Symptoms of Irritable Bowel Syndrome With Constipation (IBS-C) and How to Manage It

Irritable bowel syndrome (IBS) is a chronic digestive disorder that can cause diarrhea and/or constipation, among other symptoms. Constipation-predominant IBS (IBS-C) is a subtype of IBS that causes constipation and abdominal pain.

Rates of IBS vary widely in different parts of the world, but one large study showed that about 4% of people may live with some form of IBS. IBS-C makes up about a third of all cases of IBS.

While the cause of irritable bowel syndrome is unknown, it is considered a disorder of brain-gut interaction. This means a disruption of the two-way communication between the brain and the digestive system is causing symptoms. IBS-C may be treated with a combination of diet modification, fiber supplements, lifestyle changes, and, in some cases, medications.

A person with irritable bowel syndrome feels abdominal pain

Liubomyr Vorona / Getty Images

Common Symptoms of IBS-C

In general, the hallmark symptoms of IBS-C are constipation and abdominal pain. Constipation is when stools are hard and difficult to pass. Sometimes, this means straining to have a bowel movement. Stools may also be infrequent, such as having fewer than three bowel movements a week.

A set of guidelines called the Rome IV criteria is used to diagnose IBS and its subtypes. It includes:

1) Abdominal pain that occurs, on average, at least one day a week for at least three months and that started at least six months prior, plus at least two of the following:

  • The abdominal pain is related to bowel movements.
  • There is a change in how often bowel movements occur.
  • There is a change in how the stool looks.

2) Additionally, to be considered IBS-C, at least 25% of stools are hard (stool type 1 or 2 on the Bristol Stool Scale), and less than 25% of stools are soft (stool type 6 or 7 on the Bristol Stool Scale).

Other symptoms of constipation may be present, though they are not necessary to diagnose IBS-C. Those symptoms could include:

  • Abdominal bloating or distension
  • A feeling of incomplete evacuation (needing to go to the bathroom again even though you just had a bowel movement)
  • A sensation that something is blocking the anus or rectum
  • Gas
  • Mucus on the stool
  • Needing to use fingers to remove stool (digital evacuation)

The Cause Is Unknown

What causes IBS-C is not well understood, though research is being done to learn more. It was previously classified as a functional gastrointestinal disorder (in which symptoms occur without a known underlying cause). As a result of more studies on IBS, It is now called a disorder of gut-brain interaction.

The nervous system has a two-way street between the digestive system and the brain. One can affect the other, and that's what is thought to be happening in IBS. The brain and the gut are not communicating well enough to work effectively.

There are many causes of IBS, and there are a few risk factors, such as:

  • Abnormal motility (how the muscles move food and stool through the digestive tract)
  • Changes in the gut microbiome (the community of microbes in the gut)
  • Having an infection in the digestive system
  • Increased sensitivity to changes in the digestive tract
  • Intestinal permeability ("leaky gut," where the lining of the bowel allows more substances to pass through it)

Diagnosis No Longer by Exclusion

IBS and its subtypes (including IBS-C) used to be called a diagnosis by exclusion, meaning that testing was used to rule out other diseases and conditions before IBS was diagnosed. That's no longer the case. When the criteria for IBS are met, more testing may not be recommended.

Suspicion of other conditions may justify blood tests, stool tests, or endoscopy (imaging via inserting a tiny camera into the body). But this is no longer done as a matter of course if someone meets the Rome Criteria for IBS.

However, some people may feel better about the diagnosis of IBS after testing. People should work with their healthcare providers to decide how to move forward when a diagnosis of IBS is made.

Warning Symptoms

Some signs and symptoms are not a part of IBS-C. When these are present, further testing or treatment may be needed:

  • Bleeding from the rectum or blood on the stool
  • Fever
  • New symptoms in people over age 50
  • Symptoms that come on suddenly or get worse quickly
  • Symptoms that wake you up at night
  • Unintended weight loss

You may also need further testing if you have a family or personal history of colon or rectal cancer or inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis.

Flare-Up Factors

What causes IBS-C symptoms in one person may not necessarily bother another person with the condition.

Some people find that foods that contain carbohydrates called fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) may cause symptoms. Avoiding foods that contain FODMAPs may be one strategy to help prevent a flare-up.

