Constipation

The IBS-C Subtype
What Causes the "C" in IBS-C?
IBS-C vs Functional Constipation
IBS-C and Pelvic Floor Dysfunction
Is It Just IBS-C?
Create Your Constipation Game Plan
How Do You Experience Constipation?
Rescue Strategies
Proactive Strategies
The Menstrual Cycle and Perimenopause
Aging and Constipation

If constipation is the IBS symptom you'd like to tackle, then this section is for you.

Find out more about IBS-C and it's relationship to other subtypes of constipation.

Get lots of tips for creating your own constipation game plan, including rescue strategies to relieve constipation right now and proactive strategies that give you a better chance of not getting constipated at all!

At the end you'll find some info about constipation in different stages of life.

Video Transcript

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The IBS-C Subtype

If you generally have fewer than 3 bowel movements a week and more than 25% of your abnormal bowel movements are hard, lumpy or pellet like and less than 25% are loose or watery, then you probably fall into the IBS with Constipation (IBS-C) subtype.

Keep in mind that these are guidelines and you can have other types of stools and even some normal stools and still be considered as an IBS-C subtype.

Soft Stools

It's possible to have large, soft stools due to the "logjam effect. Hard stools (typical of IBS-C) can create a partial blockage or delay in the colon. As you continue to eat and process waste, newer, softer stool gets trapped behind the hard stool. Once the hard stool passes, the backed-up softer stool comes out along with it.

Pelvic floor dysfunction could also cause constipation without hard stool.

More Than 3

You may also poop every day, but in small amounts, so you remain backed up.

Some other symptoms of IBS-C include:

Difficult-to-pass stools
Abdominal discomfort, cramping and pain
Bloating, distension and excess gas
A sensation of incomplete bowel evacuation or blockage
Nausea, heartburn, reflux, belching

Constipation and Diarrhea?

Yes, it's possible to have both.

Long-term constipation can lead to fecal impaction, which means that poo has built up in the rectum. The main symptom is diarrhea, which leaks through the build-up of solid poo and is known as overflow diarrhea. Please see your doctor if you think this may be the case.

IBS-M (Irritable Bowel Syndrome with Mixed bowel habits), is another subtype of IBS that alternates between constipation and diarrhea.

What Causes the "C" in IBS-C?

There are many factors and body systems that could be involved in your constipation if you have IBS-C.

Keep in mind that not all of them are well understood and research is ongoing. In time, this subtype may be further subdivided as we learn more about the underlying drivers of IBS.

Although the exact combination can vary from person to person, IBS-C is thought to be primarily caused by the following factors. But everything is connected, so go to What Causes IBS? for more info.

Slowed GI Motility

The muscles lining the colon don't relax and contract properly in order to move stool along, causing waste to move slower than normal. Stool sits too long and too much water is absorbed, usually causing dry, hard stools that may be difficult to pass.

Although the large intestine is generally the place where slow transit causes hard stools, studies are showing that muscle coordination issues can also occur in the upper GI tract and the small intestine

Gut-Brain Miscommunication

This can disrupt normal motility (movement) in your GI tract.

Dysbiosis

Some people with IBS-C have an imbalance in the communities of microorganisms living in their gut. This can affect motility in many ways. Studies show that many individuals with IBS-C also have an overgrowth of gut microbes called methanogens. These bacteria produce methane gas, which actively slows down gut movement.

These physiological issues are often worsened by external triggers like mismanaged stress, poor diet, common triggers, FODMAPs, meal hygiene, poor sleep, lack of movement and dehydration.

IBS-C vs Functional Constipation

There are a number of subtypes of constipation. There are a lot of similarities between IBS-C and a subtype know as functional constipation (FC). FC is constipation with no obvious underlying cause.

The big difference between the two subtypes of constipation is pain and discomfort. If pain is regularly associated with your symptoms, then you probably have IBS-C. IBS-C pain is associated with visceral hypersensitivity (VH), which causes the threshold for pain in the GI tract to be lower than normal.

Severe constipation can cause pain and other IBS symptoms like discomfort, bloating and gas, but FC does not consistently involve these symptoms and a good bowel movement will usually ease them. If you have IBS-C your symptoms may get a little better after clearing your bowels, but some symptoms will probably persist.

