Constipation

If you're finding it hard to poo and not pooing as often as usual, you may be experiencing constipation. This is a common bowel symptom that can affect people with multiple sclerosis.

There are many successful approaches to managing constipation. Straightforward lifestyle changes to diet and exercise can make a real difference. There are also a variety of treatment options available, such as laxatives, rectal stimulants and transanal irrigation.

Constipation is defined as passing hard stools (people also call them poo or faeces) with excessive effort, usually less than three times a week. It can be accompanied by abdominal bloating and discomfort, tiredness and fatigue, and a loss of appetite.

It's not fully understood how and why constipation happens in MS. Research has identified several contributing factors which may be experienced at the same time.  

• Sluggish bowel – In some people with MS, waste travels through the colon more slowly. One of the functions of the colon is to reabsorb water. Therefore, the longer it takes for waste to travel through the colon (known as transit time), the harder and smaller your stools become.
• Reduced sensation in the back passage (rectum) – This can make you less aware that you need to empty your bowel. Poo that remains in the back passage for longer can make constipation worse and result in overflow incontinence. This is where loose, diarrhoea-like fluid passes around a hard plug of impacted poo.
• Weakness or lack of coordination of the anal muscles or pelvic floor – This can make passing stools more difficult. Problems like this can occur because of pregnancy and childbirth, long-term constipation, being overweight, excessive straining on the toilet, and heavy lifting.

For people with MS, studies have shown that up to seven in ten people experience constipation. Constipation is also common in the general population with estimates that one to two people in ten are affected, and this increases as people get older.

The aim of managing constipation is to make your stools softer so they're easier to pass. What you eat and drink, how much you exercise, and adopting regular bowel habits can make a real difference.

Eating regularly is good stimulation for your bowels. The most active time for the reflex that helps to empty the bowel is around half an hour after a meal. The response is strongest after breakfast. Skipping meals, especially breakfast, can lead to a sluggish or irregular bowel.

Making sure you have enough fibre in your diet can make a positive difference to constipation. It can even reduce the need for bowel medications, such as laxatives. Most adults in the general population don't eat enough fibre – the recommended daily amount is 30g.

Adequate amounts of fibre in your diet are necessary to maintain the bulk and softness of stools. There are two types of fibre: soluble and insoluble.

• Soluble fibre dissolves in water. It becomes a gel-like substance when it reaches your stomach. Soluble fibre is found in fruit, nuts and vegetables.
• Insoluble fibre doesn't dissolve and remains largely the same as it goes through your digestive system. It's found in wheat and grans (eg, bran-based breakfast cereals).

Eating five portions of fruit and vegetables per day, and one or two portions of wholegrain foods, can help ease constipation. The fruit and vegetables may be fresh, frozen, tinned or dried. You can also increase the fibre in your diet by adding a tablespoon of linseeds or flaxseeds to your food.

For people experiencing constipation, too much insoluble fibre (wheat and grains) can slow down the gut even further. When increasing your fibre intake, it can be useful to increase soluble fibre first (fruit and vegetables) and then increase insoluble fibre more slowly.

Any fibre should be increased gradually to avoid abdominal bloating or wind, and fluids should be increased alongside this. 

You can use a bowel diary to record any changes as you gradually alter your diet and monitor the effects these changes have.

Some people with MS try to manage bladder problems by reducing the amount of fluids they drink. However when you're not drinking enough, your body tries to reabsorb as much water as possible from food waste. This leads to harder stools.

Current recommendations are to drink at least 1.5 litres of fluid a day (about six to eight full glasses). Ideally, this should be water rather than tea or coffee which can have a dehydrating effect. Your urine should be pale or straw-coloured. If it's a darker yellow than this, it's a sign you're dehydrated.

Exercise increases the muscle contractions within your gut. This encourages movement of waste along the bowel and improves your ability to empty.

Reduced mobility and a lack of exercise can lead to weaker muscles, difficulty getting to the toilet and constipation. Staying as active as possible through regular exercise can improve constipation. If you have limited mobility or maintaining a regular exercise regime is difficult for you, even standing for short periods (including assisted standing) can help to get your bowels moving.

It's best to speak to a physiotherapist if you're considering a new exercise regime. They can advise on exercises that will best suit you and your ability.

The human body's natural posture for bowel opening is to squat. The nearest approximation is the brace and bulge technique described below.

• Knees higher than hips.
• Lean forward.
• Elbows on knees.
• Bulge out abdomen.
• Straighten spine.

Whilst sitting on the toilet, raise your knees so they’re higher than your hips. You can use a footstool, or something similar, to help. Keep your feet flat on the footstool. Lean forward, keeping your back straight. Rest your elbows on your knees, if possible. Movement of faeces can then be helped by bracing your abdominal muscles and expanding your waist.

Sometimes rocking backwards, forwards and side to side can increase abdominal pressure and encourage a bowel movement without straining.