Working with a dietitian helps understand FODMAPs because knowing which foods contain them is difficult. An abbreviated list of high-FODMAP foods includes:

  • Certain vegetables, such as artichoke, asparagus, cauliflower, garlic, green peas, mushrooms, onions, and sugar snap peas
  • Dairy products, including milk, custard, evaporated milk, ice cream, soy milk (made from whole soybeans), sweetened condensed milk, and yogurt
  • Fruits such as apples, cherries, dried fruit, mango, nectarines, peaches, pears, plums, and watermelon
  • High-fructose corn syrup and honey
  • Legumes (beans, peas, and lentils)
  • Pistachios and cashews
  • Some marinated and processed meats
  • Wheat, barley, and rye due to the protein gluten

Other foods that may be connected to flare-ups of IBS include:

  • Alcohol
  • Caffeine (coffee, tea)
  • Carbonated drinks
  • Chocolate
  • Excessive fiber, especially fruit and vegetable skins
  • Fatty foods
  • Fried foods
  • Gluten
  • High-protein diets
  • Milk and other dairy products
  • Processed foods

Other factors that may be connected to IBS flare-ups are:

  • Anxiety
  • Depression
  • Gastrointestinal infection (such as viral gastroenteritis or "the stomach flu")
  • Stressful events
  • Travel

Diet and Supplements

Making changes to diet and adding supplements may help prevent some flare-ups of IBS-C. Restrictive diets are not recommended, so working with a dietitian who can help craft a nourishing diet supporting overall health is important.

A low-FODMAP diet is recommended for many people who live with a form of IBS. The diet has several phases. It is helpful to work with a healthcare provider to get it started. Foods will first be eliminated from the diet, and some will be added back over time.

Increasing soluble fiber may help with some symptoms of IBS. Soluble fiber helps make stool softer and easier to pass. Soluble fiber can be obtained through foods or supplements, especially psyllium fiber.

A few studies have shown peppermint oil in enteric-coated capsules may help relax the intestinal muscles. The muscles working better to move stool through may relieve constipation.

Lifestyle Modifications

Increasing physical activity (exercise) may also help with IBS-C. In general, exercise helps improve overall health. It may also help get the bowels moving, making it easier to pass stool.

Exercise could also be associated with a better quality of life. People feel better overall when they exercise on a regular schedule. A healthcare provider can help recommend how to get started with exercise and work it into the overall healthcare plan.

Treatments and Medications

Treatments for IBS-C can also include mental health modalities and medication.

Caring for mental health is part of an overall treatment plan for IBS-C. Gut-directed psychotherapy that includes cognitive behavioral therapy (CBT), mindfulness, and/or hypnotherapy may be recommended. Because IBS is a disorder of gut-brain interaction, addressing the mental factors that may contribute to symptoms is a part of treatment.

Some of the prescription medications that might be used to treat IBS-C are:

  • Amitiza (lubiprostone) is a secretagogue, meaning it increases the amount of water released in the intestines and helps the muscles to work better to move stool along (peristalsis).
  • Isbrela (tenapanor) increases fluid retention in the bowel to help soften stools. It also treats abdominal discomfort by restoring the gut lining and calming the nerves that feel pain.
  • Linzess (linaclotide) and Trulance (plecanatide) help in bowel movements because they cause the intestines to release more water and make stool softer. They also help with increasing peristalsis.
  • Tricyclic antidepressants are used to treat depression and other mental health conditions. They also work for IBS by affecting the nerves in the digestive system. They may help by lessening the sensitivity of the digestive system to pain.
  • Zelnorm (tegaserod) is recommended for women under age 65 who have not had success using other treatments. This medication prompts the bowels to move stool along quicker. Its use is restricted based on the potential to cause diarrhea.
  • Motegrity (prucalopride), which is approved for chronic idiopathic constipation, may also be used in IBS-C.

Should You Take Miralax?

MiraLax (polyethylene glycol or PEG) is a type of laxative available over the counter (OTC). For people experiencing constipation, it might seem as though taking this type of laxative would solve the issues that IBS-C is causing.

However, the evidence says otherwise. Randomized controlled trials showed that MiraLax helped some people with stool consistency but not with pain or other symptoms of IBS-C. Therefore, the American College of Gastroenterology recommends against its use in treating IBS-C.

Other Tips to Manage Symptoms

It can be helpful to have options to manage or distract from symptoms and feel better. Some ideas for self-care include:

IBS-C vs. Chronic Constipation

Chronic constipation, or functional constipation, is different from IBS-C. Chronic constipation has many potential causes, such as a side effect from medication or a problem with the nerves or anatomy of the digestive system.

The major difference is abdominal pain. Abdominal pain must be present to diagnose IBS-C. Functional constipation might not cause any pain.

The treatments for the two conditions may also be different. For instance, a low-FODMAP diet may not help functional constipation. Laxatives may be helpful for constipation, though they are not recommended in IBS-C treatment guidelines. Plus, they may not work to address all the symptoms of IBS-C.

Knowing which condition is causing the constipation is important because it helps understand how best to treat it. These two conditions might be different ends of the same spectrum of disease. but that is yet unproven, and research is ongoing.

Summary

IBS-C is a complicated condition whose causes are unknown. A disruption in the gut-brain connection may be the source. A set of criteria is used to diagnose IBS-C, and other testing may not be necessary.

Treatments can include making changes to diet, lowering stress, accessing mental health care, and receiving prescription medication when other methods aren't working. Over-the-counter laxatives are not recommended because they don't help with abdominal pain. 

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Amber J. Tresca

By Amber J. Tresca
Tresca is a writer and speaker who covers digestive conditions, including IBD. She was diagnosed with ulcerative colitis at age 16.