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onstipation, which The Merck Manual defines as "difficult or infrequent passage of feces, hardness of stool, or a feeling of incomplete evacuation," can be a serious problem for many interstitial cystitis (IC) patients. While it is a relatively common occurrence in many patients with IC, it is important to note that bowel regularity is an individual issue. It may be "normal" for one person to have several bowel movements daily, while for another person, "normal" bowel function may mean one bowel movement every day and a half. Constipation, therefore, is a relative term that each individual needs to define for him- or herself, with the assistance of a physician.

 

• The limitations of the IC diet demand that most of the fiber-rich fresh fruits and some vegetables be severely curtailed or avoided entirely. Coexisting food allergies may require that patients also eliminate many of the remaining sources of fiber such as whole grains.
• Many medications commonly used to treat IC have the side effect of constipation. These include the tricyclic antidepressants and many pain compounds, including opioids.
• 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, juices—are not IC-friendly, it may often be difficult for the IC patient to find something to drink.
• People with chronic IC pain may find it difficult to get adequate exercise. Physical activity contributes to bowel regularity, as well as to general health and well-being.
• Constipation is a component of the condition known as irritable bowel syndrome (IBS), which is one of the most common of the IC-related diseases and conditions.

 

Constipation is a concern for several reasons: it interferes with the normal elimination of bodily wastes; if left untreated, it can become painful; and repeated straining to produce a bowel movement can lead to or aggravate hemorrhoids or anal fissures (tears) that may require surgical repair. For the IC patient, the added pressure that constipation produces in the pelvic area can be a source of increased pelvic pain and discomfort, and contribute to pelvic floor dysfunction.

How does the IC patient avoid constipation without aggravating his or her IC? The answer depends on what is the primary cause of the patient’s problem. Regardless of the level of discomfort you may experience from constipation, it is always essential to consult with your physician before embarking on any course of treatment.

 

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.
• If you can partake in regular aerobic exercise, such as walking, it is a good idea to do so. Exercise 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 treatment for constipation in the US. Unfortunately, they are also one of the most abused treatments. Long-term use of the type of laxatives known as "stimulant laxatives" can result in laxative dependency. More importantly, some conventional laxatives can interfere with the body’s absorption of various medications. For these reasons, IC patients with chronic constipation may want to pursue other avenues of relief.
• 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.
• If hardening of the stool is a problem, stool softeners (such as Colace^®) 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.
• You may find that a simple and easy way to relieve symptoms of constipation is to use an over-the-counter magnesium supplement.

 

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, Dr. Daniel Brookoff, 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.

 

IBS is a disorder of the entire gastrointestinal tract, the symptoms of which include abdominal pain, constipation and/or diarrhea, and abdominal bloating. Since IBS is a complicated syndrome that encompasses both constipation and diarrhea, it is essential to consult your doctor before trying to treat your irritable bowel symptoms. 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. Often patients find that some simple dietary changes can make a big difference in the severity of their IBS, so it is probably wise to look at diet first and, with the help of a physician, try to determine if any commonly consumed foods are aggravating your condition.

Generally, the judicious, gradual addition of fiber to the patient’s diet can help stabilize irritable bowel symptoms. High-fiber diets may prevent spasms from developing because they tend to keep the colon mildly distended. Additionally, anticholinergic medications (Bentyl^® , Levsin^® ) have been found to be helpful in alleviating the bowel spasms of IBS. Regardless of the source of your constipation, it is vital that you address the problem, consult with your doctor, and maintain good bowel health.

 

• The Merck Manual Seventeenth Edition, Merck Research Laboratories, 1999.
• Redding Anesthesia Associates Medical Group – Constipation FAQs, www.reddinganesthesia.com
• Brookoff, D, The causes and treatment of pain in interstitial cystitis, in Sant, G. ed., Interstitial Cystitis, Lippincott-Raven 1997; 177-192.
• www.niddk.nih.gov: "Irritable Bowel Syndrome"