What to do about constipation? 5 golden rules and the Bristol stool chart

You don't have to go to the toilet every day. In healthy people, bowel movements can range from 3 times a week to 3 times a day. If your stool is soft and comes out easily, a break of a day or two is not a problem.

We talk about constipation when you go fewer than 3 times a week, the stool is hard and comes in lumps, you need to strain a lot or you are left with a feeling of incomplete emptying after going. If these signs last more than 3 months, the constipation is considered chronic.

Constipation is seen more often in women than in men: during pregnancy, the hormone progesterone slows the bowel, and after childbirth, pain and fear delay the toilet. In some women, the cause is a rectocele. In men, long hours of sitting at work (for example, a day spent behind the wheel) and straining during heavy exercise are risks.

The Bristol stool chart is a simple table that doctors use to assess the shape of stool. The shape of the stool shows how long it stayed in the bowel: stool that stays in the bowel a long time loses its water and hardens.

The goal is type 3–4. If types 1–2 show up regularly, you have constipation; types 6–7 mean diarrhea. Whatever the shape, blood, black stool, a lot of mucus or very pale, gray-white stool is a reason to see a doctor.

Rule 1: spread your water through the day

Fiber needs water to soften the stool. When there is too little water, the bowel absorbs more of the fluid in the stool and the stool dries out.

• For most adults, about 1.5–2 liters of fluid a day, mostly water, is enough. More is needed in hot weather, after exercise and during a fever.
• Drink water evenly through the day, not all at once. Starting the day with a glass of warm water is a good habit.
• Tea, coffee and sweet fizzy drinks don't fully replace water. Choose plain water instead of a lot of strong tea and coffee.
• If you have heart or kidney disease, check your daily fluid amount with your doctor.

Rule 2: increase fiber gradually

Fiber (plant fiber) adds bulk to the stool and keeps it soft. The recommended amount for adults is about 25–30 grams a day. Foods that help against constipation:

• vegetables: broccoli, cabbage, carrots, pumpkin, leafy greens;
• fruit: apples and pears with the skin, kiwi, plums and prunes, cherry plums, oranges;
• legumes: lentils, beans, chickpeas;
• whole grains: oats, buckwheat, bran and whole-grain bread;
• fermented dairy products such as yogurt and kefir make digestion easier for some people.

Foods to cut back on: white flour products, buns and sweets, fast food, processed meat products, very fatty and fried dishes.

An important point: increasing fiber suddenly by a lot can cause bloating and cramps. Add a little more each week and be sure to drink enough water, otherwise fiber can have the opposite effect. Foods that cause gas differ from person to person, so watch your own reaction.

Rule 3: move every day

Physical activity engages the muscles of the bowel wall, while a sedentary life slows the bowel.

• The World Health Organization recommends that adults do 150–300 minutes of moderate-intensity physical activity a week. That means about 30–40 minutes of brisk walking a day.
• A 10–15 minute walk after a meal helps digestion.
• If you have a desk job, get up every hour and move for a few minutes.
• Plan intense exercise about 1 hour before or 2 hours after a meal.
• When lifting weights, don't hold your breath and strain; breathe out as you lift. This reduces pressure in the anal area.

Rule 4: don't hold in the urge, and don't take your phone to the toilet

Toilet habits are the most overlooked cause of constipation.

• Don't hold in the urge. When you hold in stool thinking "I'll wait until I get home," the bowel absorbs its water back, and the stool dries out and hardens. The next time, it is harder to pass.
• Make time for the toilet in the morning. After a meal, especially breakfast, bowel movement naturally gets stronger. Don't rush this time.
• Don't use your phone on the toilet. When you sit with a phone, you lose track of time, and 5 minutes easily becomes 20. Sitting for a long time raises the pressure in the blood vessels of the anal canal and increases the risk of hemorrhoids.
• Don't sit for more than 5 minutes and don't strain. If the stool doesn't come within 5 minutes, get up and try again when you feel the urge.
• Go only when you feel the urge. Sitting and straining for a long time without an urge does no good.

Rule 5: put a stool under your feet

When you sit at a right angle on an ordinary toilet, the end of the rectum stays somewhat bent, and you have to strain more for the stool to come out. Squatting is the natural position for emptying the bowel. A small stool creates this position on an ordinary toilet too:

• put a stool about 15–20 cm (6–8 in) high under your feet so that your knees are above your hips;
• lean your body forward a little and rest your elbows on your knees;
• relax your abdominal muscles, don't hold your breath and breathe calmly.

This simple change can reduce straining and also helps prevent hemorrhoids and anal fissure.

It is not hard to combine the rules in one day. For example:

• Morning: drink a glass of warm water when you wake up. For breakfast, have oatmeal topped with a handful of fruit or a few prunes. After eating, set aside time for the toilet without rushing.
• Midday: lentil soup or a bean dish, a large plate of salad and whole-grain bread.
• Snack: a kiwi, an apple or a pear, a glass of yogurt.
• Evening: cooked or raw vegetables with fish, chicken or legumes. Walk for 15–20 minutes after the meal.
• Through the day: keep a bottle of water with you, get up every hour if you have a desk job, and go to the toilet without your phone.

This is only an example. If you have a chronic illness, a food allergy or need a special diet, adjust the menu with your doctor.

When you follow these rules, the result is usually felt within a few days to 2–4 weeks. Because you are increasing fiber gradually, mild bloating is possible in the first week; this is normal and passes. The main condition is that the rules are regular: an effort of a day or two is not enough. If you have had constipation for many years, or the rules don't help in 2–4 weeks, the cause may lie deeper.

If constipation doesn't go away even though you follow the rules properly, the cause may lie not in your lifestyle but in the bowel itself. In women, needing to help with a finger in order to have a bowel movement often points to a rectocele, that is, a bulging of the rectal wall toward the vagina. Sharp pain on the toilet points to an anal fissure: a person who fears the pain puts off the toilet, which makes constipation worse.

Pelvic floor muscles that tighten instead of relaxing during a bowel movement, some medications (painkillers, iron supplements), an underactive thyroid and diabetes also cause constipation. In a person over 45–50 whose constipation has started for the first time, a narrowing of the bowel, including a polyp or a tumor, should be ruled out.

We explain the causes, tests and treatment methods on our constipation treatment page.

See a proctologist if:

• constipation continues even though you have followed the rules for 2–4 weeks;
• you need to help with your hand to pass stool;
• there is bleeding, even if it is slight;
• there is sharp pain in the anus during and after a bowel movement;
• constipation alternates with diarrhea, or your toilet habits have changed for no reason;
• you are over 45–50 and the constipation is new, or a close relative has had bowel cancer: in such cases, colonoscopy may be recommended;
• you are losing weight for no reason or anemia has been found.

Don't wait; seek urgent care if gas and stool aren't passing at all, your abdomen keeps swelling and vomiting has started (this can point to a bowel obstruction), or if the bleeding is heavy or the stool is black and tar-like.

To find the cause of constipation, you can see Dr. Ellada Manafova at Qafqaz Hospital in Baku; the examination is completely confidential.