First of all, the basics. You NEED to make sure you are covering your bases with water and fiber before moving on to other types of treatments. I know, I know - especially if you have small people in your household who absolutely revolt at anything green, it can be hard to keep up your own fiber intake, or to be constantly making yourself additional/different food. But, if your fiber intake isn't great, then your success with any other type of treatment will be much poorer than it could have been otherwise! So, check out my first article on bowel function that covers these basics. I also have a little information on laxatives in my second article, which is likely the first thing your doctor will tell you to try. But, most laxatives are not meant for longer-term use. However, we do have pretty good evidence to show that polyethylene glycol (aka PEG or Miralax) is safe for up to 24 months of use. But, like I said in previous articles, I would MUCH rather that you get to the bottom of your constipation rather than take a laxative long-term! And, there are so many other options that also have really good evidence behind them that tend to get ignored, like PT.
Can I take fiber supplements to increase my fiber intake?
As always, before you decide to take any kind of supplement, it's best to talk to your doctor (or dietitian!) first.
You certainly can take a fiber supplement, but as with most supplements, it's always better to get what you need from actual food vs. taking a pill. Your body typically doesn't absorb or respond to something in a pill like it does in whole foods. And in the case of fiber, you may need to swallow A LOT of pills in order to boost your fiber intake significantly. This handout has great information on fiber in general (including a chart at the end about what you can eat for the most bang for your buck to increase your fiber), and does have a small part about fiber supplements as well.
I will say though, there is some good evidence that soluble fiber supplements (like psyllium husk) can help for both constipation and IBS, whereas insoluble fiber (like wheat germ) does not. However, we still don't have great long-term studies on this topic. And it's really important to note that any fiber supplement can initially increase gas and bloating, so fiber always needs to be started slowly! It's also important to note that fiber supplements can interfere with the absorption of certain medications, and so spacing them apart from your meds, plus drinking PLENTY of water with a fiber supplement, is really important. And also know that it might take a few weeks of regular fiber supplementation to notice an effect.
What about other supplements like probiotics, etc?
This gets into very sticky territory - again, it's recommended to consult your doctor. The best I can tell you is that so far, there isn't any great evidence that any one supplement besides fiber truly makes a difference for bowel dysfunction. And then of course, anything you put into your body can have side effects, especially if you are taking other prescription medications. A great summary can be found in this short slide presentation.
I will make a special note here though about magnesium, which does have some evidence behind it, and comes in many forms like the various Natural Calm powders. Magnesium is generally very safe, but can have side effects in certain settings as with kidney disease, so just make sure to talk to your doctor if this is something you are considering starting.
If I'm good on fiber and water, what's next?
Here's where I will admit I am 100% biased, but, I think everyone with functional constipation that is having trouble managing it on their own needs to see a pelvic floor physical therapist (PT)! We have SO many tricks up our sleeve that can be super helpful that are not medication-related. And if you need help finding a pelvic floor PT near you, you can check out the Academy of Pelvic Health, Pelvic Rehab, or the Pelvic Guru PT locator pages.
One note though is that if you do have slow transit constipation (refer back to my second article where I talk about this more), then you likely will need some type of medication to help stimulate your colon to move your waste along. PT is most helpful for people with defecation disorders, but can still be somewhat helpful for slow transit too!
How can pelvic floor PT help with constipation?
There are SO many answers to this, but I will try to make it brief! First of all, we can help you figure out where your contributors to constipation may lie. Is it water, fiber, movement, how you are having your bowel movements, the timing of your meals, contribution from a DR or from pelvic floor dysfunction? Or any combo of those things! This is where PT can be really helpful, because we can look at the whole picture and make a lot of recommendations, vs. being stuck with "only" medication or surgical advice, for example.
So here's a few basic recommendations to tempt you into considering PT further :)
Don't hold your breath. Like, for real. I can't tell you how important it is that you are exhaling with the "push" for a bowel movement (BM)!! And, with this push your belly does need to slightly bulge outwards. You should not be pulling belly to spine when pushing for a BM! If you are a chronic breath-holder & abdominal-tightener, this can be really tricky to unlearn, but is absolutely vital. A PT can help teach you how to do this better.
HOW you sit on the toilet to have your bowel movement is also so, so important! I can't stress this enough, because it automatically helps you relax your pelvic floor without you having to do anything. I talked about this a little bit in my first article, and linked to this webpage that covers the basics.
If you have either a diastasis rectus abdominis (DRA)/umbilical hernia or prolapse, providing external support to those areas of the body can help! For DRA/hernia, placing your hands on your belly to have something to "push" against can be really helpful (or wearing an abdominal binder if you already have one). For prolapse, pushing up against the perineum (the area between the vagina and the anus) can be helpful. Or, if you have a rectocele in particular (the rectum is falling into the vaginal canal), then placing your finger inside the vagina and pushing back on the back wall of the vagina can also be incredibly helpful. There are also now devices you can purchase for this particular purpose, such as the Release and the Femmeze (not sure if you can buy the Femmeze in the US??)
