Why is Constipation a Concern?

For the IC patient, constipation can exacerbate bladder symptoms and pelvic pain. The added pressure that constipation produces in the pelvic area affect bladder and pelvic floor nerves and muscles, contributing to pain and floor dysfunction. In addition, straining to produce a bowel movement when you are constipated can be painful in itself, and repeated straining can lead to or aggravate hemorrhoids or anal fissures (tears), which may require surgical repair.

Possible Causes of Constipation in IC Patients

There are many reasons why people with IC may become constipated:

• Dietary restrictions. The limitations of the IC diet demand that most fiber-rich fresh fruits and some vegetables be limited. Coexisting food allergies may require that patients also eliminate many of the remaining sources of fiber such as whole grains.
• Medicines. Many medicines commonly used to treat IC have the side effect of constipation. These include the tricyclic antidepressants and many pain compounds, including opioids.
• Limited fluid intake. While it is a good idea for persons with IC to maintain a normal level of fluid intake, many IC patients limit their liquids in an effort to reduce the number of bathroom visits each day, or because they associate bladder filling with pain. Additionally, since so many commonly consumed beverages -- tea, coffee, sodas, many juices -- are not IC-friendly, it may often be difficult for the IC patient to find something to drink.
• Limited exercise. People with chronic IC pain may find it difficult to get adequate exercise. Physical activity contributes to bowel regularity.
• Related medical conditions. Constipation is a component of irritable bowel syndrome (IBS), which is one of the most common of the IC-related diseases and conditions. Another condition related to IC, pelvic floor dysfunction (PFD), is known to be exacerbated by chronic constipation.

Constipation and Irritable Bowel Syndrome (IBS)
IBS is a disorder of the entire gastrointestinal tract, the symptoms of which include abdominal pain, constipation and/or diarrhea, abdominal bloating, and even nausea. IBS is a complicated syndrome that encompasses both constipation and diarrhea. Because abdominal pain is such a large component of the IBS experience, it is important for those who also have IC to get their IBS under control, if at all possible. Sometimes, simple dietary changes and over-the-counter medicines can make a big difference in IBS symptoms. With your physician's help, determine if any foods you commonly consumer aggravate your condition and discuss what dietary changes and medicines might help you.

Like IC, more and more is being learned about IBS, but it is still a condition that is not well understood. While high fiber diets and supplements were a standard treatment for IBS in the past, it is now known that high fiber diets/supplements can actually make symptoms worse for some people with IBS. There is more information available about the specific types of fiber that may be the most helpful. Soluble fiber appears to be the best fiber choice for IBS. Some examples of soluble fiber include rice, oatmeal, barley, quinoa, corn meal, potatoes, carrots, mushrooms, and chestnuts.

Soluble fiber seems to promote normal contractions of the colon which, in turn, help with both diarrhea and constipation symptoms of IBS. Traditional IBS diet therapies that include deep, green leafy vegetables and bran may not be the best choices for controlling IBS after all. Also talk with your healthcare provider about soluble fiber supplements.

Constipation Related to Specific Medicines
If you believe your constipation is related to a specific medication, your doctor may be able to prescribe an alternative medication that is less constipating. The classes of medications that commonly cause constipation problems in some chronic pain patients are:

Non-steroidal anti-inflammatory medications (NSAIDs) such as ibuprofen (Motrin); Tricyclic antidepressants such as amitriptyline (Elavil); Opioids (narcotic pain medicines) such as codeine, Vicodin or Lortab, Darvocet, morphine, Oxycontin, methadone, Dilaudid.

Noted pain specialist and ICA Medical Advisory Board Member, Daniel Brookoff, MD, PhD, writes in reference to opioid medications, “It is important to get patients on a good bowel regimen. Many patients start out with a stool softener (e.g., docusate/Colace) and a mild fiber-based cathartic (e.g., senna/Senokot), but most will need to use laxatives such as milk of magnesia, magnesium citrate, or lactulose/Duphalac.These laxative agents are safe and not ‘habit-forming’ like the stimulant laxatives. Some patients with interstitial cystitis notice a decrease in their bladder symptoms with the successful establishment of a [daily] regimen.”

Bulk laxatives, such as Metamucil, may not be appropriate for patients on large doses of opioid pain medications. Consult your physician before taking any medication—over-the-counter or prescription—along with opioid pain compounds.

Constipation Not Related to Medications or Irritable Bowel Syndrome (IBS)
For individuals whose constipation is not the result of a particular medication and who do not suffer from IBS, the suggested methods for alleviating the constipation are relatively straightforward:

• Drinking a moderate amount of water every day is essential for good health, but especially the health of your bladder and bowel.
• Exercising not only promotes good bowel function, but good health in general.
• Over-the-counter laxatives (Ex-Lax, Dulcolax, Correctol, Carter’s Little Pills, Fletcher’s Castoria) are the most common treatments for constipation in the US. However, long-term use of the type of laxatives can result in laxative dependency. Also, some conventional laxatives can interfere with the body’s absorption of various medications. The most “natural” way to prevent constipation is to eat a diet with a variety of fiber-rich foods—whole grains, various types of bran, broccoli, raw vegetables and fruits, dried fruits such as prunes, etc. Unfortunately, for those whose IC is aggravated by diet or who have food allergies, many of these foods may be off-limits. Bulking agents such as bran or psyllium provide needed fiber and, because they are essentially food substances and not drugs, are suitable for long-term use. Some of the psyllium products (Metamucil, Citrucel) may contain additives and flavorings that may irritate sensitive bladders. If this occurs, try Konsyl, or unadulterated psyllium fiber (available at most health food stores). The most common side effects of bran and psyllium are bloating and flatulence. Starting with a low dosage and gradually increasing your body’s tolerance to the bran or psyllium can help you to avoid excessive gas or bloating.
• Stool softeners (such as Colace), if hardening of the stool is a problem, can also be used from time to time. Mineral oil is an old home remedy that is effective as a softening agent, but it may also decrease absorption of fat-soluble vitamins. It can also produce rectal incontinence. You may find that increasing your fluid intake and adding a small amount of tolerable fiber to your diet will be enough to promote regularity. Others may need to pursue a more aggressive regimen.

Revised November 5, 2008