Chronic Idiopathic Constipation (CIC) Symptoms, Diagnosis and Treatment

Chronic idiopathic constipation (CIC) is a health condition in which a person experiences chronic symptoms of constipation, yet no visible cause can be identified through standard diagnostic testing. 

The term idiopathic is used because it means there is no known cause. 

While estimates vary, as many as 35 million adults in the U.S. may suffer from CIC.

People who are at higher risk include women, older individuals of all ages and genders, and those who have a lower socioeconomic status.

Symptoms

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Signs and symptoms of chronic constipation include:

  • Passing fewer than three stools a week
  • Having lumpy or hard stools
  • Straining to have bowel movements
  • Feeling as though there’s a blockage in your rectum that prevents bowel movements
  • Feeling as though you can’t completely empty the stool from your rectum
  • Needing help to empty your rectum, such as using your hands to press on your abdomen and using a finger to remove stool from your rectum

Many people who have CIC also report experiencing the following symptoms alongside the constipation:

  • Abdominal pain or discomfort
  • Bloating
  • Gas pain

Constipation may be considered chronic if you’ve experienced two or more of these symptoms for the last three months.

 

What factors may contribute to CIC?

There are several factors that may contribute to the development of CIC.

Fluid absorption

The colon may be absorbing too much fluid from the stool, or the muscles in the colon may be moving too slowly. This can cause the stool to become dry, hard, and difficult to pass.

Muscle contractions

The muscles of the colon may be contracting too slowly, which can reduce the movement of stool through the colon and cause infrequent stools.

Decreased urge

Some patients may have less sensitivity, which may reduce the urge to have a bowel movement. Other patients may have extra-sensitive nerves, which can cause discomfort.

Problems with the nerves around the colon and rectum

Neurological problems can affect the nerves that cause muscles in the colon and rectum to contract and move stool through the intestines. Causes include:

  • Damage to the nerves that control bodily functions (autonomic neuropathy)
  • Multiple sclerosis
  • Parkinson’s disease
  • Spinal cord injury
  • Stroke

Difficulty with the muscles involved in elimination

Problems with the pelvic muscles involved in having a bowel movement may cause chronic constipation. These problems may include:

  • The inability to relax the pelvic muscles to allow for a bowel movement (anismus)
  • Pelvic muscles that don’t coordinate relaxation and contraction correctly (dyssynergia)
  • Weakened pelvic muscles

Conditions that affect hormones in the body

Hormones help balance fluids in your body. Diseases and conditions that upset the balance of hormones may lead to constipation, including:

  • Diabetes
  • Overactive parathyroid gland (hyperparathyroidism)
  • Pregnancy
  • Underactive thyroid (hypothyroidism)

Diagnosis

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If you suspect that you have CIC, your doctor will most likely do a physical exam and run some bloodwork in order to rule out other illnesses.

Other diagnostic tests may be recommended depending on your symptoms and medical history.

  • Blood tests

Your doctor will look for a systemic condition such as low thyroid (hypothyroidism) or high calcium levels.

  • An X-ray

An X-ray can help your doctor determine whether our intestines are blocked and whether there is stool present throughout the colon.

  • Examination of the rectum and lower, or sigmoid, colon (sigmoidoscopy)

In this procedure, your doctor inserts a lighted, flexible tube into your anus to examine your rectum and the lower portion of your colon.

  • Examination of the rectum and entire colon (colonoscopy)

This diagnostic procedure allows your doctor to examine the entire colon with a flexible, camera-equipped tube.

  • Evaluation of anal sphincter muscle function (anorectal manometry)

In this procedure, your doctor inserts a narrow, flexible tube into your anus and rectum and then inflates a small balloon at the tip of the tube. The device is then pulled back through the sphincter muscle. This procedure allows your doctor to measure the coordination of the muscles you use to move your bowels.

  • Evaluation of anal sphincter muscle speed (balloon expulsion test)

Often used along with anorectal manometry, this test measures the amount of time it takes for you to push out a balloon that has been filled with water and placed in your rectum.

  • Evaluation of how well food moves through the colon (colonic transit study)

In this procedure, you may swallow a capsule that contains either a radiopaque marker or a wireless recording device. The progress of the capsule through your colon will be recorded over 24 to 48 hours and will be visible on X-rays.

In some cases, you may eat radiocarbon-activated food and a special camera will record its progress (scintigraphy). Your doctor will look for signs of intestinal muscle dysfunction and how well food moves through your colon.

  • An X-ray of the rectum during defecation (defecography)

During this procedure, your doctor inserts a soft paste made of barium into your rectum. You then pass the barium paste as you would stool. The barium shows up on X-rays and may reveal a prolapse or problems with muscle function and muscle coordination.

  • MRI defecography

During this procedure, as in barium defecography, a doctor will insert contrast gel into your rectum. You then pass the gel. The MRI scanner can visualize and assess the function of the defecation muscles. This test also can diagnose problems that can cause constipation, such as rectocele or rectal prolapse.

CIC vs. Irritable Bowel Syndrome

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Constipation-predominant irritable bowel syndrome (IBS-C) shares many of the same symptoms as CIC. And in fact, by definition, CIC is only diagnosed if the criteria for IBS has not been met.

The main difference between the two disorders is that the diagnostic criteria for IBS-C require that there be the experience of chronic pain associated with bowel movements.

