A few years ago a man went to hospital with an unusual complaint. His kids were embarrassed by the way he looked and he wanted treatment to save them being teased at school.

The man, in his mid-thirties, was slightly built and perfectly ordinary except for a huge bloated abdomen which made him look pregnant. The director of the hospital’s anorectal physiology unit said the man had been like that all his adult life, was quite comfortable and regarded himself as normal until the children began ragging him about having a baby. He also regarded as normal the fact that he only had one bowel motion a month.

The level of acceptance and tolerance people have about their bowel function is amazing. Because bowel habits are not openly discussed, people believe what they do is normal. Current medical opinion is that a normal range for bowel motions is three a day to three a week.

On investigation, this man was found to have a disorder known as ‘megacolon’. The colon is usually three or four centimetres in diameter but his was the diameter of a football. Such a distended colon is beyond repair and the only option is to remove it. The enlarged sections were duly cut out and today the man has a flat abdomen and a regular bowel habit.

Fortunately, megacolon is not too common and the majority of men with constipation have a bowel that looks healthy. Most suffer from simple constipation. There is nothing wrong with the way their bowel works, they have no medical disorder, and their constipation responds to a change in diet.

Those with complex or severe constipation have a problem with bowel function and need more than a dietary change. They may have a slow transit difficulty, an imbalance in fluids or an abnormality in defecation. Such men may need laxatives and it is very important that they take the correct ones.

There are two types of laxative: those that stimulate the colon to make it contract and push the stool along, and those that alter the nature of the stool by, for example, drawing in water to make it bulkier, softer and easier to pass. Non-stimulant (bulking) laxatives can be used safely in the long term and won’t damage the colon. Stimulating laxatives can, however, cause considerable damage if used long term. They work by stimulating the nerves and eventually damage these nerves and affect muscle function.

The level of laxative abuse in Australia is alarming. As many as one in five men use them. Amazingly, 80 per cent of users don’t consider themselves constipated and believe taking laxatives is standard behaviour. Some men casually pop twenty or thirty pills a day. Just because a laxative is described as ‘natural’ doesn’t mean it’s not harmful.

Constipation means different things to different people, and in 1992 a symposium of international experts was convened to try to reach some consensus on definition, cause and treatment. Constipation is now defined in terms of frequency, hardness of stool and straining. Straining more than 25 per cent of the time is abnormal. With these three factors taken into account, between 15 and 18 per cent of Australian men would be considered constipated.

Men should train themselves to respond promptly to an urge to defecate. The urge is there because the bowel is stretched. If the urge is not obeyed, the bowel accommodates and dilates further, and a larger volume is needed before an urge is again felt. Further, as the stool waits, the bowel absorbs more of its water and it becomes harder.

Constipation can also be a consequence of other disease or a side effect of drugs and is known to be associated with depression, because with depression the metabolic rate can become sluggish and the bowels can, too. It can also occur, although rarely, in people suffering from an underactive thyroid or increased levels of calcium in the blood. Several drugs, particularly analgesics and codeine-based pain-killers, can cause constipation, too.

Any change in normal daily routine, such as a holiday, can cause constipation. It is not known if this is a local effect in the bowel or a psychological response. It can occur in the first few days of the holiday, before any dietary change could have had an effect.

The relationship between the psyche and constipation is not clearly understood, although the international symposium was told it was common after trauma such as an accident, bereavement or major surgery. There is also some evidence that a positive history of sexual abuse is associated with constipation in women. The same research has not been done in men.


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