The oldest medical document that has ever been found, the Ebers Papyrus, which dates back to 1,500 B.C., shows that from the period before Christ people were concerned about their bowels, so it's no surprise that today people suffer with constipation and that it's at epidemic proportions in The Bahamas, where many people consume a high fat, low fiber diet, according to Gastroenterologist Dr. E. Marcus Cooper.
"An excerpt from the Ebers Papyrus says, 'The uncleanness within is greater by much than the uncleanness without. And he who cleanses himself without, but within remains unclean, is like a tomb that outwards is painted fair, but is within full of all manner of horrible uncleanliness and abominations.' This is basically referring to what goes on in your bowels. People have always been obsessed with their bowels. Particularly in the Caribbean and The Bahamas, everybody is obsessed with their bowel habits and bowel movements, and this is not anything new. This is a very common problem."
Dr. Cooper, who heads Gastro Care Bahamas, said constipation in The Bahamas is an epidemic and that if he has 10 patients in his office in a day, seven of them either come to him for gas and bloating or constipation.
But the major misconception about constipation he found most people come to him with, he said, is that they believe they should have a bowel movement after every meal. It's something he says that is true and not true.
"There is something called the Gastro Colic Reflex which is that reflex that causes you to move your bowels after every meal. The reflex is only present in babies, which is why every time you feed a baby the baby poops, because they don't have control of that reflex. With the Gastro Colic Reflex, you eat some food and your bowels prepare to make room for what's going to be coming down the track, and so you empty the end of your rectum or colon. As we get older we're able to control that so that we don't poop every time we eat."
Dr. Cooper, who spoke at the recent Doctors Hospital Distinguished Lecture Series, said women in particular tend to control their Gastro Colic Reflex better than men, because they want to relive themselves in a familiar environment. Men, he said, can poop just about anywhere. But after suppressing the reflex over many years, he said a person can develop constipation.
"So when people say I heard you should have a bowel movement every time you eat, that is true -- we have a reflex that regulates that. But if you don't have a bowel movement every time you eat, it's not abnormal. It's something that we control and over time we modify it and things change," said the doctor. Some people feel if you don't go after every meal, you're constipated, and that's not true. There's a range of what we consider to be normal when it comes to bowel movement.

Definition of constipation
The medical definition of constipation must include two or more of the following (during at least 25 percent of defecations) -- straining during at least 25 percent of defecations, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal obstruction or blockage, manual maneuvers to facilitate evacuation, fewer than three defecations per week, loose stools that are rarely present without use of laxatives; insufficient criteria for IBS. The doctor said the criteria should be fulfilled for at least three months, with symptom onset at least six months.
"If every time you go to the bathroom you have to sit there awhile and have to strain, or if you have to take a book or a phone and you're on social media, it's probably because you are constipated. If you go sit on the toilet, nothing happens in two minutes, come back, it's not your time," he said.
"If you go to the bathroom and you have a bowel movement, and you get up and five minutes later you get up and feel like you haven't had a complete pass, that's a symptom that suggests that you are indeed constipated from a medical definition. Sensation of blockage is sometimes there, but not consistently, and if you have fewer than three bowel movements in a week. So what's considered normal is a range of three times per day to three times a week. If you're infrequent to less than three times per week, then you do fit the definition of constipation."
Dr. Cooper said he has seen patients who go as infrequently as once per month, which is definitely constipation.

Risk factors for constipation
The risk factors for constipation include female gender, advanced age, low income, medications/medical conditions, sedentary lifestyle and poor diet.
He said that women are prone to constipation more commonly than men, and that it is particularly due to their tendency to suppress their reflex to go every time they eat. That suppression, he said, tends to start in their teens and progresses into their early 20s and 30s, because they don't want to go to the bathroom at work, and don't want to go anyplace but at home. Over time, he said, a person's bowels are actually able to accommodate a lot more feces and so after a while they don't have the urge to go anymore, and that's when it becomes a problem.
Men, he said, have other problems -- and constipation is not usually one of them.
The other reason why women are usually more constipated than men, he said, involves stress, and the loss of certain hormones responsible for bowel habits as they approach menopause, and after menopause. Hygiene and pregnancy, he said, play their part in constipation as well.
Advanced age, he said, doesn't necessarily mean bowel habit problems. Medically, he said, they use the Rome criteria to make a constipation determination for people in their 50s, 60s and 70s.
"As you get older, your body becomes pretty well-adjusted to everything, and you have a routine and a schedule. If you start to become constipated in your 60s, that's a bad sign -- that means that this is probably not regular constipation, but could be an obstruction or blockage, and you really should see a doctor about it."
Certain medications -- opiods for pain, iron supplements, diuretics (water pills), antidepressants, antihistamines (allergy medication), antispasmodics (Baralgin/Buscopan), anticonvulsants (seizure medications), Aluminum antacids (indigestion medications), NSAIDS (Motrin, Ibuprofen/Aleve), CCB (high blood pressure pills), slow down your bowels and can contribute to constipation.
Medical problems associated with constipation include Multiple Sclerosis, Lupus, Parkinson's disease, stroke, spinal cord injuries, diabetes, thyroid diseases and kidney failure.

