Symptom Awareness
Maintaining Bowel Health
One of the prominent symptoms of MS is often problems with bowel movements. In fact, approximately one-half to two-thirds of individuals with MS will experience bowel problems at one time or another. The most frequent symptom is constipation, although some people may experience diarrhea or incontinence (loss of bowel control).
Bowel dysfunction can impact people's lifestyle and how they feel about themselves. It can cause discomfort and may affect sleep as well as outside activities - such as employment and socializing with friends. With instances of diarrhea or loss of control, people can become greatly embarrassed and feel very alone in their circumstances.
Resolving bowel problems is crucial to one's physical, emotional, and social well-being. Controlling these symptoms often requires a change in diet and routine, the addition of bulk supplements, and possibly medications. As always, readers are advised to consult their physician before making any changes to their diet, lifestyle, or treatment plan.
Constipation
Constipation is the difficult or infrequent elimination of solid waste from the body. This is the most common bowel symptom found with MS and may be caused by a variety of reasons. While demyelination from MS may be involved with constipation, other factors may frequently come into play.
Constipation usually occurs when not enough fluid is present in the stool. Ironically, this may occur when people decrease their fluid intake to help with bladder problems. Effectively treating bladder issues to allow for adequate fluid intake is an important factor in treating constipation.
Reduced fluid in the stool also occurs when bowel activity (as the stool moves through the intestines) is slowed, causing too much fluid to be absorbed through the intestinal wall. When this happens, stools become hard and difficult to move.
Less effective signals between nerves damaged by MS could play a role in slowing down bowel activity, but factors such as reduced physical activity (often from mobility or fatigue issues), along with certain medications (including tricyclic antidepressants and anticholinergic drugs), can also slow down bowel activity. Weakness, pain, depression, stress, poor diet, and privacy issues, as well as other medical conditions (such as hypothyroidism), are additional factors that affect the regularity of bowel movements.
With MS, constipation is sometimes caused or compounded by decreased sensation in the rectal area. When this occurs, patients don't feel the urge to have a bowel movement, causing the stool to backup and become hard.
Constipation may cause certain physical symptoms, such as a distended abdomen, intestinal gas, reduced appetite (sometimes with nausea and vomiting), the sensation of needing to make a bowel movement but not being able to do so, loss of energy, and headache. When seeing a medical professional, he or she will need to evaluate the entire situation to make a specific diagnosis in terms of what factors are involved. The attending doctor or nurse will want to know: how often the patient has a bowel movement (frequency, time of day); details about bathroom accessibility and privacy; dietary habits and exercise/ activity levels; and how much fluid and fiber is taken in daily.
After evaluating the situation, the medical professional may recommend a strategy to provide long-term management for bowel regularity. Surprisingly, laxatives are not the first choice for treating constipation. Making appropriate changes to the diet, increasing physical activity, and following a daily routine are typically prescribed as a first line of treatment.
Changing diet, activity level, and routine
Dietary changes, if advised by one's doctor, normally begin with the addition of foods high in fiber. Adding dietary fiber (bulk) to the diet will help stools to be softer and move more quickly through the intestines. Care must be taken not to add too much fiber too quickly to the diet, as this may result in excess gas and possibly diarrhea. Fiber needs to be introduced in small amounts and gradually increased, allowing time for the body to adjust to the change.
Fiber may be added to the diet by eating fresh fruits (with the skin on, if applicable), vegetables, fruit juices, whole-grain breads, and bran cereals. Some foods and drinks, such as sauerkraut, cabbage juice, pickles, yogurt, garlic, prunes, and prune juice, may act as natural laxatives. One or two tablespoons of powdered or granular 100% bran may be added to cereal each morning. Moderation is the key, as too much bran can also cause constipation by clogging the intestines.
If advised by one's doctor, drinking eight to 12 cups of fluid daily (preferably water) is important to good bowel health. Balanced meals should be eaten at similar times each day and in a comfortable atmosphere. Eating sweets, fried foods, meats high in fat, and spicy foods may need to be avoided or eliminated from the diet.
Increasing exercise or activity (under the guidance of a doctor) is usually recommended as a way to increase bowel activity and treat constipation. Walking is a good activity for those who are able; others may benefit from exercises done in a sitting or lying position. A health professional or physical therapist can recommend specific exercises that are appropriate for the individual being treated.
Establishing a regular time for a bowel movement is equally important to promoting regularity. The time and place should be determined according to convenience, comfort, and privacy. Bowel activity naturally occurs approximately 15 to 30 minutes following a meal, so this is the best time for the patient to be ready. Individuals should select the time of day that best fits their schedule, immediately after a meal, to use the bathroom - regardless of whether or not the person feels the need for a bowel movement. Having a warm drink, such as coffee or tea, may assist the process.
Individuals should plan on spending as much as 30 minutes in the bathroom at the same time each day following a meal. While results may not come immediately, over time the body will get on this schedule and soon bowel movements will become a daily routine at the same comfortable and private, time and place. Attention must be given to eating the meal and visiting the bathroom around the same times each day.