Treatment strategies differ, so it's important to know which subtype you have.

If you're on this site, then you've probably already gotten your IBS diagnosis.

But if you'd like to know more about constipation subtypes, check out Andrea Hardy's ebook "Backed Up"

IBS-C and Pelvic Floor Dysfunction

Pelvic Floor Dysfunction (PFD) is also a subtype of constipation. But unlike FC, which exists with IBS-C on more of a spectrum, it's possible to have both IBS-C and PFD.

People with PFD have difficulty relaxing or coordinating the muscles in their pelvic floor and this can prevent them from passing stool. The rectum may hold soft or normal-consistency stool, but the muscles, ligaments and/or connective tissues of the pelvic floor needed to push it out do not work correctly.

This can lead to straining, feelings of incomplete evacuation or painful bowel movements.

To find out more about PFD, go to the Pelvic Floor Therapy section.

IBS-C and PFD

PFD is not considered to be a primary cause of IBS-C, but rather a condition that often occurs along with IBS-C that can make IBS-C constipation worse. Both conditions are heavily influenced by the nervous system and stress through the gut-brain axis, so it's not surprising that they frequently occur together.

And of course, like so many things concerning IBS, the relationship between the two subtypes can be bidirectional.

Many individuals with IBS-C have pelvic floor issues. Either they can't relax the muscles of the pelvic floor or they have paradoxical contractions, which means that these muscles involuntarily tighten or squeeze when they should be relaxing. Passing stool is more difficult and this makes constipation worse.
Constant straining from constipation can create a feedback loop because it may tire or tighten the pelvic floor muscles over time.

Is It Just IBS-C?

There are a number of conditions that present with constipation that are not IBS-C and should have been ruled out before you received your IBS-C diagnosis. These include conditions like IBD, celiac disease, hypothyroidism and colorectal cancer.

But there are also conditions that are a bit sneakier and may not have been caught during your initial diagnosis. Conditions that are sneaky because they can more easily masquerade as IBS-C or they can occur alongside IBS-C, often making symptoms worse.

Don't go looking for trouble!

If you've been diagnosed with IBS-C, first try management strategies for IBS.

If nothing works for you, then consider talking to your doctor or dietitian about other conditions.

Intestinal Methanogen Overgrowth (IMO)

IMO occurs when the gut has abnormal numbers of methane producing microbes in both the small and large intestine. It used to be known as "methane SIBO", but is now starting to be considered as a distinct condition. Methane gas slows the gut down and can lead to constipation. It's possible to have IMO and IBS.

Currently, breath testing is the only way to determine if you have IMO and these tests aren't always reliable. Research on this topic is ongoing.

Endometriosis

This is a condition in which tissue similar to the lining of the uterus grows outside the uterus. Many symptoms overlap with IBS. Symptoms can be very different from person to person, just like IBS, and it might not be easily diagnosed. It's also possible to have endometriosis and IBS.

Tell you doctor if you also have any of the following symptoms which are not symptoms of IBS: severe pain during periods, sex, bowel movements or peeing, chronic pain in your pelvis (all the time), heavy bleeding during or between periods, irregular periods, trouble getting pregnant.

Histamine Intolerance (HIT)

HIT occurs when a person has a low level of DAO, an enzyme that breaks down histamines. When they eat histamines or histamine-producing foods, the chemical can build-up in the body and cause GI symptoms similar to IBS. Histamine is a link between the gut's immune system, nervous system and microbiome and is considered to be a key mediator in IBS.

This is a developing area of research, but there is evidence that some people with IBS have lower levels of the DAO enzyme. Unfortunately, there are not yet tests that can confirm a diagnosis of HIT. A reduction in IBS symptoms after following a histamine-reduced diet is currently the only way to tell if HIT is an issue.

Create Your Constipation Game Plan

Just like any game plan, different situations require different plays.

People experience constipation in different ways and for different reasons. The first step in creating your own constipation game plan is to understand how you experience constipation. Check out the following section How Do You Experience Constipation? for some advice about playing digestive detective.

Your personal constipation game plan should also be two-fold. Check out Rescue Strategies for things you can try if you're already constipated and Proactive Management Strategies for building habits that will help prevent you from becoming backed up in the first place.

