Bowel dysfunction which can cause both constipation and involuntary bowel movements affects approximately 60 percent of people with MS. Addressing the problem requires systematic persistence on the part of both the patient and clinician. It’s important to remember that bowel dysfunction, like other MS symptoms, can change over time, and that referral to a gastroenterologist is appropriate when conservative measures have been unsuccessful.
Constipation may be reduced by following these suggestions:
Review your medications. Several categories of medication can precipitate or exacerbate constipation, and a review of medications should be the first step in evaluating constipation. Common drugs that contribute to constipation include antihypertensives, anticholinergics, analgesics/narcotics, sedatives/tranquilizers, tricyclic antidepressants, some antibiotics, antacids, diuretics, and iron supplements.
Manage bladder problems first and drink plenty of fluids. If bowel and bladder dysfunction are both present, bladder problems should be addressed first. Once urinary symptoms are no longer a major problem, patients should increase fluid intake in order to prevent desiccated (dried up) stool which is difficult to move along the gastrointestinal (GI) tract and evacuate. The generally recommended fluid intake is 2 Liters per day.
Consume fiber-rich diet, bulk formers, and concentrated sugar preparations. In addition to fluids, prune juice and/or dried fruits are helpful. 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. Always drink one or two glasses of clear fluid (e.g., water, apple juice, broth, tea) to gain full benefit. Liquid sugar concentrates (such as Sorbitol, Lactulose, and Golytely) are another option and act by drawing water into the intestine, thereby softening the stool. Side effects are rare, and these agents are useful for long-term management.
Behavioral modification. Once you have a plan in place that fits into your lifestyle, stick to it. Exercise regularly. Schedule a regular time for evacuation that takes advantage of the gastrocolic reflex which peaks 20–30 minutes after meals, especially following breakfast.
Medication. Oral medications (such as Colace, Surfak, Peri-colace, and Phillips’ Milk of Magnesia) and dietary supplements (such as magnesium) help to ease the passage of stool through the GI tract. Suppositories can help to lubricate the stool (glycerin suppository) or chemically stimulate the rectum to evacuate stool (bisacodyl suppository). It is important that the patient or caregiver inserts the suppository against the rectal wall and not into the stool. Enemas (such as Enemeez Mini-Enema) contain a stool softening laxative. Fleets or tap water enemas should be reserved for episodic use.
Involuntary bowel or fecal incontinence can result from several pathologic situations: sphincter dysfunction, constipation with rectal overload and overflow, and/or diminished rectal sensation. Since fecal incontinence is often associated with constipation, many of the interventions are similar. However, there are a few factors to consider first when fecal incontinence is reported.
Dietary irritants (such as caffeine and alcohol) should be considered as contributing factors and eliminated. Medications that reduce spasticity may need to be adjusted. Anticholinergic drugs can be helpful when a hyperactive bowel is the underlying cause of incontinence. But since these drugs also affect bladder function, careful initiation and titration are needed, and post-void residual urine volume should be monitored to avoid precipitating urinary retention. An impacted bowel may lead to incontinence. When diarrhea leads to bowel incontinence, the cause of the diarrhea needs to be identified and addressed.
For more information regarding bowel dysfunction, read the “Bladder and Bowel” special issue of MS in Focus published by the Multiple Sclerosis International Federation (July 2014).