Bowel problems - factsheet
Date of issue: June 2008
Contents
- 1. Introduction
- 2. Why do bowel problems arise in MS?
- 3. Common bowel problems in MS
- a) Constipation
- Causes
- Management
- b) Faecal incontinence
- Causes
- Management
- 4. Useful organisations
- 5. References and further reading
- Acknowledgements
Introduction
Bowel problems are commonly experienced by people with MS. Estimates vary about the number of people affected and the problem is thought to be underreported. However, it is believed that around half of all people with MS experience bowel problems at some stage.[1,2]
Common bowel problems in MS include:
- constipation and evacuation problems - which relate to the difficulties encountered in emptying the bowel;
- faecal incontinence - where there is a lack of control over bowel opening.
It is not uncommon for people with MS to experience both constipation and faecal incontinence at the same time.
Bowel control is an extremely complex process that involves the coordination of many different nerves and muscles. For people with MS, bowel and bladder problems have been frequently linked to lower limb dysfunction. This means that problems with mobility are often accompanied by bladder and bowel problems presenting added management difficulties. However, with the right information and support, the majority of bowel problems can be managed satisfactorily.
Though bowel problems are often difficult to talk about and can cause some embarrassment, it is important to know that there are teams of health professionals who are dedicated to the management and support of people who experience these problems. It is important for people to know that they are not alone in their experiences and the sooner help is sought, the sooner the focus can shift from the problem to the solution! Many hospitals and primary care trusts now have a continence advisor or continence nursing service that deals specifically with bladder and bowel problems. In some areas people may be able to refer themselves to continence services, or alternatively, MS Specialist nurses and GPs can make a referral.
While bowel problems are a common symptom of MS, it must be remembered that there can be other causes such as medications or other underlying conditions that may account for such symptoms. It is therefore essential that any bowel problems are properly assessed by a continence advisor or an MS Specialist nurse.
2. Why do bowel problems arise in MS?
In normal bowel function, digested food passes into the colon, which then extracts water from it before passing the waste product through to the rectum to be expelled.
In order to control bowel movements, most people become aware of the need to evacuate, what is known as the 'call to stool'. This awareness occurs when faeces move into the rectum causing it to expand and send messages back to the brain of the need to evacuate. The rectum is filled with sensitive nerve endings, which can tell the difference between solid or liquid stool, or wind. In MS, these messages can be interrupted, so that bowel movements can be affected.[3] Other bowel problems in MS may arise as a result of disruption between messages from the brain to various parts of the digestive system.
Diagram of the bowel
3. Common bowel problems in MS
a) Constipation
Constipation is more prevalent in the developed world. It is estimated that around one-fifth of the adult population that eats a western diet experiences constipation at some stage in their lives.[3]
Various definitions of constipation exist, but a useful working definition is: "the passage of hard stools, less frequent than the patient's own bowel pattern".[4]
How and why constipation happens in MS is not fully understood, although it is thought to be caused by disruption to the messages that travel between the brain and the digestive system.
Research has identified a number of particular causes of constipation in MS, as well as contributing factors. Some people may experience a combination of these.
Causes
- The sluggish bowel / slow transit bowel
- Reduced sensation
- Evacuation difficulties
- Reduced fluid intake
- Reduced mobility
- Medications
- many of the drugs used for bladder problems eg tolterodine (Detrusitol) and oxybutynin (Ditropan, Lyrinel)
- anti-spasticity drugs such as carbamazepine (Tegretol)
- antidepressants such as amytriptylline (Triptafen), imipramine (Tofranil), which may be prescribed for pain relief, and the selective serotonin reuptake inhibitors such as fluoxetine (Prozac) and paroxetine (Seroxat)
- some dietary supplements eg iron tablets.
- Other causes
In some people with MS, waste travels through the colon much more slowly than in healthy people.[5] This delay in transit time is most likely explained by the disruption in messages to the brain that can occur in MS. As digested food moves through the colon water is extracted and waste product is pushed through to the rectum to be expelled. Slow transit time in the colon increases the amount of water that will be squeezed out of digested foods, making stools much harder, smaller, and difficult to pass. As a result of this the individual may experience constipation.
A simple test for the sluggish bowel is to eat a large tablespoon of sweet corn with a meal, record when it was eaten, and then monitor when it is passed (the sweet corn will be easy to see). This will give a rough indication of how long it takes food to pass through the bowel. For women, this is about 32 hours, and for men, about 27 hours. If it takes longer than this to pass the sweet corn, then an individual may have a sluggish bowel.