Constipation treatment
Dr. Cooper said fiber and exercise are important in speeding up the body's evacuation process.
"Fiber is the most important thing you can do -- especially if it's mild constipation. You have to get more oats and bran cereals, wheat and fruit and vegetables into your diet."
He said he does have patients who tell him they eat oatmeal every morning and eat lots of vegetables, but that they are still not regular. But he said regular dietary fiber often doesn't have a significant laxative effect, so even though a person is consuming lots of fruits and vegetables, sometimes it doesn't work, which he said is true for moderate to severe cases of constipation. At that point, he said, the patient probably needs a supplemental fiber like Metamucil, Benefiber, Konsyl or Fiber One in their diet.
"Supplemental fiber once a day does wonders for helping you move your bowels," he said.
And he says it's true what your grandmother told you, that prunes do work.
"We've had scientific studies that show prunes work. People strain less than normally just by eating prunes. And probably if you get enough prunes it's just as good as Metamucil, so if you don't like that gritty taste from Metamucil and think it tastes nasty, get yourself a box of prunes and go to town."
If people continue to eat poorly and consume peas and rice, and macaroni and cheese, and potato salad and fried fish every day, with no vegetables or salad in sight from which to get their fiber, he said they're going to continue to have problems with constipation.

Hemorrhoids
Nobody wants to talk about having a hemorrhoid, but a person with hemorrhoids is very common, according to Dr. Cooper. Hemorrhoids are just blood vessels that everyone has in their rectum and nothing abnormal. From time-to-time he said they get swollen, particularly if a person is constipated and straining.
Of the two types of hemorrhoids there are external and internal.
External hemorrhoids are the ones you can feel; internal hemorrhoids are the ones you don't. So if you're seeing blood in your stool and you don't feel anything or see anything when you examine yourself, the doctor said you could still have a hemorrhoid, it's just internal.
Hemorrhoid severity is graded. A grade one is a hemorrhoid that stays inside the body; grade two pop out and go back in by themselves; grade three hemorrhoids pop out and you have to push them back in; and if they can't go back in, it's a grade four hemorrhoid.
Hemorrhoid symptoms and complaints include itching, burning, bleeding, pain, tenderness and swelling. And he says blood in the stool is never normal. And that even if you've been told you had a hemorrhoid before, a person should not assume that bleeding is coming from the hemorrhoid. He said he's seen cases where people were never recommended to have a colonoscopy, and a year later, they have colon cancer. He said whenever blood is seen in the stool, that it's always best to be checked out.

Treatment
Grade one and two hemorrhoids he said are treated with medication. For more severe hemorrhoids, surgery and banding have to be done.
In previous years, Dr. Cooper said hemorrhoid surgery was one of the most painful surgeries performed -- and was worse than having open-heart surgery. Today, he said, hemorrhoid surgery and management is no longer painful. You can have your hemorrhoid taken care of in a procedure that takes minutes and go right back to work, as it's painless.
"Something that we're doing now at my office now, which is new ... this procedure can be done in about 15 minutes. I insert a device about the size of my finger, identify the base of the hemorrhoid, and pull it into the device. I make sure you're not having any pain, and then I put a band on it. This takes five minutes. You can go right back to work. And it's totally painless. Hemorrhoid surgery and hemorrhoid management is no longer painful. This is something you can have done without having to have surgery."

Anal fissures
Anal fissures are the other big pain in the butt, which he said are so painful, he has seen grown men come into his office and fall onto their knees because they are so painful.
"Anal fissures are small tears in the anal canal. Sometimes you don't even see it, but these things will cause you to have pain for hours. What happens is you go to the bathroom, have a bowel movement, it's very painful having a pass, and the pain lasts for seven hours afterwards. People feel worn out. They have to go and lay down because they're just so tired. These things are extremely painful, and don't get better unless you treat them."

Causes
Trauma from horseback riding and riding a bicycle can result in anal fissures. Constipation is a common cause, as well as diarrhea. If a person is going to the bathroom a lot, a tear can develop. The pushing during childbirth can also result in a fissure, as well as sexual abuse.
Symptoms include a little blood, anal pain, or spasming that lasts for hours that prevents the fissure from healing.
Management of fissures includes eating high fiber diets, sitz (Epsom salts) baths, bulking agents, topical anesthetics, and topical anti-inflammatory meds.
Dr. Cooper said Botox, which is used for moderate to severe frown lines and crow's feet in the face, is what he uses for fissure treatment once people get to him. He said once people get to him, it's usually because nothing has worked for them.
"By allowing that muscle to relax, you allow the fissure to heal. Botox is very effective. I've only had about two patients who did not respond to Botox who required surgery."
To cure pains in the butt, the doctor said lifestyle modification is key.
"You can't go wrong with fiber. It cures all pains in the butt," said Dr. Cooper. "Increase fluid intake -- nothing is as good as plain old water, avoid straining, and avoid long toilet times."
In the doctor's final analysis, people should exercise, eat healthy and ensure they get checked out.

Click here to read more at The Nassau Guardian