Supplements and medications
The type of treatment prescribed depends on the cause of one's constipation. For instance, if the problem is a lack of bulk, then bulk formers may be recommended. As bulk is increased, the stool is able to absorb more water, which adds substance to the stool. Bulk formers typically work within 12 to 24 hours, but could require a few days to produce results.
Bulk formers, which may be taken at night, are not habit-forming and may be used on a regular basis. These are available in powder, wafer, and chewable tablets, depending on the brand. Popular bulk formers include psyllium (such as Metamucil® and Perdiem Fiber®), methylcellulose (Citrucel®), and others. When used for constipation, bulk formers need to be taken according to instructions and include following the dose with one or two glasses of water.
If the stool is too hard, stool softeners can help to provide relief by pulling water from the body's tissues. These are non-habit forming but must be used regularly to be effective. Stool softeners include docusate sodium (Dulcolax® stool softener) and docusate calcium (Kaopectate® stool softener). Stool softeners generally require two to four days to provide results.
If difficulty in expelling the stool is the problem, a laxative (oral stimulant) may be prescribed. Again, long-term use of stimulants may reduce their effectiveness. Laxatives have chemicals that irritate the bowel, thereby increasing intestinal activity and allowing the stool to be moved along more quickly. Certain over-the-counter laxatives should be avoided as they can be strong and habit-forming. Individuals may consult their doctor regarding brands to avoid; drugs and brand names are constantly changing, so labels should be read closely.
Milder laxatives with less-harsh chemicals gently promote a bowel movement, often overnight or within the day (usually within eight to twelve hours). Magnesium hydroxide (Milk of Magnesia®) and some brands with a natural vegetable laxative (such as Perdiem® and Senokot®) are examples of milder laxatives.
Another option for treating constipation is the use of suppositories. Often these may be used along with the laxatives just mentioned, but always check with a medical professional before combining any medical treatments.
Suppositories typically work in less than an hour. Glycerin suppositories provide lubrication for smoother elimination, while others, such as bisacodyl (Dulcolax® Suppositories), contain a medication to encourage movement of the rectal muscles. Naturally, suppositories which contain medication are not as mild as those offering only lubrication. The latter may be used occasionally, every other day, or daily if needed (as recommended by one's doctor).
Enemas may be used when a number of days have passed without a bowel movement. (A physician should be consulted if the number of days since a prior bowel movement has been excessive.) Different brands and types, such as Fleet's® enemas may be recommended. These usually relieve constipation but should not be used on a regular basis as the bowel could become dependent upon them.
Diarrhea and Fecal Incontinence
Diarrhea and fecal incontinence are not common MS symptoms, although occasionally these conditions are seen as a result of the disorder. For instance, people who have lost muscle control and feeling in their legs and lower part of their bodies may lose the ability to control bowel movements. Others may experience this condition from inappropriate nerve signals to the intestines.
Fecal incontinence is often temporary. Finding the exact cause is important and MS should not automatically be blamed. Sometimes the flu or a virus can be the cause, and medications such as antibiotics or even those to relieve constipation may promote fecal incontinence.
Once the cause of the problem has been identified by the physician, changes in routine or medications may be recommended. Altering the diet according to the doctor may also help.
As noted earlier, bowel movements often occur soon after a meal, when activity in the intestines is taking place. Visiting the bathroom immediately following a meal can often help the patient to manage diarrhea or incontinence. Special attention must be given to keeping the skin clean and monitoring skin integrity to avoid sores and infection.
Interestingly, bulk formers - which are used to treat constipation - may also be used in the treatment of diarrhea and incontinence. While absorbing water, they help to make the stool firmer. Metamucil®, Perdiem Fiber®, and Citrucel® are examples of bulk formers that may prove useful. When used for this condition, no more than one dose per day should be taken and no extra liquid should follow this dose.
With persistent diarrhea, a doctor may recommend a diarrhea medication such as Kaopectate® or Imodium® . These work to slow intestinal activity. Occasionally, medication which blocks bladder spasms may have an effect on slowing down bowel muscles also. Other therapies include bowel retraining and biofeedback.
Summary and Resources
Individuals with MS who are experiencing bowel problems should consult a medical professional to resolve these issues for physical, emotional, and social wellbeing. Good bowel health and regularity may often be attained under the supervision of a medical professional through:
- A healthy diet that includes adequate fiber and liquids
- Increased activity levels which include some type of exercise
- Establishing a routine of visiting the bathroom at the same time each day immediately following a meal
- Depending on the type of problem, adding bulk supplements, softeners, medications, suppositories, and/or enemas
- Bowel retraining and biofeedback
- Evaluating and treating compounding conditions if necessary, such as depression, stress, certain medications, and other medical conditions
A combination of medications, supplements, and changes in diet and routine may be needed initially to treat bowel dysfunction. Over time, however, individuals may find that once their body has adjusted to a new schedule of having a bowel movement at the same time each day, they may do so without the need for medications. As always, any changes to one's diet, exercise, or medication regimens should only be done under the guidance of one's physician.
Resources for this article include:
The Multiple Sclerosis Association of America's publication,
Burks J.S., Johnson K.P.,
Halper J., Holland N.J.,
Schapiro R.T.,
— Susan Wells Courtney