Various medical assessments, performed by an MS nurse or continence advisor, can also be used to determine whether a sluggish bowel is the cause of any bowel problems experienced.
Managing and treating a sluggish bowel follows the general rules for constipation (see Managing Constipation below).
Some people with MS may have limited sensation in the rectal area. This can result in reduced awareness of the need to empty the bowel, or the 'call to stool'. If this is ignored for too long, constipation can result. In addition to the management strategies mentioned below, the use of suppositories may also help. It is important to take professional advice before using them.
Some people with MS have a problem passing stool out of the rectum, although it may have travelled normally through the colon. Sometimes this may feel like being constipated but with soft-formed stool. A possible cause is a lack of co-ordination of the muscles around the pelvic floor that control bowel emptying. Aside from the more general management strategies, people experiencing evacuation difficulties may benefit from specific exercises (see Managing Constipation below).
Some people with MS manage their bladder problems by reducing the amount of fluids they drink. To compensate, the body will try to extract as much water as possible from food waste, leading to harder stools, increasing the likelihood of constipation. It is important to drink enough. Current recommendations are at least 1.5-2 litres of fluid a day, which is around 8 glasses. The exact amount will vary according to someone's weight and height as the calculation is based on 30mls of fluid per 1kg of body weight.[6] It's worth discussing the amount of fluid needed with a continence advisor or MS specialist nurse, particularly if it causes or increases bladder problems.
Reduced mobility can lead to a lack of exercise and, sometimes, weaker muscles. Exercise and muscle strength are thought to be important as they can help increase the muscle contractions within the gut, improving an individual's ability to pass waste.
Reduced mobility can also create difficulties in getting to a toilet promptly, causing someone to hold on to stools. Holding on to stool - delaying the time someone empties their bowels - can also lead to constipation.
Needing help with toileting -'performing' at the convenience of carers - can also create problems with constipation, which are not easy to manage.
Many common MS medications list constipation as a possible side-effect, including:
There may be other causes of constipation; for example, many women experience changes in bowel pattern at times of hormonal fluctuation such as menstruation or during pregnancy.
Managing constipation
There has been very little research into which treatments for bowel problems are most successful in MS. Consequently, management is based on the experience of people with MS and continence advisors.
The main steps for managing constipation are:
- an assessment of daily diet.
- a regular bowel habit
- give it time
- posture
- abdominal massage
- review of existing medications and dietary supplements
This looks particularly at fibre and fluid intake.
Fibre: Adequate amounts of fibre are necessary to help soften stools. However, the right type of fibre is significant. For people with a sluggish bowel, too much bran (eg bran-based breakfast cereals) can bulk up stools and slow down the gut even further. Fibre from the recommended five portions of fruit and vegetables per day should help with constipation. Significant increases in fibre should be introduced gradually, to minimise unwanted side effects such as bloating and wind.
Fluid: Sufficient fluid intake is important, and this is around 1.5-2 litres of fluid per day - 8 cups or 6 mugs. As discussed on page 6, exact amounts vary from person to person. More fluid is needed in warm weather.
Often people will learn to open their bowels at a specific time of day. The most active time for the reflexes that empty the bowel is around half an hour after breakfast. It is important that a continence advisor provides support about how to develop and practise a regular bowel routine.
It is important that people are not rushed when trying to open the bowel. If, after twenty minutes, nothing has happened, the person should stop and try again after the next meal (eating and drinking will stimulate bowel movement) or the next day.
The human body's natural posture for opening bowels is to squat. However, in the western world, this is no longer common. The nearest approximation is the 'brace and bulge' technique. Sitting on the toilet, raise the knees so they are higher than the hips, and using a footstool or a pile of telephone directories or something similar, lean forwards and rest arms on top of legs if at all possible, as shown in this diagram.
This is a very specific technique used with the 'brace and bulge' position, as some people find 'brace and bulge' does not work on its own. Abdominal massage needs to be taught by an MS specialist nurse, a continence advisor or other trained person (as a specific technique is involved).
It is possible that existing medications or dietary supplements are causing, contributing to, or exacerbating symptoms. It is therefore important to identify any of these potential factors and to consider alternatives where available.
