It's one of those personal ailments that plagues millions of Canadian adults, who often suffer in silence because they're too embarrassed to talk about, well, about not being able to "go."
Let's face it, constipation isn't exactly dinner conversation.
But the quest for regular bowel movements can become all-consuming for some people, especially those who are chronically stopped up, no matter how many prunes, flax seed and laxatives they consume.
Lynda Lucier doesn't want to be obsessed by bowel movements — or in her case, the lack of them — but she doesn't have much choice.
"I could take laxatives every day of the week and never go," Lucier, a hairdresser in Windsor, Ont., says by phone. On this particular day, it had been five days since her last BM.
When she was in her 20s, Lucier had ulcerative colitis and was continuously in and out of the bathroom with diarrhea. But at some point in her 40s, "I went from one way to the total opposite.
"I would go five or six days without even going to the bathroom," says Lucier, 56. "I had to go two sizes bigger in my clothing ... I don't even have to eat. I just have to drink water and my stomach will bloat up like I'm nine months pregnant.
"And then it gets full of gas and you're like so crampy and you just want the day to end."
An estimated 15 to 30 per cent of Canadians are affected by chronic constipation, and that figure rises to about 50 per cent when it comes to the elderly, says Gail Attara, president of the Gastrointestinal Society.
"They have an ongoing sensation that feels as if they need to move their bowels — it's all they can think about."
People with the condition often don't want to admit they can't do what they assume almost everyone else does with natural ease, and many are embarrassed by the topic. Others say they don't want to waste their doctor's time dealing with something they think isn't a "valid illness."
In fact, it can often take years for people to seek help from their doctors, says Attara, whose organization supports research and provides information to consumers about gastrointestinal and liver health.
The first step, says Vancouver gastroenterologist Dr. James Gray, is determining whether a patient really has chronic constipation, after ruling out a tumour or other obstruction.
"The definition sort of traditionally has always been frequency of bowel movements, that you must go every day and if you don't then you're in trouble. And that was very Victorian — you have to keep flogging your bowels until you go every day," explains Gray.
"A lot of older people grew up with this idea.... So there is a lot of toileting behaviours and people become kind of obsessed with this idea that they must go. And then they were giving themselves enemas and stronger and stronger laxatives, all with that goal of the once-a-day bowel movement which is probably the average but which is certainly not mandatory."
The reality is that frequency of nature's call can vary dramatically from one person to another, he says.
"So my definition is what's comfortable. If the stool passes easily and you're not having to strain or push, then that's normal for you. And that might be twice a week or three times a day."
Under optimal conditions, food moves through the colon, or large intestine, which absorbs water to form waste products, or stool. Muscle contractions in the colon, called peristalsis, push the stool toward the rectum for elimination.
Constipation occurs when the colon absorbs too much water or peristalsis is sluggish, leading to hard, dry stools that are difficult to evacuate.
Common causes include too little fibre in the diet and too much meat and dairy; medications such a codeine and morphine; and supplements like calcium and iron. Lack of physical activity and inadequate hydration can also lead to constipation, especially in the elderly. A host of other drugs can also contribute to lethargic bowels, as can certain medical conditions, such irritable bowel syndrome and Parkinson's disease.
Travel that upsets a person's circadian rhythms and throws meal times out of whack can also cause the colon to shut down, at least temporarily. Mood can also affect the bowels, though the connection is hard to measure scientifically, offers Gray.
"But I think many people would say that if you become kind of depressed and sluggish in your mental function, it could have a little bit of an effect on your bowel function, too. And people, when their mood changes, often they don't eat as well, they don't drink as well, so their reduction in fibre and fluid becomes an issue as well."
For those deemed to be occasionally or chronically costive, there is a veritable cornucopia of treatments.
Prunes and prune juice. Ground flax seed. Legumes and whole-grain products. Increased fluid intake, especially water, fruit and vegetable juices.
"You need something that will bulk up, so you need the fibre and the fluid with it, because it's the combination of the fluid absorbing into the fibre that activates the fibre and makes (stools) bulkier," explains Gray.
Toronto naturopath Erica Cowan advises patients who are persistently blocked up to start by modifying their diet.
"If you're eating eight servings of fruits and vegetables a day, or even five servings a day, it's very difficult to be constipated," she says, adding that starting off the day with warm water containing a good squeeze of lemon juice can help get the bowels moving.
Cowan, who practices at the Mahaya Forest Hill Integrative Health clinic, also recommends including healthy oils such as olive, coconut or flax seed in the diet, as well as taking probiotics in pill form to help promote healthy gut flora. Sticking to regular meal times also helps promote regularity.
When diet changes don't do the trick, many people turn to laxatives, most of them over-the-counter preparations that work in a variety of ways. Bulk-forming laxatives soften stools, but must be taken with water to prevent bowel obstruction, and they can interfere with absorption of some medications. Stimulants, such as senna-based products, increase muscle contractions in the intestines, while osmotics are designed to hold fluid within the colon to help stool pass more easily. There are also stool softeners, lubricants like mineral oil, and saline laxatives that draw water into the colon, including the old standby Milk of Magnesia.
While doctors often recommend laxatives for seemingly intractable cases, Cowan believes the purgatives are prescribed too liberally or self-prescribed by plugged-up patients desperate for relief.
"Over time, if you continue to abuse laxatives or just depend on them, the bowels stop responding to them," she asserts. "So then you have twice the problem: first you were constipated, now you're constipated so much that even stimulating laxatives don't work."
Among physicians, there is debate as to whether continuous laxative use creates dependency. Gray, for one, believes that's a misconception, and he says the medical literature seems to agree.
"There's nothing to really support the idea that your bowel becomes addicted to these products. I think the reality is people have sluggish, lazy bowels ... for reasons that aren't always clear to us."
Doctors are excited about the new drug Resotran (prucalopride), recently approved by Health Canada to treat women whose chronic constipation has not been relieved by laxatives. (There were not enough men in clinical trials to demonstrate it works in males.)
The drug, which stimulates peristalsis, is taken for a certain period in a bid to restore regular bowel movements, says Attara of the Gastrointestinal Society.
Lucier took Resotran for a month and had great success, but her bowels soon reverted to their old ways. Her doctor told her to combine the drug with probiotics and it worked — at least on this day.
While the hairdresser hopes the medication will end her constipation woes, having no drug plan would make its $156-per-month cost a financial hardship.
Still, recalling what it's like when she finally does get Nature's call, Lucier admits it may be worth it.
"It's like the best feeling in the world. It's like not having a vacation for a year — and then all of a sudden you're there."
Gastrointestinal Society: www.badgut.org