This post was co-authored by Grace McClure and Dr. Nicholas Frisch), M.D., OS, MBA.
Constipation after surgery is no laughing matter. Although “toilet talk” may not everyone’s favorite dinner table topic, it is a frequently asked question between patients and surgeons and in support communities and forums. To get to the bottom (no pun intended) of why constipation after surgery concerns so many patients, we spoke to orthopedic surgeon and PeerWell advisor, Dr. Nicholas Frisch.
Dr. Frisch explains constipation as “going a few days off of your normal pattern, which is different for everyone. If you’re more than a few days past your normal routine, this could indicate something more serious is going on and warrant further medical attention.”
Read on as we explain: the symptoms of constipation, why post-operative constipation is common, how to prevent constipation before it happens, and what to do once you’re bowel movements are in a serious funk.
Symptoms of Constipation:
Constipation is loosely defined as having “less than three bowel movements in one week” or as Dr. Frisch puts it “going a few days off of your normal pattern”. Here are the symptoms of constipation:
- Noticeably fewer bowel movements than normal (e.g. if you typically have twice daily bowel movements, not going for 2 days might be your version of constipation)
- Feeling bloated
- Abdominal, stomach or rectal pain
- Stool is hard, small, or pebble-like
- Difficulty during the bowel movement
- Feeling like “you still have to go” after your bathroom break
- Feeling slow or sluggish
Why is Constipation After Surgery Common?
After surgery (like a hip or knee replacement, ACL reconstruction, back surgery, etc.) you’ve essentially created the “perfect storm” for constipation. Pain medication, lack of exercise/ activity, diet changes, and anesthesia are all proven contributors to constipation. In fact, opioid pain medication alone (not even in combination with any other factors) cause constipation in as many as 40% of patients. In other words, post-op constipation in some capacity is very common.
Dr. Frisch explains constipation after surgery as “multifactorial”. He explains that constipation can be “triggered by stress and surgery is stressful. A change in diet and the type of food you eat can also cause constipation. Add in decreased fluid intake and dehydration, the medication themselves, as well as anesthesia, and there is an impact.”
Constipation can be caused/ worsened by:
- Narcotic pain medication (typically from opioid prescription medication)
- General anesthesia (not from local or regional)
- Inflammation (caused by surgery trauma or complications like an infection)
- Lack of exercise, movement or inactivity
- Dietary changes (like fewer vegetables, less fiber etc.)
- Stress, anxiety, and depression (e.g. feeling overwhelmed after surgery can cause stress and feeling constipated can add to this stress, creating a vicious cycle)
- Dehydration (not drinking enough water)
- Underlying conditions (like Parkinson’s disease, thyroid disorders, irritable bowel syndrome, etc.)
5 Ways to Manage Constipation After Surgery
After surgery, you’re not going to be at your best. Adding constipation into the mix may feel like the cherry on the cake. However, there are numerous proven ways to get your bowels back on track so that you can focus on recovery.
1. Add Fiber to Your Diet
Before surgery, you may have made some dietary adjustments in order to boost healing. Foods that a rich in protein, calcium, vitamin D, vitamin C, etc. are great ways to kickstart the body into restoring tissue, bone, muscle etc. However, your pre-op and post-op diet may look a little different.
After surgery, you’re going to need to incorporate extra fiber into your diet. Fiber adds “substance” to your stool, pulling water and making your stool easier to pass. Fiber can be thought of as your digestive track’s “chimney sweep”- cleaning you out.
Women should consume at least 25 mg of fiber a day and men should have at least 38 mg.
Food High in Fiber:
- Pears (5.5 grams per pear)
- Raspberries (6.5 grams/100 grams)
- Avocado (6.7 grams/100 grams)
- Artichokes (10.3 grams/100 grams)
- Dark chocolate (10.9 grams/100 grams)
- Kidney beans, chickpeas, lentils (11-15 grams/ 1 cooked cup)
- Popcorn (14.5 grams/100 grams of dry kernels)
- Lentils (15.6 grams/ 1 cooked cup)
- Oats/ oatmeal (16.5 grams/1 cup of raw oats)
- And the frontrunner: Chia seeds/ chia seed bars (100 grams of dried chia seeds contain 34 grams of fiber!)
2. Enjoy the Magic of Prunes
You’ve heard it before, but the rumours are true: prunes are magic for constipation. Prunes (aka dried plums), prune juice (often served warm), and dried plum powder are natural remedies to regulate your bowel movements. The medical community has backed the use prunes for constipation, citing that they can be very effective at alleviating constipation and symptoms.
In fact, a study published in Alimentary Pharmacology and Therapeutics performed a trial with two patient groups who suffered with constipation. One group ingested 100 grams of dried prunes and the other group took 22 grams of psyllium (a soluble fiber) each day. After 3 weeks, the prune group had “improved stool frequency and stool consistency compared with psyllium”. In other words, prunes (which contain a natural laxative called “laxative sorbitol” and fiber) are proven to be effective at relieving constipation.
Tip: Prunes are both preventative and reactive. Start consuming 100 grams of prunes (about 10 dry pitted prunes) in the days leading up to your surgery and throughout recovery— especially if taking opioid prescription pain medication.
