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MS information for health and social care professionals Bowel dysfunction

Although bowel problems are common in patients with MS they are generally under reported and neglected[1]. Wiesel et al[2] reported that the prevalence of bowel dysfunction in patients with multiple sclerosis is higher than in the general population. Up to 70% of patients complain of constipation or faecal incontinence, which may coexist[2,3]. Sullivan and Ebers[4] also reported that 53% of people with MS complained of constipation and another study of a large number of people with MS found that 43% had constipation and 53% faecal incontinence.

Bowel dysfunction is a source of considerable ongoing distress in many patients with MS. Symptoms related to the bladder and bowel are related by patients as the third most important symptom, limiting their ability to work, after spasticity and incoordination2. Bowel problems encompass many difficulties ranging from chronic constipation to irritable bowel syndrome (IBS), with or without faecal incontinence (FI). Management of these problems is influenced by many factors, including people's expectations of 'what is normal', tradition, and culture[5]. Bowel habits can vary from two or three times daily to twice weekly or less.

Bowel control is extremely complex, involving a delicate coordination of many different nerves and muscles. Overall bladder and bowel dysfunction has been linked to lower limb dysfunction1, meaning that paralysis of legs and walking difficulties are often accompanied by bladder and bowel problems, thus compounding management difficulties.


Neurological control

In order to control bowel actions, it is necessary to be aware of the need, or 'call to stool'. This awareness occurs when the faeces move into the rectum causing the rectum to expand and send messages via the sensory pathways of the need to evacuate. At this point the finely tuned nerve endings are able to differentiate between whether the stool is solid, liquid or wind. However in MS the messages are often either lost or incomplete, leaving a situation in which it may be difficult to differentiate between the calls.


Faecal incontinence

FI was highlighted in the Department of Health: Good practice in continence services[6]. It gave best estimates of the prevalence of FI as 1% of adults living at home, with 17% of the very elderly reporting symptoms. Special groups such as those with long term physical disabilities, neurological conditions and learning disabilities are more likely to encounter problems. An understanding of pelvic floor anatomy and physiology is required to appreciate how neurological dysfunction affects the mechanisms involved in normal continence. The pelvic floor muscle helps to regulate the defecatory process and maintain continence. Neurological integrity and sensation are a key factor[7].


Constipation

It is estimated that 2-20% of people eating a western diet experience constipation[8] and American studies estimate that 17% of the adult population would be constipated at some point in their lives[9]. With the added complication of the neurological damage, it is therefore not surprising that people with MS suffer with constipation. Common problems that increase constipation are: reduced fluid intake, reduced mobility, reduced call to stool and defecation difficulties. NB Many drugs routinely prescribed for people with MS may also contribute to the problem (see below: Medication Review)

The 'Rome' diagnostic criteria[10] define constipation as demonstrating two or more of the following symptoms:

  • Straining for at least a quarter of the time
  • Lumpy/hard stool for at least a quarter of the time
  • A sensation of incomplete evacuation for at least a quarter of the time
  • Two or fewer bowel movements per week

The NICE guidance[11] on management of MS identifies bowel problems and makes four key recommendations:

  1. Each professional in contact with a person with MS should consider whether the person has any problems controlling bowel function.
  2. Any person with MS who has apparent constipation should be offered advice on changes that may help.
  3. Any individual with faecal incontinence should be assessed for constipation with overflow.
  4. Consideration for routine suppositories or enemas if ongoing difficulties.

Bowel assessment

should consider dietary changes and the need to increase or decrease fibre and fluid intake. If the appetite is poor, it may be unrealistic to expect a daily bowel action producing stool of an average weight of 100g as described by Heaton[12]. Unfortunately, childhood training may have conditioned many people to expect this and they may needlessly take laxatives on a regular basis[13]. An essential part of the assessment process is the completing of a bowel diary, recording the consistency of the stool.

Bowel care assessment pathway
Standard Statement (activity) Variance / reason for it and action taken
If there are any signs of undiagnosed bleeding, or black tarry stool (and patient is not taking ferrous sulphate) stop pathway and refer to doctor immediately
Observe for any signs of obstruction, ie vomiting and pain (refer to GP immediately)
If taking medication known to cause constipation, consider review
Record details of amounts and types of fluid intake, refer to fluid matrix for appropriate intake
Establish constipation. Complete a bowel diary. Use Bristol stool form chart to record stool consistency[12]
Complete a food diary to establish fibre intake. Fibre supplement may be required
Does evacuation ever need to be assisted?
Establish if incontinent of stool and record containment option
Obtain consent for any invasive procedure
Obtain consent for any invasive procedure

Establish follow up procedure		 Date:

Signature:

Reproduced and adapted by kind permission of Valerie Bayliss Continence Advisor, London NHS Trust, Basingstoke, developed from "Pathways for continence care: background & audit"[14]


Management options


1. Review diet, fibre score

Diet is clearly an important factor in bowel management. If the stool is too hard a fibre supplement might be required. Alternatively if the stool is too soft it may be more sensible to reduce the fibre intake.

