipation, including children.

What Does Constipation Actually Look Like?

There's a common belief that if you're opening your bowels every day, you can't be constipated. That's not necessarily the case.

Constipation may involve:

• Fewer or infrequent bowel movements
• Hard, dry or pellet-like stools
• Straining to pass a bowel movement
• Feeling that you haven't completely emptied
• Feeling that there is an obstruction or difficulty passing stool
• Spending a long time on the toilet
• Needing to use particular positions or manoeuvres to help pass a bowel movement
• Bloating and abdominal distension
• Abdominal discomfort or cramping
• Regularly needing laxatives, enemas or other interventions to help achieve a bowel movement

Some people may still open their bowels every day, but only because they regularly use laxatives, enemas or other bowel supports. These can be appropriate and sometimes medically necessary, but if you are unable to comfortably and consistently pass a bowel movement without them, it may be worth exploring why your bowel isn't functioning effectively on its own.

This is why I like to look beyond the question, "How often do you go?"

How easily you pass a bowel movement, what the stool looks like, whether you feel completely emptied, whether you require assistance to go, and how your digestive system feels afterwards can tell us much more.

Functional Constipation or IBS-C?

Constipation doesn't automatically mean that you have Irritable Bowel Syndrome.

Functional Constipation and IBS with constipation (IBS-C) can look similar, but there are differences.

IBS-C generally involves recurrent abdominal pain associated with changes in bowel movements, whereas Functional Constipation is characterised predominantly by difficult, infrequent or incomplete bowel movements without the pattern of abdominal pain required for an IBS diagnosis.

Understanding the difference can be important when deciding what needs to be investigated and how someone's digestive health should be supported.

What Happens When Constipation Becomes Chronic?

The effects of chronic constipation can extend beyond simply feeling uncomfortable.

Ongoing constipation may contribute to:

• Bloating and abdominal distension
• Abdominal discomfort and cramping
• Excessive straining
• Haemorrhoids
• Anal fissures
• Changes in appetite
• Fear or anxiety around bowel movements
• Disruption to work, school, exercise, travel and social activities
• Reduced quality of life

And when you've lived with these symptoms for months or years, it's very easy to adapt your life around your bowels without realising how much they are affecting you.

Why Am I Constipated?

There isn't one universal cause of chronic constipation.

This is one of the reasons simply telling everyone to "eat more fibre and drink more water" doesn't always solve the problem.

Constipation may be influenced by a combination of factors, including:

Diet and fibre intake
Some people aren't consuming enough fibre, while others are already eating a high-fibre diet and adding more leaves them feeling even more bloated and uncomfortable.

Hydration
Adequate fluid intake is important for normal bowel function, particularly when increasing dietary fibre.

Eating enough food
Very restrictive diets, skipped meals and chronically low food intake can also influence bowel regularity.

Movement and lifestyle
Regular physical activity can help support normal intestinal motility.

Medications and supplements
Certain medications and supplements can contribute to constipation. This is something worth reviewing with your prescribing healthcare professional rather than simply stopping medication.

Stress and the nervous system
The gut and nervous system are closely connected. Ongoing stress, anxiety and changes in routine can influence digestive function and bowel habits.

Hormonal and metabolic health
Changes in thyroid function and other health conditions may contribute to altered bowel motility.

Pelvic floor function
Sometimes constipation isn't simply about stool consistency. Coordination of the muscles involved in having a bowel movement can also affect someone's ability to empty their bowels effectively.

And then there is another piece of the puzzle that we're continuing to learn more about - the gut microbiome.

Constipation and Your Gut Microbiome

Your gut microbiome is the community of microorganisms living within your gastrointestinal tract.

The relationship between constipation, intestinal transit time and the microbiome is complex. Slower movement through the bowel can influence the environment in which gut microorganisms live, while microbial activity and the substances produced by these microorganisms may also interact with intestinal function.

This doesn't mean that every person with constipation has "bad gut bacteria" or that the microbiome is responsible for every case of constipation.

However, I do believe microbiome testing can be incredibly valuable in persistent or complex digestive cases.

Rather than continuing to guess which direction treatment should take, comprehensive microbiome testing can provide a useful baseline and help us better understand what may be happening within your digestive environment.

Depending on the test used, we may gain insight into areas such as microbial diversity and composition, the abundance of particular microorganisms, digestive and metabolic functions, and patterns that may be relevant to your individual symptoms and health history.

For me, testing isn't about finding a "perfect" microbiome or treating every result that sits outside a reference range. It's about combining your test results with your symptoms, health history, diet and other relevant investigations to help guide a more individualised treatment plan.

Sometimes, it can provide the missing piece of your digestive puzzle that helps us decide where to go next.

I prefer to test, not guess — when testing is going to give us information that can genuinely influence treatment.

What About Methane and IMO?

In some people with chronic constipation, we may also consider methane production and Intestinal Methanogen Overgrowth (IMO).

Methane is produced by microorganisms known as methanogens - technically archaea rather than bacteria.

Higher intestinal methane production has been associated with slower intestinal transit and constipation in some individuals.

This is particularly relevant when someone experiences persistent constipation alongside symptoms such as significant bloating, abdominal distension and difficulty completely emptying their bowels.

However, methane isn't responsible for every case of constipation.

Testing and treatment should be considered within the context of the person's symptoms and health history rather than assuming that constipation automatically means SIBO or IMO.

What About Constipation in Children?

Constipation isn't just an adult problem.

It is also common in children and can become incredibly stressful for both the child and their family.

Sometimes the signs are obvious — a child simply isn't opening their bowels regularly.

But childhood constipation can also present in other ways.