Read on for some game plan tips!

Don't Panic!

Regular bowel moments are considered 3 times per day to every 3 days and it's normal to have fluctuations in bowel habits. Getting stressed about pooping will only make things worse.

Once you've created your game plan, use your short and long term strategies to get back on track.

Be Proactive

The longer you go before you poop, the more difficult it becomes. If you don't go for a few days there's a good chance you won't go for a few more. So don't wait until your constipation is really bad before you do something about it. Figure out which rescue strategies work for you.

Proactive management is even better. Building healthy habits that support digestion and discovering your IBS-C triggers means you won't have to rely as heavily on rescue strategies in the first place.

Get Help from the Pros

Poo is a taboo subject for a lot of people, but it shouldn't be. Everybody does it and it's a necessary bodily function.

So talk to your doctor and, if you can afford it or get access, a registered dietitian (preferably one that specializes in gut health).

How Do You Experience Constipation?

I borrowed an analogy of why people experience constipation differently from gastroenterologist Dr. Justin Brandler that I found on the Canadian Digestive Health Foundation website.

Understanding your own constipation experience can help you discover constipation strategies that work for you. Having IBS, of course, presents its own challenges and you may have to try additional strategies that are not standard for other types of constipation.

Consider trying this top down approach while playing digestive detective. You could have issues in more than one category and the suggestions are just examples of things you could try.

The Toothpaste Analogy

1) Poop Consistency (Paste)

The first thing to look at is the consistency of your stool. If stools are hard and difficult to pass it could be a problem with your paste.

Try: Fibre, proper hydration, osmotic laxatives

2) Intestinal Smooth Muscle (Tube)

If the muscle that wraps around your intestines and squeezes stool through your bowel isn't working properly, things may move through too slowly.

Try: Stress management, movement, gut microbiome health strategies, stimulative laxatives

3) The Cap (Exit)

If you can't get the cap off to let stool out, there could be an issue with your pelvic floor that interferes with the propulsion of stool through your rectum.

Try: Pelvic floor therapy, relaxing the pelvic floor, yoga for the psoas, squatty potty

Rescue Strategies

The ultimate goal of long term IBS management is to reduce symptoms, including constipation. Because the truth is it's impossible to control every aspect of your life at all times and sometimes constipation happens. It may also take some time to figure out the IBS strategies that work for you and to establish helpful habits, so you may need some SOS type help as you're starting your IBS journey.

This section focuses on more immediate solutions for constipation, although you may add some of them to your proactive IBS management routine. Always keep in mind that what works for someone else may not work for you, so put your detective hat on.

Fibre

I wanted to mention fibre in this section because it's the advice you'll see most often for constipation. Sometimes fibre can help if you're already mildly constipated. Find out more about fibre for constipation in the next section and check out Fibre and IBS in the Healthy Eating section.

However, piling on the fibre may also make your symptoms worse. Fibre adds bulk to your stool. If you're already blocked with hard stool, adding fibre forces your digestive system to push an even bulkier mass through an already clogged space. When gut bacteria ferment this sudden influx of fibre, they produce excess gas that can't escape through the blockage. This can cause cramps and distension.

If you're seriously backed up, doctors usually recommend clearing the impaction with hydration and osmotic laxatives (which pull water safely into the bowel to soften the stool). Once you're "cleaned out", you can work on increasing your fibre intake if necessary.

Other Foods for Constipation

Certain foods can speed up movement in the gut and improve laxation.

Kiwis (2 a day)

- It’s thought that an enzyme called actinidin helps to stimulate the bowels - green kiwis have

more, but golden also a good option

- High in fibre

- 2 kiwis a day for 4 weeks four may naturally increase bowel movements and reduce straining.

Prunes (5-6)

- The sugar in prunes (sorbitol) pulls water into the bowels to speed up and soften things

- If you don't like prunes try other fruits with sorbitol like pears or apples

Caffeine

- Can stimulate your bowels

- Can also be a common IBS trigger

Hydration

Hydration is super important, especially if you up your fibre intake.