Below is a simple fibre score to assist this review

Score
Food		 1 2 3
Bread White Brown Wholemeal/Granary
Breakfast cereal Rarely or never eat or eat sugar coated cereal Corn flakes puffed rice Bran flakes wholewheat flakes muesli
Potatoes, pasta, rice Rarely or never eat Eat potatoes, white rice or pasta most days Eat potatoes in jackets, brown rice or pasta most days
Pulses, beans, nuts Rarely or never eat Once a week or less Three times a week or more
Vegetables (all kinds other than pulses potatoes beans) Less than once a week 1-3 times per week Daily
Fruit (all kinds) Less than once a week 1-3 times per week Daily

Your total score:
0 - 12: Increase your fibre
13-17: Good
18: Excellent


2. Review fluid intake

The normal function of the bowel is to absorb water. If fluid intake is low, constipation can occur. A fluid matrix is a guide to suggest volume of fluid intake per 24 hours dependent on weight. For example, a person weighing 9 stone should drink 3 pints of fluid per day, whilst for someone weighing 13 stone, it should be 4.5 pints[15].


3. Defecation dynamics

Position, angle, relaxation and mobility are all important factors. Correct posture, bracing the abdomen and bulging to increase abdominal pressure may all assist the passage of stool from the sigmoid colon into the rectum.


4. Medication review

Many medications can influence bowel management. The following groups of drugs are associated with constipation:

  • aluminium antacids
  • anticholinergics
  • antiepileptics
  • antidepressants
  • antiparkinson
  • antipsychotics
  • calcium supplements
  • diuretics
  • gastrointestinal cytoprotectant
  • iron tablets
  • opiates

NB. Anticholinergics and antidepressants are very commonly prescribed for people with MS.


5. Stool consistency

If the stool is too soft, bulking may be considered; if too hard, softening may be necessary. The majority of simple constipation is managed by a combined approach of diet, exercise, oral stimulant laxatives and/or faecal softeners as with spinal cord injury. Constipation in a small percentage of MS patients is a mechanism for managing faecal incontinence since, if the stool is kept firm, it does not easily escape.

Categories of laxatives:

  • Bulk-forming drugs must be taken with fluid in order to increase stool size. People with decreased fluid intake for any reason may therefore not benefit. For people with neuropathic damage, bulking may not be helpful as it may be difficult to push out a large stool mass. These drugs are suitable for long-term use eg bran, ispaghula (fybogel, regulan, konsyl and isogel), methylcellulose (celevac), sterculia (normacol).
  • Stimulants are suitable for shortterm use if dietary and bulkforming laxatives are not effective. However, once a pattern is established, they may be given, for example, every 2 or 3 days to help stimulate evacuation of a soft, formed stool. Those with poor appetite may also benefit from using the gastro-colic reflex and a toileting regime. Eg senna, bisacodyl, docusate, glycerol & picosulphate, also combined with ispaghula (manevac).
  • Osmotic laxatives are not recommended as first-line treatment or for continual use as they can lead to dehydration. They always produce watery stools but enemas are useful for removal of impacted stools. Eg lactulose, lactitol, movicol, magnesium hydroxide, magnesium sulphate (epsom salts), carbalax suppositories, micro-enemas & phosphate enema
  • Faecal softeners are not recommended for oral use but arachis oil enemas may still be used when stools are hard and impacted

Indications for use:
Prescribing a particular laxative depends on bowel frequency and stool consistency (using the Bristol Stool Form Scale)[12].


Bristol Stool Form Scale

Bristol Stool Form Scale - type 1: separate hard lumps, like nuts (hard to pass. Type 2: sausage shaped but lumpy. Type 3: like a sausage but with cracks in the surface. Type 4: like a sausage or a snake, smooth and soft. Type 5: soft blobs with clear-cut edges (passed easily). Type 6: fluffy pieces with ragged edges, a mushy stool. Type 7: watery, no solid pieces, entirely liquid

6. Evacuation difficulties

It is acknowledged that a small percentage of people with MS rely on assisted evacuation techniques. The RCN published[16] (April 2004) the following indications for assisting evacuation:

  • Faecal impaction
  • Incomplete defecation
  • Inability to defecate
  • Other bowel emptying techniques have failed
  • Neurogenic bowel dysfunction

Types of assisted evacuation

  • Perineal support
  • Digital stimulation
  • Manual evacuation

Perineal support

Support to the perineal body can aid defecation in some women. Perineal support is needed when conditions arising from posterior vaginal wall prolapse, make emptying the rectum difficult. Many women find it helps to either support the perineum or the posterior vaginal wall to assist defecation[17].

Digital stimulation

Is the need to stimulate the anus or anal sphincter to enable evacuation. In spinal injured patients if the lesion is above the cauda equina (upper motor neurone), then it is usually possible to stimulate a defecation reflex digitally. Digital stimulation either with the insertion of suppositories or by gentle rotation of the gloved finger just inside the anus, stimulates the rectum to contract.