Some or all of these steps should enable many people to manage their constipation. However, some people may require additional help, particularly people who are experiencing evacuation difficulties alone, ie, a feeling of fullness in the rectum without the ability to pass stool. Some people in this situation may require medicines to help with their problems, which should be discussed with a continence advisor first. Common medications include:
- stool softeners
- enemas
- osmotic laxatives
- stimulant laxatives
- suppositories
- anal irrigation
eg docusate (Docusol, Norgalax) or lactulose (Duphalac, Lactugal). As their name suggests, they soften stool, making it easier to pass.
fluids injected into the rectum. They can be used to clear out the bowel and should only be administered by a competent health professional.
eg macrogol (Movicol) which work by drawing water from the lining of the gut to smooth out the stool and make it easier to pass.
eg Bisacodyl. Sometimes a stool softener, used on its own is not always sufficient and a stimulant such as Bisacodyl may be added, especially in the case of a slow transit bowel. Taken in tablet form, Bisacodyl acts on nerve endings in the walls of the intestine and the rectum. It causes the muscles in the intestine to contract more often and with greater force. When the intestine contracts it moves the gut contents along faster, thereby alleviating constipation. Use of Bisacodyl must be monitored by a health professional.
capsules inserted into the rectum to help soften faeces.
(also known as transanal irrigation or rectal irrigation) eg Peristeen. Peristeen Anal irrigation is a system that can be used in the management of both constipation and faecal incontinence. The system works by introducing warm tap water (36-38°C) into the rectum using a catheter. The person sits on the toilet while their rectum is filled with water. This is then emptied from the lower bowel along with its contents, into the toilet. The system is only available after assessment by a qualified health professional, who will also teach the method of administration.
b) Faecal incontinence
Faecal incontinence - having no control over passing stools - can happen in MS for a variety of reasons. This most embarrassing of symptoms is normally treatable but needs proper assessment and management by a continence advisor or MS specialist nurse.
Typical problems, and their treatments, are: [3]
- Reduced sensation causing incontinence
- Constipation causing incontinence
- Incontinence due to other causes
Loss of or limited sensation can result in a lack of awareness of the need to empty the bowel, which may cause incontinence rather than constipation. The first line of treatment is to try to establish a regular bowel habit. Further treatment will depend on the individual's response.
Constipation that causes faecal incontinence is known as 'faecal impaction with overflow'. What happens is that the rectum fills up with very hard, impacted stools that effectively form a plug in the bowel. Watery matter may leak round the side of this, causing diarrhoea.
A normal treatment plan is to clear the impaction first, most often by using some form of laxative such as a stool softener, or perhaps a suppository or enema. However, this is not always successful so it is important that long-term management takes place in consultation with a health professional, as this may involve a combination of medicines with other techniques.
Too much fibre in the diet, over-use of laxatives, or gastrointestinal viruses can all cause incontinence. It is very important that the cause of any sudden episode of incontinence is correctly identified. Diarrhoea caused by a gastrointestinal virus may or may not need medical treatment, but should always be properly assessed by a GP.
Over-use of laxatives is associated with increased rates of faecal incontinence. Here again, changes to diet, establishing a predictable bowel routine and sometimes prescription of some medications such as Loperamide may help.
Managing faecal incontinence
- Exercises
- Loperamide (Imodium)
- 'Biofeedback' retraining
- Anal irrigation
- Surgery
Specific exercises practised over a period of time may help strengthen the muscles around the anus and allow the individual greater control over them. These exercises are typically taught by a continence advisor.
This is known as an antimotility medicine as it acts to slow down movement of the intestine. Loperimide is an oral tablet that is usually used to treat acute diarrhoea. It works by making the stools more solid and less frequent. While it can be used to treat some types of faecal incontinence, it will not be effective in the treatment of others, such as faecal impaction. It is therefore necessary to follow the advice of a continence specialist or MS nurse when using Loperimide.
This technique is only available in some very specialised centres. It works by retraining an individual's awareness about opening their bowel, involves several hospital visits, and can be quite a lengthy process. One small study suggests limited success in people with MS, that it works better in people with limited disability and a relapsing/remitting disease course.[7]
eg Peristeen - see management of constipation above
Few people with MS ever have to consider this as an option and it is usually only necessary in cases of severe bowel incontinence that cannot be managed in any other way. Surgery normally offered is a stoma operation, bringing the end of the bowel out through the wall of the abdomen so the stool is collected in a special bag. While for some people this can be a positive decision, it is often a last resort and needs to be carefully discussed with the bowel surgeon, continence advisor or MS specialist nurse.
Aside from the above mentioned management strategies, there are a number of other factors that deserve consideration by people experiencing bowel problems, including:
- Skin care
- Containing the problem
Caring for sore skin around the anus is important; steps to take include avoiding perfumed soaps, creams and lotions, washing and drying the sore area carefully after every bowel movement, and wearing loose cotton underwear that allows skin to breathe. Barrier creams such as Cavillon can be useful to prevent soreness, and a continence advisor or MS specialist nurse should be able to advise about this.