Your small intestine absorbs most of the fluids you consume to supply your body and if you don't drink enough then the waste products that reach your colon could be on the drier side. This can slow down the movement of the waste through your colon, which causes more water to be absorbed. Your stool gets hard and more difficult to pass.

Laxatives

There is often a stigma around using laxatives, but they are a legitimate tool in your constipation toolkit. Definitely try other strategies as well, but if you're struggling with constipation certainly give them a try. Best to talk to a healthcare professional about what might be right for you.

Check out the Constipation Medications section for more info.

Move Your Body

Even if you don't feel like exercising because you're feeling constipated and bloated, moving your body will help you move your bowels.

Check out the Get Moving for IBS section for more info and ideas.⁠

Relax Your Pelvic Floor

If you're having trouble "getting the cap off", relaxing your pelvic floor may help.

Diaphragmatic breathing and releasing the psoas could help to relax your pelvic floor. For more info check out the Pelvic Floor Therapy section.

Toilet Position

Using a small stool under your feet to bring your knees above above your hips may help, especially if you strain a lot and have trouble releasing stool. The change in angle could put your pelvis and colon in better alignment to open the rectum and relax muscles in the pelvic floor.

Squatty Potty is a popular brand name, but anything that comfortably elevates the knees will do.

Stress Management

Unmanaged stress can slow down your digestion and intestinal movement. Relaxing your mind helps switch your nervous system back to "rest-and-digest" mode. Having go to stress management techniques may be especially helpful for for IBS constipation.

It may take time to find things that work for you, but once you do you can use them as part of your rescue strategy for constipation. For some ideas go to the Stress Management section.

Abdominal Massage

There is some evidence that abdominal massage can help you get things moving and many different modalities of massage have been studied.

You can try different kinds to see if there's one that helps you or you could try self-massage. At the very least it may help you to relax and manage stress!

Proactive Strategies

The IBS Management Strategies section is full of information and tips on proactively managing your IBS and reducing symptoms like constipation.

In this section I wanted to highlight some things that might be particularly helpful for constipation. They aren't rescue strategies that will be helpful in the moment if you're already constipated, but they may help to keep you from getting constipated in the first place.

Fibre

Fibre may help if you're mildly constipated, but it's really better to think of it as a proactive constipation strategy that's part of your daily routine.

It's best to increase your fibre intake slowly, because increasing it too quickly can cause abdominal discomfort and bloating. Aim for consistency throughout the day and try to have it with every meal. A high fibre breakfast (10g) is a good way to start the day. Your bowels are more active in the morning and it may help you to go. Stay properly hydrated as fibre needs fluid to do its job.

For more on fibre through the lens of IBS, go to the Healthy Eating section.

Beware of High Fat Diets

Dietary fats can slow down movement in your gut. This could lead to constipation, especially if your diet is consistently high in fats. Many high fat diets are also low in fibre, which could make matters worse.

Check out the Healthy Eating section for more info.

Don't Under Eat

The muscles in your gut that are responsible for moving things along need energy. When you aren't getting enough calories for your body's basic needs, digestion can slow down significantly. Skipping meals, following a restrictive diet or over-exercising could add to your chances of becoming constipated. Your fibre intake may also be low, making things worse.

Make sure you get enough calories (most women need at least 1600 kcal/day and men at least 2000 kcal/day). Focus on eating regularly, even small meals and snacks, to stimulate digestion.

Stress Management

It's best to work stress management techniques into your daily life to keep you from getting constipated in the first place. For some ideas go to the Stress Management section.

Bowel Training

Bowel training starts with trying to use the bathroom at the same time everyday, whether you feel you need to go or not. About an hour after breakfast is often suggested, because colon is quite active at that time and eating signals it to move things along. This can be especially helpful if you don't often feel the urge to go.

Make sure you give yourself some time, try for 5 minutes. At first you may feel silly just sitting there, so try some deep belly breathing for relaxation. Don't strain or force things to happen.

Don't Ignore the Urge

Ignoring the urge to go can change how the bowel muscles work and interfere with your body's rhythms. Doing it every once in a while isn't a big deal, but doing it repeatedly disrupts the natural communication between your brain and colon. Your rectum can become less sensitive, so you no longer feel the urge, and your constipation may get worse as time goes on. The longer stool stays in your colon the more water it absorbs, making it harder to pass.