In the real world, many doctors will tell their patients that they have IBS if they are experiencing chronic constipation without an identifiable cause, regardless of whether or not pain accompanies bowel movements.

Some researchers believe that the two disorders are not so distinct. Many people who have a diagnosis of CIC do experience abdominal pain and discomfort and there are many people who find themselves switching from one diagnosis to the other over time.

It is possible that the two disorders actually fall upon the same continuum. One important distinction between the two may be related to treatment, as people with IBS-C appear to be more likely than those with CIC to respond to treatment options that are effective for pain relief, while those with CIC appear to be more likely to respond to certain medications or treatments that target the functioning of the muscles of the large intestine.

Treatment

Treatment for chronic constipation usually begins with diet and lifestyle changes meant to increase the speed at which stool moves through your intestines.

If those changes don’t help, your doctor may recommend medications or surgery.

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Diet and lifestyle changes

Your doctor may recommend the following changes to relieve your constipation:

  • Increase your fiber intake

Adding fiber to your diet increases the weight of your stool and speeds its passage through your intestines. Slowly begin to eat more fresh fruits and vegetables each day. Choose whole-grain breads and cereals.

Your doctor may recommend a specific number of grams of fiber to consume each day. In general, aim for 14 grams of fiber for every 1,000 calories in your daily diet.

A sudden increase in the amount of fiber you eat can cause bloating and gas, so start slowly and work your way up to your goal over a few weeks.

  • Exercise most days of the week

Physical activity increases muscle activity in your intestines. Try to fit in exercise most days of the week. If you do not already exercise, talk to your doctor about whether you are healthy enough to start an exercise program.

  • Don’t ignore the urge to have a bowel movement

Take your time in the bathroom, allowing yourself enough time to have a bowel movement without distractions and without feeling rushed.

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Laxatives

Several types of laxatives exist. Each works somewhat differently to make it easier to have a bowel movement. The following are available over the counter:

  • Fiber supplements. 

Fiber supplements add bulk to your stool. Bulky stools are softer and easier to pass.

Fiber supplements include:

    • Psyllium: Metamucil, Konsyl, others
    • Calcium polycarbophil: FiberCon, Equalactin, others
    • Methylcellulose: Citrucel
  • Stimulants.

Stimulants cause your intestines to contract, including:

    • Bisacodyl: Correctol, Dulcolax, others
    • Sennosides: Senokot, Ex-Lax, Perdiem

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  • Osmotics

Osmotic laxatives help stool move through the colon by increasing secretion of fluid from the intestines and helping to stimulate bowel movements.

Examples include:

    • Oral magnesium hydroxide: Phillips’ Milk of Magnesia, Dulcolax Milk of Magnesia, others
    • Magnesium citrate
    • Lactulose: Cholac, Constilac, others
    • Polyethylene glycol: Miralax, Glycolax
  • Lubricants

Lubricants such as mineral oil enable stool to move through your colon more easily.

  • Stool softeners

Stool softeners moisten the stool by drawing water from the intestinessuch as:

    • Docusate sodium: Colace
    • Docusate calcium: Surfak 
  • Enemas and suppositories

Tap water enemas with or without soapsuds can be useful to soften stool and produce a bowel movement.

Glycerin or bisacodyl suppositories also aid in moving stool out of the body by providing lubrication and stimulation.

Other medications

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If over-the-counter medications don’t help your chronic constipation, your doctor may recommend a prescription medication, especially if you have irritable bowel syndrome.

  • Medications that draw water into your intestines

A number of prescription medications are available to treat chronic constipation. They work by drawing water into your intestines and speeding up the movement of stool.

  • Serotonin 5-hydroxytryptamine 4 receptors

Prucalopride helps move stool through the colon. Such as:

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  • Peripherally acting mu-opioid receptor antagonists (PAMORAs)

If constipation is caused by opioid pain medications, PAMORAs reverse the effect of opioids on the intestine to keep the bowel moving. Such as:

Training your pelvic muscles

Biofeedback training involves working with a therapist who uses devices to help you learn to relax and tighten the muscles in your pelvis.

Relaxing your pelvic floor muscles at the right time during defecation can help you pass stool more easily.

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During a biofeedback session, a special tube (catheter) to measure muscle tension is inserted into your rectum. The therapist guides you through exercises to alternately relax and tighten your pelvic muscles.

A machine will gauge your muscle tension and use sounds or lights to help you understand when you’ve relaxed your muscles.

Surgery

Surgery may be an option if you have tried other treatments and your chronic constipation is caused by a blockage, rectocele or stricture.

For people who have tried other treatments without success and who have abnormally slow movement of stool through the colon, surgical removal of part of the colon may be an option.

Surgery to remove the entire colon is rarely necessary.

Reference:

https://www.mayoclinic.org/diseases-conditions/constipation/

https://www.mayoclinicproceedings.org/article/S0025-6196(19)30123-5/fulltext

https://www.singlecare.com/blog/trulance-vs-linzess/

https://www.verywellhealth.com/chronic-idiopathic-constipation-1944861

https://www.ajmc.com/journals/supplement/2019/reviewing-treatment-data-and-the-role-of-serotonin-in-cic/update-on-the-management-of-chronic-idiopathic-constipati?p=2

https://www.linzess.com/types-of-constipation/cic-symptoms

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