3. Try Laxatives
There are many different types of over-the-counter and prescription laxatives. Laxatives come in drinkable juices, tablets, capsules, gummies, powders, enema form etc. It can be overwhelming to choose the best laxative, so work with your physician or ask a pharmacist to select the best laxative for you.
Did you know: A stool softener is a laxative. A stool softener (called an emollient laxative) is just one of the many types of laxatives available.
Here are the different types of laxatives (so that you can struggle less in the pharmacy isle):
- Stool softener (emollient laxative): This laxative softens the stool and is the “entry-level” laxative. It is best used for mild constipation as it is generally the least effective type. Here’s a list of various stool softener brands.
- Bulk-forming laxative: This is a common type of laxative that works by helping to keep water in your stool. This is not fast-acting, so it’ll take longer to feel relief. Popular brands include: Metamucil, Citrucel, FiberCon.
- Hyperosmotic laxative: Drawing water into the intestines, this type of laxative also helps keep water in your stool. * Hyperosmotic laxatives are often used for those with chronic constipation.
- Mineral oil/ lubricant laxative: Made of mineral oil, this laxative coats your stool. Lubrication makes it easier to go to the washroom and also keeps your stool hydrated…and slippery. This type can offer immediate relief, and is best used for the short-term. It is taken orally and large pharmacies will have a house brand.
- Saline laxative: Like the hyperosmotic laxative, this type also draws more water into your intestines. Also called “magnesium citrate”, this laxative is usually in beverage form and works within 6 hours.
- Stimulant laxative: Increasing movement in your intestines, this is fast-acting. This type can be taken via tablet, with suppository, or by liquid. The medicinal ingredients vary but popular brands include: Dulcolax, Senexon, Senokot, Correctol, Ceo-Two Evacuant.
Note: Laxatives should not be used on a regular basis. If you are using them for longer than instructed (generally more than a couple of days) contact your physician.
4. Stay Hydrated: Drink and Drink Some More!
After surgery, keeping hydrated is extremely important. In order for your bowels to work properly and for you to easily pass stool, you need to be hydrated. If you don’t have enough water in your intestines or colon, your body will soak up the water that would otherwise make up a healthy stool.
After surgery, you’re more susceptible to dehydration. Opioid pain medication (that may be prescribed after orthopedic surgery) can dehydrate you. In addition, some laxatives can also contribute to dehydration. If you’re constipated, add extra drinking water into your routine. Aim to drink 8+ cups of water per day. Herbal teas also count towards your water intake.
Tip: If your drink contains alcohol, added sugar, or caffeine, it will not be as hydrating. Aim to drink 8 cups of water (sparkling, flat or warm) per day.
5. Get Moving!
If you’re recovering from a hip or knee replacement, back surgery, ACL or many other invasive surgeries, your mobility will be diminished. Dr. Frisch explains that “anytime you have surgery, you will go through times where you’re less active. Sedentary life can trigger constipation.”
A study published on PubMed offers this summary: “The most important factors known to promote constipation are reduced physical activity and inadequate dietary intake of fibres, carbohydrates and fluids.”
When it comes to combating your constipation, moving is necessary. The saying “motion is lotion” takes on a whole new meaning in relation to your bowels. Increasing movement, exercises, walking, stairs etc., as prescribed by your surgeon is critical for getting “regular”.
Tip: Within your pain comfort level, walk, perform daily exercises, go up and down stairs etc. Always pair movement with hydration to kick it into the next gear.
When Is Your Constipation a Problem?
It’s common to experience constipation after surgery, but when is it problematic? At what point should you reach out to your doctor? Dr. Frisch explains that he recommends patients involve their care team “when you’ve deviated from normal bowel behaviour and you’re noticing discomfort”. After surgery, especially within the first few days after discharge, constipation can signal other serious issues.
Dr. Frisch explains that “If you’re not passing gas or having a bowel movement, that may be indicative that bowels aren’t functioning.”
Play it safe and reach out to your care team if you’re experiencing constipation. Your physician will run through progressive protocols that will address common causes of constipation. This usually means taking a stool softener, adding in an extra 2-3 cups of water, drinking prune juice, adding fiber-rich foods and supplements etc. Taking laxatives and stopping opioid pain medication may be the gradual next step.
“Ultimately, if you have a history of constipation, go back to what has worked in the past” adds Dr. Frisch.
No matter how constipated you are, there are steps that you and your physician will work through to get you back to your normal.
Dr. Nicholas Frisch, M.D., OS, MBA is an award-winning orthopedic surgeon based out of Rochester, Michigan. He focuses on minimally invasive joint replacement surgery and complex revisions. Dr. Frisch completed his residency at Henry Ford Hospital in Detroit and his Adult Reconstruction Fellowship at Rush University Medical Center in Chicago. Dr. Frisch is has won Orthopedics Best Clinical Article Award, the AAHKS Healthcare Policy Fellowship, Outstanding Resident Award Henry Ford Hospital, the Ford Motor Co. Connected Health Challenge, and more.