Listen to your body and try to go as soon as you can if you feel the urge. Take the time to check in throughout the day, especially an hour or so after meals. Try gut directed meditations to reconnect with your body's signals.

Create Daily Routines

Your body operates on circadian rhythms, 24-hour biological cycles that regulate sleep, hormones, metabolism, and digestion. The master clock is in your brain and your gut has its own local clocks in the stomach, small intestine, and colon. These local clocks help to regulate many functions in your gut and they rely on timing cues like when you wake, eat or move and how consistent your sleep schedule is.

If you have IBS these cues could matter even more because the gut–brain system is already more reactive and less tolerant of disruption.

Try going to bed and waking up around the same time every day, protecting the first hour or two of your day to eat, hydrate, move gently and respond to urges to go, eat at regular intervals and exercise earlier in the day if possible. Even if you have a busy schedule, do what you can!

Medications and Supplements

There are also medications that work on a proactive basis, usually proscribed for more severe cases. Talk to your doctor and take a look at the Constipation Medications Section.

Check out the evidence for supplements that may help with constipation.

Constipation as a Side Effect

Constipation is a side effect of a number of medications. Supplements, even though they seem more "natural", could also be constipating. Talk to your doctor about your medications and dietary supplements for other conditions. It's possible they may be able to suggest an alternative or adjust the dosage.

Don’t change or stop any proscribed medicine or supplement without talking with a health care professional.

The Menstrual Cycle and Perimenopause

If you were designated female at birth, fluctuating hormones during your menstrual cycle and perimenopause can increase your chances of being constipated.

I wish I could tell you about a magic strategy to "fix" this, but the general advice is to follow tips and strategies for relieving or preventing IBS-C constipation in general.

What can help is awareness. If you know there's a certain time of the month or a certain time of life that you could be more prone to constipation, then you have an opportunity to be proactive instead of reactive. You could try to be stricter about following the strategies that work for you and hopefully lessen your chances of being constipated.

Menstrual Cycle and Constipation

As if periods aren't bad enough, during certain phases of your menstrual cycle you can also be more prone to constipation. This can feel like a double whammy for people who also suffer from IBS-C.

Understanding how your digestions could be affected during your menstrual cycle allows you to be more proactive with your constipation management or, at the very least, to cut yourself some slack and not feel like a failure if your normal strategies aren't working as well as they usually do.

Menses Phase: 1st day of your period

Follicular Phase: Day 1 - ovulation

Hormone estrogen rises

Ovulation: About day 14 (based on 28 day cycle)

Mature egg is released from an ovary into the fallopian tube

*Luteal Phase: Approximately day 15 - 28

Hormone progesterone rises after egg leaves the ovary

The luteal phase, when progesterone starts to rise, is the one that IBS-C folks need to be aware of. Progesterone acts on the smooth muscle in your gut, relaxing the muscles and significantly slowing down digestion, which is thought to lead to constipation. Declining estrogen may also play a role.

You may find the days leading up to your period are the worst, when progesterone is peaking. Once your period actually begins, progesterone drops and prostaglandins take over. They help the uterus shed it's lining and can sometimes have the opposite effect. You may temporarily experience loose stools or diarrhea

Perimenopause and Constipation

During perimenopause, estrogen and progesterone levels fluctuate and decline. This causes changes in many body systems that can worsen constipation, another double whammy for people with IBS.

Slower motility - digestion slows down allowing stool to sit longer in the colon
Gut microbiome shifts - affects microbiome diversity
Increased cortisol levels - can slow down digestive process
Increased intestinal permeability - can affect gut microbiome and gut-brain axis
Gut-brain axis - disrupts communication

Aging and Constipation

There's lots of reasons why constipation can worsen with age. Gut muscles and nerves contract more slowly, which means stool sits in the colon longer and absorbs more water. Reduced appetite and thirst cues may mean you aren't getting enough fibre or fluids. You may experience physical issues that get in the way of exercise and movement. Medications and other medical conditions may have constipation as a side effect.

Management strategies that worked when you were younger may not work quite as well as they used to. You may have to up the ante when it comes to proactive strategies!