Give yourself time when trying to open your bowels. Find a time when you're not rushing to do other things. Use a toilet where you feel comfortable and relaxed. Breathe gently and make sure you're not straining while you're on the toilet.

If after ten minutes, nothing has happened, stop and try again after your next meal or the next day. Establish a routine for emptying your bowels at a regular time. Health professionals often call this a bowel management routine.

Abdominal massage can help to encourage movement of faeces through the gut. Your MS specialist nurse or continence advisor can teach you how to do this.

Abdominal massage involves rubbing your stomach in a clockwise motion using the heel of your hand or a fist. Your hand should gently, but firmly, massage up the right side of your abdomen, across at the level of your belly button, and then down the left side of your abdomen. The massage is best done in a semi-reclined position for approximately ten minutes. Regular use of an abdominal massage technique whilst lying on your back can also be beneficial.

It’s possible that constipation may be a side effect of the medication you’re taking. Drugs for bladder symptoms, spasticity and depression can have this effect. This includes medications such as solifenacin, tolterodine, baclofen, paroxetine and amitriptyline. Iron supplements and antacids (used to relieve indigestion and heartburn) can also contribute to constipation. It’s therefore important to identify any of these and work with your health professionals to find alternatives if possible.

Reaching out to a health professional – such as your MS nurse, GP or a bladder and bowel (continence) service – is an important first step in getting the right treatment for bowel accidents. You may feel embarrassed or uncomfortable talking about bowel problems, but your health professionals will have lots of experience talking about these kinds of symptoms. You can usually contact your local bladder and bowel service directly without a referral from your GP.

Laxatives are medicines used to treat constipation. They’re often used if lifestyle changes haven’t been effective. They’re usually taken orally, either as a tablet or a powder you mix with water.

Many over-the-counter laxatives are licensed for short-term use only. They can become less effective if you take them long term. 

There are different types of laxatives which work in different ways. Speak with your MS specialist nurse or continence advisor to find the approach that works best for you. This might involve a bit of trial and error to begin with.

• Bulk-forming laxatives increase the bulk (or weight) of your poo. This makes them bigger and softer, which helps to stimulate your bowel. This type of laxative works in the same way as soluble fibre. They may be useful if dietary fibre can’t be increased. Bulk-forming laxatives are used daily at regular times. A good fluid intake is essential. Overuse can result in sluggish stool transit. An example of a bulk-forming laxative is ispaghula husk (Fybogel).
• Osmotic laxatives make faeces softer by drawing water from the lining of the gut. This smooths out your stools, making them easier to pass. Macrogol (Movicol, Laxido, CosmoCol) and lactulose are examples of osmotic laxatives. Some osmotic laxatives can increase gas and stomach bloating (eg, lactulose).
• Stool-softener laxatives increase the amount of water in your poo. This softens them and makes them easier to pass. Docusate (DulcoEase, Dioctyl, Norgalax) is one example of a stool softener. A stool softener used on its own may not always be sufficient. A stimulant laxative may also be needed, especially if you have a sluggish bowel.
• Stimulant laxatives make the muscles of the colon contract more often and with more force. This helps to move the contents of your gut along more effectively. Stimulant laxatives take 8–12 hours to work. If you need help getting to the toilet, it’s important to plan when you’re going to use stimulant laxatives. Use them when you know you’ll be able to get to the toilet in time. Senna and bisacodyl are both stimulant laxatives.

Rectal suppositories and enemas can be used to lubricate your poo and make it easier to pass. They can also stimulate your bowel to empty. They come in the form of capsules, liquid or gel which you insert into your rectum.

Rectal stimulants are an important part of a bowel management routine as they allow you to choose when to open your bowels.

• Suppositories are solid, bullet-shaped medications inserted into the rectum. They lubricate the faeces and stimulate the rectum to push out the faeces.
• Enemas are fluids inserted into the rectum to stimulate emptying. Mini enemas can be inserted on a regular basis to help the bowel to empty. Large-volume enemas are usually given by a health professional. They can be used on an occasional basis.

Transanal irrigation – also known as rectal irrigation – involves introducing warm tap water into your bowel. The water is inserted via the anus, using a catheter or cone, whilst you sit on the toilet. The water helps to wash faeces out of the bowel and encourages the bowel muscles to contract. This helps to push the faeces out without straining.

Transanal irrigation can be useful if you’ve been unable to successfully manage your bowels with lifestyle changes and medication. There are several systems available on prescription, including Aquaflush, Navina, Peristeen and Qufora. Some irrigation devices are small enough to be discreetly carried in your bag.

Assessment and training with a suitable healthcare professional is essential before using transanal irrigation.

All the treatment options discussed above can be used as part of your bowel management routine. This will help you regularly open your bowels to avoid constipation.

• Bladder and Bowel Community – a charity providing information and support for people with all types of bladder and bowel related problems
• Continence Product Advisor – a website providing evidence based information on a wide range of continence products
• Bladder and Bowel UK – a charity offering advice, support and practical help for people with bladder and bowel problems, including information resources and a confidential helpline