You may notice:

• Hard, dry or very large stools
• Pain when passing a bowel movement
• Straining
• Tummy pain or bloating
• Reduced appetite
• Avoiding the toilet
• Crossing their legs, clenching or unusual postures when they need to go
• Fear or distress around bowel movements
• Irritability around toileting
• Soiling or stool leakage in their underwear

When Holding On Becomes a Cycle

One of the difficulties with childhood constipation is that it can become a cycle.

A child experiences a hard or painful bowel movement.

They remember that it hurt.

The next time they feel the urge to go, they hold on.

The stool remains in the bowel for longer, more water is absorbed and it becomes harder and more difficult to pass.

Then the next bowel movement hurts again.

Over time, withholding can become an established behaviour even after the original trigger has passed.

Changes around toilet training, starting childcare or school, reluctance to use unfamiliar or public toilets, changes in routine, restricted food choices, inadequate fluids and stressful experiences can all potentially contribute.

Can You Have Diarrhoea and Still Be Constipated?

Surprisingly, yes.

Constipation doesn't always look like hard stools and an inability to open your bowels. In some cases, a person may experience loose or watery stools, urgency or even faecal leakage while still having retained stool in the bowel.

This is sometimes referred to as overflow diarrhoea or overflow incontinence.

When harder stool becomes retained, softer or more liquid stool may pass around it. This can look and feel like diarrhoea, particularly if you are experiencing urgency or unexpected leakage.

Some people may notice:

• Episodes of loose or watery stool despite regularly feeling constipated
• Small amounts of stool passing unexpectedly
• Faecal staining or leakage in underwear
• Difficulty controlling urgency
• A feeling of incomplete evacuation even after passing loose stool
• Bloating, pressure or abdominal discomfort
• Alternating between hard stools and loose bowel movements
• Periods of several days without a satisfactory bowel movement followed by sudden loose stools

For adults, faecal leakage can be particularly difficult to talk about. It can feel embarrassing and may affect confidence, exercise, work, travel, intimacy and social activities. But it is a symptom worth discussing with your healthcare practitioner.

Importantly, faecal leakage isn't always caused by constipation. Other gastrointestinal conditions, pelvic floor dysfunction, medication effects, neurological conditions and problems affecting bowel control can also contribute.

If you are experiencing new, persistent or worsening faecal leakage, changes in bowel control or unexplained diarrhoea, it is important to speak with your GP or appropriate healthcare professional so the underlying cause can be properly assessed.

Having loose stools doesn't necessarily mean your bowel is completely empty — and experiencing diarrhoea doesn't always rule out constipation.

This can be particularly confusing for parents.

Sometimes a child who is significantly constipated may experience overflow soiling, where softer or more liquid stool passes around retained stool.

It can look like diarrhoea or a toileting behavioural issue when constipation may actually be contributing.

Persistent constipation, pain or soiling in a child deserves appropriate assessment rather than simply assuming they will grow out of it.

When Should Constipation Be Medically Investigated?

While constipation is common, persistent or unexplained changes in bowel habits shouldn't automatically be self-treated.

Medical assessment is particularly important when constipation is accompanied by concerning symptoms such as:

• Blood in the stool or unexplained rectal bleeding
• Significant or worsening abdominal pain
• Persistent vomiting
• Unexplained weight loss
• Fever or feeling systemically unwell
• Significant abdominal swelling or distension
• A sudden or unexplained change in bowel habits
• Symptoms suggestive of bowel obstruction
• Poor growth or weight gain in a child
• Significant pain or distress around bowel movements in a child

Your GP or specialist can help determine whether further medical investigation is required.

My Approach to Chronic Constipation

When someone comes to see me with chronic constipation, my goal isn't simply to find something that will "make you go".

I want to understand why your digestive system may be struggling in the first place.

That means looking at the whole picture.

Depending on the individual, we may explore:

• Your bowel habits and stool consistency
• How long you've experienced constipation
• Bloating, abdominal pain and other digestive symptoms
• Your diet and fibre intake
• Fluid intake
• Meal patterns and whether you're eating enough
• Food restriction or fear around certain foods
• Medications and supplements
• Stress and nervous system health
• Hormonal and thyroid health
• Movement and lifestyle
• Previous gastrointestinal infections or digestive conditions
• Relevant medical investigations and pathology
• Whether further testing may actually provide useful information

For some people, microbiome or breath testing may help us understand another part of the picture.

For others, it isn't necessary.

I prefer to test when testing is going to give us useful information - rather than testing simply for the sake of testing.

Most importantly, treatment should be individualised.

Adding increasingly large amounts of fibre, cutting out more foods or relying indefinitely on products to stimulate bowel movements isn't necessarily addressing why constipation keeps returning.

Constipation Is Common — But It Doesn't Have to Become Your "Normal"

If you've been struggling with constipation for months or even years, you may have become accustomed to planning your life around your bowels.

You might know which foods make you bloated, which days you'll struggle to go, how long you'll need in the bathroom or which activities you avoid when your digestive system isn't behaving.

But common doesn't always mean normal. Sometimes we need to look beyond the bowel movement itself and ask:

What is contributing to this pattern?

By looking at digestive function, nutrition, lifestyle, nervous system health and, where appropriate, further testing, we can start building a clearer picture of what your digestive system may need.

If you or your child are experiencing ongoing constipation, naturopathic care can work alongside your GP or other healthcare professionals to help investigate contributing factors and develop an individualised approach to digestive health.

 

 

Katrina Froome Naturopathy
Gut Health • IBS • SIBO/IMO • Women's Health

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This information is for educational purposes and is not intended to diagnose or replace medical advice. Persistent or concerning changes in bowel habits should be discussed with an appropriate healthcare professional.