Even for people without Multiple Sclerosis, constipation is a very common problem, as evidenced by the number of remedies available in chemist shops, but there are some special issues that may make constipation worse, more frequent, more continuous or, indeed, more problematic for people with MS.
Until a few years ago problems with bowel function were thought to be relatively minor; however, recent research studies, as well as the views of people with MS, have clearly indicated that these can be a real problem. The most common issue is constipation – that is infrequent, incomplete or difficult bowel movements. There may also difficulties with bowel urgency, where there is a need to pass a stool immediately or urgently, or with bowel incontinence, where control of defaecation is ef fectively reduced or lost.
Constipation
Constipation is problematic in MS because it can make other symptoms, such as spasticity and urinary difficulties, worse as well as producing pain or discomfort. Constipation may result from several causes in MS:
• Demyelination may reduce the speed with which the movement passes through the bowel; as moisture is drawn from the stool continuously, the lower the speed, the more the movement becomes dry and hard and difficult to pass.
• You may have decreased sensation in your bowel or rectal area thus not realizing that a bowel movement is needed, and therefore the stool is left in your bowel for a very long time.
• You may have too low a fluid intake thus making the stool dry and hard.
• You may have weakened those muscles that push the stool out and thus have difficulty in this respect.
• In some cases drugs for other symptoms or for the MS itself may affect either the dryness of the stool, or the capacity to push it out.
When MS becomes more severe, it is much more likely that people with the disease will have difficulty evacuating their bowels, as various
body systems linked to this process become less efficient. You may need to undergo detailed medical investigation and get help for this problem.
For most people with Multiple Sclerosis who have constipation, especially in the earlier stages of the disease, the advice is very similar to that for other people with the same problem. In particular:
• Your diet should be high in fibre (e.g. bran, cereals, fruit and vegetables), which allows stools to pass more easily through the intestinal tract.
• Fluid intake should also be increased for the same reason.
• Getting as much exercise as possible can help, although clearly this particular advice will be less easy to follow by those who are bed- bound or using wheelchairs. In this latter case seek advice from your physiotherapist.
• Proprietary bulking agents (such as Fibogel, Metamucil, Mucasil), and stool softeners, can help produce regular motions.
• You could use laxatives, suppositories or enemas occasionally if all else fails, but be careful about using any of these too regularly, because they can actually increase constipation if overused, by slowing down natural bowel function still further.
• Finally, make time for regular daily bowel habits (see below).
As medical and related products are often readily available and may be recommended by some to deal with various problems associated with constipation, it is important to describe briefly some of these products.
• Bulk formers. These are useful when there is inadequate bulk in the motion. They add moisture and content to the stool. The bulk formers should be taken with a couple of glasses of water. They distend the gastrointestinal tract making the passage of stools easier. Motions should pass through in a day or so after their use. Bulk formers are not habit forming and can be used regularly.
• Stool softeners. If the cause of the constipation is a hard stool, which is difficult to pass, then a stool softener can draw increasing moisture into the stool from body tissues therefore softening it and helping elimination. Again these are not habit forming and can be used regularly
• Laxatives. These should be used only occasionally; they are not only very habit forming, but also lead to a weakening of the remaining muscular control of the bowel. Harsh laxatives in particular should be avoided, because basically they are chemical irritants of the bowel tract. Softer laxatives, which should only be taken occasionally, can lead to passing motions in 10–12 hours.
• Suppositories. These, placed in the rectum, both provide chemical stimulation and lubrication. They may be used occasionally to stimulate a bowel movement.
• Enemas. These should be used only very occasionally because the bowel may become dependent on them if they are used frequently.
You may have to be patient to try and find the right combination of strategies that works for you. It is likely that a successful overall strategy will consist of a good fluid intake, a diet with high fibre, as much exercise as possible, and a regular time for a bowel movement – 30 minutes after a meal is usually the most opportune time.
Faecal incontinence
This has been a neglected area in Multiple Sclerosis. Recent research has revealed that something like two-thirds of people with MS have some bowel problems and, over several months, nearly half, in one study, had some degree of what is described as ‘faecal’ or ‘bowel incontinence’. Of course, what appears to be an involuntary release of faeces produces a very unpleasant situation. There may be a link between urinary and bowel incontinence (from weakened muscles, from spasms in the intestinal area induced by MS, or from a full bowel pressing on the bladder), but the link is not always clear.
The exact causes of bowel incontinence are not always easy to find, even in the few centres with special facilities for investigating these issues, but there are several pointers to what may be happening in many cases. Involuntary spasms in the muscles affecting the bowel area are probably the most common causes of such incontinence. Sensation may be reduced in the bowel area and you may not be aware that there has been a build-up of faecal material, until an involuntary movement of the anal sphincter occurs. Prior constipation might lead to this build-up and release of faecal material, as well as a lack of coordination in the muscles controlling bowel movements.
There are a number of ways in which the problems of faecal incontinence may be helped. It is important to ensure that you have bowel movements (and thus bowel evacuation) on a regular basis. You should avoid substances that irritate the bowels such as alcohol, caffeine, spicy foods, and any other triggers to involuntary bowel action that you can identify. For such a symptom, antibiotics may be a trigger, thus you need to avoid their unnecessary use. It is also important to eliminate the possibility that the faecal incontinence is caused by a bowel infection – to test for this possibility you will need to consult your doctor.
Spasms
Stabbing pains in your midrif f may be caused by ‘bowel’ or ‘colon spasms’. These are due to either Multiple Sclerosis directly or changes in bowel function and regularity. Changes in diet and supplementary bulking agents may be all that is required to deal with this problem. If it persists, then antispasmodic drugs may calm your bowel or colon.
Management techniques
Although constipation and bowel incontinence may look like two separate problems, often they may be linked, so initially it is a good idea to try similar management. This involves establishing what is often known technically as a ‘bowel regimen’. In addition to checking your diet, making a regular time of day in which you try and have a bowel movement can be very helpful. Once this regular time is established, it is important that you stick to it – even though you may not feel the urge to go. You may find that drinking some warm liquid, such as tea, coffee or water, will help. This ‘retraining’ is not an easy task and may take some weeks or even months to achieve, but there is some evidence that it can reduce both constipation and bowel incontinence.
You can undergo some complex tests for difficult problems with bowel incontinence, but there are still relatively few specialist centres to assess and help manage these problems. Thus for most people with MS, a tried and tested combination of everyday techniques will probably be a good first step.