Dear Dr. Wong: Our teenage son has a serious problem with constipation. It started when he was a young boy. At that time, he was admitted to the hospital; our doctor put a tube into his stomach to instil medicine and gave him several enemas. It relieved his serious constipation.
Over the years, we had tried all sorts of treatment. Unfortunately, he either had very loose stool or he got constipated once we stopped his medicine; we couldn’t get to a happy medium. We have tried stool softeners, fibre supplements, laxatives and, most recently, Restoralax; nothing seems to work well for him.
He has gotten worse since the pandemic. He stays inside because he is terrified of catching the virus. His only exercise is on the controller of his videogames. We are desperate for help.
Answer: Constipation is one of the most common conditions that family doctors and pediatricians see in their office. Unless it is managed properly, it can continue into adulthood and become a life-long struggle.
The food that we eat is digested in the stomach and small intestines. Nutrients are absorbed; what remains unabsorbed is passed into the large intestines and out as stool. Along the way, water is absorbed. How much water is absorbed depends on the amount of fluid we drink, as well as water loss through sweating and breathing. We also lose water through the kidneys; this is necessary to remove waste from the body.
There is a natural mechanism to balance fluid intake and loss. If we need water, we get thirsty; the large intestines can absorb more water into the body if needed. If stool is staying in the rectum and adjacent large intestine for longer periods of time, more water will be absorbed from the stool. This will make the stool more solid and harder to pass; it can cause discomfort, pain and sometimes bleeding.
There are many reasons constipation happens. When stool gets to the rectum, it stretches the rectal wall and sends a signal to the brain: time to poop. If it is inconvenient, he can suppress the urge, which goes away after a while. Hours later, the urge will return. Repeated suppression of this signal will lead to excessive accumulation of stool in the rectum; this can happen when he is playing videogames. Water is absorbed from the stool in the meantime, making it larger in size and harder to pass.
Occasional constipation can be treated with stool softener. However, chronic and recurrent constipation requires more intervention. It is important to consider a diet with more fibre from fruits and vegetables; fibre supplements may also be necessary. Drinking lots of water can reduce water absorption by the large intestines. Regular physical activities (like walking, jogging, biking and swimming) can prevent constipation. Playing too much videogames has the opposite effect.
Treatment with stool softeners like lactulose and PEG (also called Restoralax) can be effective. They work by holding onto water in stool, keeping it soft. They need to be used daily, not on and off, to be effective. Most people make the mistake of starting them after they got constipated and stopping them as soon as constipation improves. They get into cycles of loose and hard stool. Instead of stopping them when stool is loose, one should reduce the dose of stool softener and allow the stool to become less loose.
Treatment of chronic constipation can take months. It is totally safe to use stool softeners for many months to retrain the bowel. There is no such thing as becoming dependent on stool softener. It is also important to recognize the signal or urge to have a bowel movement. Instead of ignoring the signal, he has to go to the bathroom to pass the stool, even a small amount, instead of allowing it to stay in the rectum and become hard stool.
When constipation is severe, it may be necessary to use laxatives or enemas for a short period of time to remove impacted stool. However, it is important to start stool softener early and continue that for a long time to prevent recurrence of constipation.
Dr David Wong is a retired pediatrician in Summerside and recipient of 2012 Distinguished Community Paediatrician Award of Canadian Paediatric Society. His columns will appear in The Guardian on the last Tuesday of every month. A collection of his previous columns is at askdrwong.ca. If you have a question for him, mail it to Prince County Hospital, 65 Roy Boates Ave., Summerside, P.E.I., C1N2A9.