I am a 21-year-old female who has experienced problems having bowel movements since I was 17 (after having a knee surgery to repair and ACL). I may have a bowel movement once every 7 to 14 days and when I do, it is very large and of a hard consistency... which normally cannot be flushed down the toilet. I am active as I walk and run a treadmill three to five times a week, go to college, and work. I experience some pain in my stomach, some bloating, and occasional nausea. I tend to eat regularly and most of the time healthy foods. I drink water 99 percent of the time. I have tried stool softeners, laxatives, and enemas with no real success. The only drug that will allow me have a bowel movement is magnesium citrate, which I have only used a few times because I am scared to use it regularly.

I did go see a gastroenterologist about a month ago who told me to drink more cokes (caffeinated drinks) and to eat more fatty foods. He ran no tests. This has not worked and I would like a suggestion on what I need to do or what could possibly be the problem. I am afraid that by not having BMs that I could develop colon cancer.

Dear Reader,

Exercising regularly, drinking plenty of water, and eating a well-rounded diet like you describe are excellent ways to promote healthy bowel function. Many people think they need to have a bowel movement every day, but the reality is that people's bodies vary, and healthy adults range from three bowel movements per day to three per week.

Your symptoms seem to fit the definition of constipation, which is defined as having less than three bowel movements per week, hard stools, feeling like you can't fully empty your bowels, or straining during bowel movements. Long-term constipation can result in damage to your large intestine or hemorrhoids caused by blood-vessel breaks from straining to pass hard stools. No evidence suggests constipation is a cause of colon cancer; and while it can be a symptom, it is somewhat unlikely in someone under the age of 40.

There are many potential causes of constipation, but one of the most common is lack of fiber in the diet. Fiber helps retain water and bulk as stool passes through the digestive tract. According to the Dietary Guidelines for Americans, it's recommended that adults consume 25 to 38 grams of fiber per day. If you haven't already, you might try focusing on gradually increasing fiber in your diet. Vegetables, fruits, and bran (try high fiber cereal or sprinkling two to three teaspoons of unrefined bran on fruit) are all great sources. Scientific evidence suggests consuming fat and caffeine as recommended by your health care provider may actually be more likely to cause constipation than relieve it.

Constipation can also be caused by slow transit of stool through the large intestine, which causes more water to be drawn out of the stool and results in hard, dry stools that are more difficult to pass. Over-the-counter antacids, bismuth subsalicylate (i.e., Pepto Bismol), iron salts, anticholinergic drugs, certain antihypertensives, opioids, and many sedatives can cause slow transit of stool. Conditions such as an underactive thyroid gland (hypothyroidism), diabetes, and Parkinson's disease may also cause slow transit. Obstruction of the large or small intestine by cancerous growths (again, unlikely in someone your age), foreign objects, or scar tissue following surgery can block passage of food through the digestive system. Other factors, such as depression and stress, are sometimes associated with constipation as well.

You're right to be wary of over-use of laxatives. Although over-the-counter laxatives with fiber are fine for occasional use, long term use can cause diarrhea, dehydration, or dependence. The magnesium citrate you used is generally not recommended to be used for more than a week.

You mentioned having knee surgery at the time you started experiencing constipation. There is no clear connection between the surgery itself and your current digestive difficulties. However, it may be a good idea to ask your health care provider if any medications you took after surgery are known to cause constipation.

You may want to consider talking with a registered dietitian to evaluate how your diet is affecting your condition. If increasing the fiber content of your diet, drinking six to eight glasses of water a day, and continuing to be physically active most days doesn't help, a gastroenterologist can run tests to help determine the source of the problem. A blood test can diagnose an under-active thyroid gland or high levels of blood calcium, and a barium enema or colonoscopy can diagnose blockages, including cancer. It sounds like you've been dealing with a pretty uncomfortable problem for a few years, so seeing a provider who will run some tests seems very reasonable. 

Here's hoping the situation passes,


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