Manual evacuation

The practice of digital removal of faecal matter is rarely described in the nursing literature[18]. Caution has been expressed in one text because of the risk of stimulation of the vagus nerve in the rectal wall can slow the clients heart[19].

Many nurses remain confused about their professional and legal responsibilities because of the invasive nature of the procedure. Whilst advances in oral, rectal and surgical treatment have resulted in a decreased need for manual evacuation, this procedure is still an important part of bowel management routine for some people. The RCN guidance[16] recognises this and supports its use where necessary after individual assessment. The National Patient Safety Agency also recognised the importance of the procedure and published guidance in 2004[20].


7. Containment advice and products

The containment of incontinence can improve home care and there are many products available both over the counter and on prescription. Non-prescription items include commodes and bed protection; prescription items range from medication to appliances and anal plugs.


Conclusion

Bowel management in patients with MS has been largely trial and error although general recommendations include maintaining a high fibre diet, high fluid intake, regular bowel action and the use of laxatives or enemas. However the evidence to support the efficacy of these recommendations is scant. What is important is that each patient is given the opportunity for a proper clinical assessment of their bowel problem and various management possibilities explored. In the absence of clinical trial data on bowel management in MS, consensus guidance of clinical practice should be agreed from a team specialized in bowel dysfunction.


References

  1. DasGupta R, Fowler CJ. Bladder, bowel and sexual dysfunction in multiple sclerosis: management strategies. Drugs 2003;63(2):153-166.
  2. Wiesel PH, Norton C, Glickman S et al. Pathophysiology of bowel dysfunction in multiple sclerosis. Eur J Gastroenterol Hepatol 2001;13(4):441-448.
  3. Blakke A. Myhr KM, Gronning M et al. Bladder, bowel and sexual dysfunction in patients with multiple sclerosis - a cohort study. Scand J Urol Nephrol Supp 1996;179:61-66.
  4. Sullivan SN, Ebers GC. Gastrointestinal dysfunction in multiple sclerosis. Gastroenterology 1983;84(6):1640.
  5. Powell M, Rigby D. Management of bowel dysfunction: evacuation difficulties. Nurs Stand 2000;4(47):47-54.
  6. Department of Health. Good practice in continence services. London: Department of Health; 2000.
  7. Cooper ZR, Rose S. Faecal incontinence: a clinical approach. Mt Sinai J Med 2000;67(2):96-105.
  8. Cook T, Frall S, Gough A et al. The conservative management of constipation in adults. J Assoc Chartered Physiother Womens Health 1999;85:24-28.
  9. Sonnenberg A, Tsou VT, Muller AD. The "institutional colon": a frequent colonic dysmotility in psychiatric and neurologic disease. Am J Gastroenterol 1994;89(1):62-66.
  10. Thompson WG, Creed F, Drossman DA et al. Functional bowel disease and functional abdominal pain. Gastroenterology Int 1992;5(2):75-91.
  11. National Institute for Clinical Excellence. Multiple sclerosis - Management of multiple sclerosis in primary and secondary care. NICE Clinical Guideline 8. London: NICE; 2003.
  12. Heaton K. The Bristol Stool Form Scale. In Understanding your bowels. 4th edition London: Family Doctor Publications; 2001.
  13. Edwards C. Down down & away! An overview of adult constipation and faecal incontinence. In: Getliffe K, Dolman M, editors. Promoting continence: a clinical and research resource. London: Ballieres Tindall;1997. p177-226.
  14. Bayliss V, Cherry M, Locke R et al. Pathways for continence: background and audit. Brit J Nurs 2000;9(9):590-592, 594, 596.
  15. Abrams P, Klevmark B. Frequency volume charts: an indispensable part of lower urinary tract assessment. Scand J Urol Nephrol Suppl 1996;179:47-53.
  16. Royal College of Nursing. Digital rectal and manual removal of faeces. Guidance for Nurses. London: RCN;2004.
  17. Hart D, Norman J, Collander R. Gynaecology Illustrated. 5th edition. Edinburgh: Churchill Livingstone;2000.
  18. Addison R. The last resort. J Comm Nurs 1996;10(8):18-20.
  19. Kozier B. Fundamentals of nursing. 6th edition. London: Pearson Higher Education;2002.
  20. National Patient Safety Agency. Ensuring the appropriate provision of manual bowel evacuation for patients with an established spinal cord lesion. National Patient Safety Information 01:London; 2004.

Bibliography

  • Bywater A, While AE. Management of bowel dysfunction in people with multiple sclerosis. Br J Comm Nurs 2006;11(8):333-341.
  • Coggrave M. Management of neurogenic bowel. Br J Neurosci Nurs 2005;1(1):6-13.
  • Coggrave M, Wiesel PH, Norton C. Management of faecal incontinence and constipation in adults with central neurological diseases. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No: CD002115.
  • National Institute for Health and Clinical Excellence. Faecal incontinence: the management of faecal incontinence in adults. NICE Clinical Guideline 49. London:NICE;2007.