BOWEL DYSFUNCTION is common in multiple sclerosis with symptoms reported by approximately 60% of MS patients.  Both constipation and involuntary bowel movements may occur with constipation being the more frequent complaint.  Constipation can be reduced by following a stepwise process.

Medication Review

Several categories of medication can precipitate or exacerbate constipation, and a review of medications should be the first step in evaluating constipation.

• Antihypertensives
• Anticholinergics
• Analgesics/narcotics
• Sedatives/tranquilizers
• Tricyclic antidepressants
• Some antibiotics
• Antacids
• Diuretics
• Iron supplements

Bladder Management and Fluid Intake

• If bowel and bladder dysfunction are both present, bladder problems should be addressed first.  Many patients practice fluid restriction in an attempt to control distressing urinary symptoms such as frequency, urgency and incontinence. 
• Once urinary dysfunction is no longer a major problem, it will be possible to increase fluid intake in order to prevent desiccated stool, which is difficult to move along the gastrointestinal (GI) tract and evacuate. 
• The generally recommended fluid intake is 2 Liters per day.

Diet-Fiber, Bulk Formers, and Concentrated Sugar Preparations

• In addition to fluids, prune juice and/or dried fruits are the easiest, and often most effective dietary measures. 
• Sufficient dietary fiber is essential.  If a high fiber diet cannot be achieved, bulk supplements such as Metamucil, FiberCon, Perdiem, or Citrucel can be used.  One or two glasses of clear fluid (e.g., water, apple juice, broth, tea) should be taken with these agents for full benefit. 
• Liquid sugar concentrates are another natural intervention.  They act by drawing water into the intestine, thereby softening the stool.  Preparations include Sorbitol, Lactulose, and Golytely.  Side effects are rare, and these agents are useful for long-term management.

Behavioral Interventions

• Educate to promote adherence to whatever plan is developed.
• Initiate and maintain a regular program of physical exercise.
• Schedule a regular time for evacuation that takes advantage of the gastrocolic reflex 20–30 minutes after meals, especially breakfast.
• Integrate the planning with the person’s life style and cultural mores.

Oral Agents

A variety of oral agents facilitate the passage of stool through the GI tract:

• Colace (docusate 100 mg)
• Surfak (docusate 240 mg)
• Peri-Colace (docusate and casanthranol)
• Phillips’ Milk of Magnesia

Suppositories

The patient or caregiver must be instructed to insert the suppository against the rectal wall and not into the stool.

• Glycerin suppository to lubricate the stool
• Bisacodyl suppository to chemically stimulate the rectum to evacuate stool

Enemas

Most useful is the Enemeez Mini-Enema (a stool softening laxative).  Fleets or tap water enemas should be reserved for episodic use.