There are some pads and pants that can help with incontinence though finding a suitable product is often a case of trial and error. A continence advisor and organisations such as Promocon will offer guidance on the most appropriate continence products (see Useful organisations below). Commodes and bedpans are another option worth considering if getting to the toilet in time is a problem.
RADAR, the campaigning group for disabled people's rights, operates the National Key Scheme. The scheme offers independent access to disabled people to around 6,500 locked toilets around the country. Keys are available for a small charge directly from RADAR - see Useful organisations below - or in some cases, from local authorities. Owning a RADAR key increases the number of accessible toilets someone can use. There is also a register of RADAR toilet locations available to purchase on online.
Urgency cards may also prove useful as they explain why a person might need to use a toilet quickly. The card can be presented to give immediate access to a toilet when there are long queues or when an individual needs to use a shop's facilities, for example.
4. Useful organisations
Incontact
RADAR
Coloplast
Colostomy Association
Promocon
Incontact is a national charity for people affected by bladder and bowel problems. It provides support and information, represents the interests of people with continence problems, and runs local support groups in many areas.
Website: www.incontact.org
Telephone: 0870 770 3246
email: info@incontact.org
RADAR is a national network of disabled people and disability organisations. Its main role is to lobby for a bigger voice for disabled people's rights. It also runs the National Key Scheme for access to disabled toilets.
Website: www.radar.org.uk
Telephone: 0207 250 3222
email: radar@radar.org.uk
Coloplast Limited, manufacturer of Peristeen and other healthcare products and services.
Website: www.coloplast.co.uk
Telephone: 01733 392000
For further information about Peristeen Anal Irrigation call 0800 132 787
The Association provides support and care for people who have undergone a stoma operation for a colostomy. It also provides a helpline and has a network of 800 volunteers.
Website: www.colostomyassociation.org.uk
Telephone: 0800 587 6744.
PromoCon provides a national service, working as part of Disabled Living, Manchester to improve the quality of life for all people with bladder or bowel problems by offering product information, advice and practical solutions to both professionals and the general public. They offer a confidential helpline for individuals and health professionals.
Website: www.promocon.co.uk
Telephone: 0161 834 2001 10am-3pm Monday to Friday
email: promocon@disabledliving.co.uk
5. References and further reading
- Wiesel PH, Norton C, Glickmann S, Kamm MA.
Pathophysiology of bowel dysfunction in multiple sclerosis.
European Journal of Gastroenterology and Hepatology 2001;13(4):441-448 - Bakke A., Myhr KM, Gronning M, Nyland H.
Bladder, bowel and sexual dysfunction in patients with multiple sclerosis: a cohort study.
Scandinavian Journal of Urology and Nephrology. Supplement. 1996; 179: 61-66 - Rigby D.
Bowel dysfunction. In: Multiple sclerosis: information for health and social care professionals.
Letchworth Garden City: MSTrust; 2007. - National Prescribing Centre.
The management of constipation.
Prescribing Nurse Bulletin 1999;6(1):1-4 - Norton C.
Bowel management in multiple sclerosis.
Gastrointestinal Nursing 2004;2(6):31-35 - Ritz P.
Factors affecting energy and macronutrient requirements in elderly people.
Public Health Nutrition 2001; 4(2B): 561-568. - Wiesel PH, Norton C, Roy AJ et al.
Gut focused behavioural treatment (biofeedback) for constipation and faecal incontinence in multiple sclerosis.
Journal of Neurology, Neurosurgery and Psychiatry 2000; 69(2):240-243. - MS Trust.
Bowel problems chatroom. 26 April 2006.
Provides examples of problems experienced by people with MS, with advice from an MS specialist nurse, a nursing lecturer specialising in continence problems, and a doctor specialising in Uro-Neurology.
Acknowledgments
This publication has been written by the MS Trust with the help of experts - those who live with MS and those who work professionally with people with MS.
We would like to thank our Readers' Panel of people with MS, together with Deborah Rigby, Continence Advisor Bristol PCT and Annette Leach, MS specialist nurse, Royal Berkshire Hospital, Reading, for all their help and advice in the development of this factsheet.
- Find out more
- This factsheet is also available in pdf format
If you have specific questions about any aspect of MS, email the MS Trust Information Service or ring us on 01462 476700.