Most of the time, people who have constipation have pelvic floor muscles that are too tense/tight, NOT too weak. Doing more Kegels or pelvic floor strengthening will not help! Learning how to RELAX your pelvic floor while you exhale (which is the opposite of what we do in MommaStrong - different purposes under different conditions!) is essential. Generally it takes pelvic floor PT to teach you how to do this.
What happens at a PT appointment?
First, lots of "exercise" training to coordinate your abdominals, pelvic floor, and breathing as I mentioned above. This is accomplished a lot of different ways, but will ALWAYS involve lots of training in deep breathing. And yes, generally a rectal exam is needed, but is much-preferable to a lot of similar medical tests that I outlined in my second article! And, we can absolutely skip the intra-rectal part if that isn't something you are comfortable with. We have lots of other tricks up our sleeve, including:
Biofeedback training. This can be done externally with superficial electrodes, or with internal vaginal or rectal electrodes. Basically it helps us see visually on a computer screen what your muscles are doing, and has LOTS of great evidence for helping with defecation disorders in particular. This is particularly effective for people that have a really hard time telling what their pelvic floor is doing, especially for learning to relax the pelvic floor.
Manual therapy & massage. This can be on your belly, using gentle massage to help stimulate the colon, or internal to the pelvic floor to help those muscles relax. You can also do abdominal massage at home, as there is also really excellent evidence this can be helpful too! You can either do the "I-Love-U" massage that we also use on infants, or massage in the direction that your stool moves through your colon from right to left.
Visceral mobilization. This is essentially an advanced version of the abdominal massage, where your PT will target the specific connections of fascia and ligaments around your organs. Not all PTs are trained in this, so if it's something that you would like to try, make sure to call and ask before booking an appointment!
Electric stimulation. TENS (transcutaneous electrical nerve stimulation) can be incredibly helpful for constipation, even for slow transit. It can be placed on the abdomen, over the sacral nerve roots, or at other acupressure-like points on other areas of the body to help the bowels.
If I don't have the time/money/energy for PT right now, what else can you tell me?
I have a lot of other great advice for you! All of this can also help if you are pregnant too, when your ability to take other supplements is limited.
Don’t skip breakfast. Having food hit your stomach in the morning helps “wake up” your digestive system, and lets the colon know more food is on the way. This stimulates your body’s gastrocolic (or emptying) reflex in order to make room for the new food. Bonus if you can drink something warm, and eat something high in fiber.
Eat regular meals at similar times each day. Your gastrocolic reflex also occurs after every meal, so eating regular meals is better than small snacks or grazing throughout the day. You can also try sitting on the toilet for 10 minutes about 20-30 minutes after every meal in order to take advantage of this emptying reflex. (Note: don’t strain if stool isn’t ready to come out. If nothing happens, get up and go about the rest of your day.)
Give yourself enough time to have a bowel movement in the morning, if possible. Your colon is 2-3x more active in the morning, and establishing a “routine” for having a bowel movement in the morning helps you become regular every day.
Don’t ignore the “call to stool.” If your body is telling you it’s time to have a bowel movement, try to respond if appropriate. Chronically delaying the urge to have a bowel movement not only disrupts the body’s way of knowing when you need to poop, it also increases the storage capacity of the rectum, further exacerbating constipation.
Keep regular bedtime and waking times (hahahaha....but, it is true that it helps). The bowels have their own circadian rhythm that gets disrupted when sleeping patterns are inconsistent.
Exercise regularly. More physical activity stimulates the body’s ability to move stool through the colon. There is evidence specifically that 20-60 minutes of exercise 3-5 days per week improves symptoms and quality of life for IBS.
What about if I'm pregnant or newly postpartum?
Some of these interventions aren't safe for pregnancy, so check out this article on constipation in pregnancy and postpartum! However, if you are pregnant, you can absolutely do all of the "behavioral" things I mentioned above (fiber, water, breathing, sitting on the toilet correctly, and then the last several bullets about eating and not ignoring the call to stool!).
Bharucha, A. E., & Wald, A. (2019). Chronic Constipation. Mayo Clinic proceedings, 94(11), 2340-2357. https://doi.org/10.1016/j.mayocp.2019.01.031
LaCross, Jennifer A. PT, DPT, PhD(c)1; Borello-France, Diane PT, PhD2; Marchetti, Gregory F. PT, PhD2; Turner, Rose MLIS3; George, Susan PT, DPT4. Physical Therapy Management of Functional Constipation in Adults Executive Summary: A 2021 Evidence-Based Clinical Practice Guideline From the American Physical Therapy Association's Academy of Pelvic Health Physical Therapy. Journal of Women's Health Physical Therapy 46(3):p 147-153, July/September 2022. | DOI: 10.1097/JWH.0000000000000245