Many people with multiple sclerosis experience bowel problems. One of the possible problems is constipation, when hard stools (poo or faeces) are passed less than three times a week.
There are many successful approaches to managing constipation and straightforward lifestyle changes to diet and exercise can make a real difference. There are also a variety of treatment options available and health professionals, including your MS specialist nurse, GP and continence services can work with you to find the ones that are right for you.
What is constipation?
Constipation is defined as passing hard stools (people also call them poo or faeces) with excessive effort usually less than three times a week. This can be accompanied by bloating of your abdomen and discomfort, tiredness, and a loss of appetite.
What causes constipation?
It is not fully understood how and why constipation happens in MS but research has identified a number of factors which may be involved and can be experienced at the same time.
Sluggish bowel occurs in some people with MS where waste travels through the colon more slowly. As one of the functions of the colon is to reabsorb water, the longer this takes (known as transit time), the harder and smaller stools can become.
Reduced sensation in the rectum can lead to a loss in awareness that you need to empty your bowel, so that stool remains in the rectum for longer. This can make constipation worse and potentially result in overflow incontinence.
Weakness or lack of coordination of the anal sphincters, weakness of the pelvic floor muscles (the muscles that form the "floor" of the pelvis and support the bladder and bowel) and problems in the rectum which might have been caused by excessive straining on the toilet, during childbirth or because of heavy lifting, can also cause difficulties.
How many people experience constipation?
For people with MS studies have shown that up to seven out of 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.
What can I do if I’m constipated?
The aim of managing constipation is to produce stools that are not too hard or soft, and allow you to easily and effectively empty your bowels on a regular basis.
Food and drink
The thing that helped me personally was adding more fibre to my diet. This means eating bran flakes or muesli for breakfast.
A person with MS
Eating regularly is good stimulation for bowels. The most active time for the reflex that helps to empty the bowel is around half an hour after a meal, and the response is strongest after breakfast. Skipping meals, especially breakfast, can lead to a sluggish or irregular bowel habit.
Making sure you have enough fibre in your diet can also make a positive difference to constipation and 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.
Lots of people I see swear that porridge has a really big impact on constipation.
Adequate amounts of fibre are necessary to maintain the bulk and softness of stools. There are two types of fibre -soluble which is found in fruit, nuts and vegetables, and insoluble in the form of wheat or grains. For people with a sluggish bowel, too much insoluble fibre (eg bran-based breakfast cereals) can slow down the gut even further.
Fibre from the recommended five portions of fruit and vegetables per day, with one or two portions of wholegrain foods, can help with constipation. You can also increase the fibre in your diet by adding a tablespoon of linseeds or flaxseeds.
Increase fibre gradually to avoid abdominal bloating or wind and increase fluids along with this. The fruit and vegetables may be fresh, frozen, tinned or dried.
You can use a bowel diary to record any changes as you gradually alter your diet and monitor the effects these changes have.
The recommended daily amount of fibre is 30g.
|Food||Type||Amount required for 2g of fibre|
1 small slice
2 small slices
|Rice and pasta||
|Food||Type||Amount required for 2g of fibre|
Cauliflower, cabbage, carrots
Apple, orange, pear
I found drinking much more water than I used to and cutting out tea and coffee had a really beneficial effect.
A person with MS
Some people with MS try to manage bladder problems by reducing the amount of fluids they drink, however to compensate the body will try to reabsorb as much water as possible from food waste and this in turn leads to harder stools.
Current recommendations are 1.5- 2.5 litres of fluid a day (ideally water rather than tea or coffee which can have a dehydrating effect) or about eight full glasses. Producing pale, straw coloured urine shows that your intake of fluid is adequate.
There are some foods and drinks that can overstimulate bowel activity or draw excess fluid into the colon. These include:
- Drinks containing caffeine including tea, coffee, cola, hot chocolate.
- Prunes and figs
Food that contains the sweetener sorbitol increase likelihood of constipation.
It doesn't have to be specific exercise - you'd be surprised what a difference just walking around can make to the bowel
A person with MS
Exercise is thought to be important as it helps to increase the muscle contractions within the gut, promoting transit along the bowel and improving your ability to pass waste.
Reduced mobility may create difficulty in getting to a toilet, which can also lead to constipation. Reduced mobility can lead to lack of exercise and, sometimes, weaker muscles – so staying as active as possible and finding and maintaining an exercise regime that works for you is really important.
Posture during bowel opening
The human body's natural posture for bowel opening is to squat. The nearest approximation is the 'brace and bulge' technique shown below:
Whilst sitting on the toilet, the knees are raised so they are higher than the hips (you can be use a footstool, or something similar to help); back is straight; lean forward, resting your elbows on knees, if possible; movement of stools can then be helped by bracing the abdominal muscles and bulging the abdominal wall outwards.
- Knees higher than hips
- Lean forward
- Put elbows on knees
- Bulge abdomen
- Straighten spine
Give it time
I like to have great things to read in the toilet – everyone comments and giggles when they've been there.
A person with MS
It is important to give yourself time trying to open your bowels. Try to find time when you are not rushing to do other things and a toilet where you feel comfortable and relaxed.
If, after twenty minutes, nothing has happened, stop and try again after the next meal or try the next day.
Abdominal massage before or whilst opening your bowels can help to encourage movement of stool through the gut ready to be pushed out. It can be used with the 'brace and bulge' position, as some people find 'brace and bulge' does not work on its own. Your MS specialist nurses or continence advisor can teach you how to do this.
Abdominal massage involves rubbing your stomach using the heel of your hand, or a fist to massage gently but firmly up the right side of your abdomen, across at the level of your belly button and down the left hand side of the abdomen. Regular use of an abdominal massage technique whilst lying on your back can also be beneficial.
Review your medicines
It is possible that medicines you are taking can cause or contribute to constipation as a side effect. Drugs for bladder symptoms, spasticity and depression as well as iron supplements and antacids can have this effect. It is therefore important to identify any of these and work with your health professionals to find alternatives if possible. Your bowel diary can help you monitor this.
How is constipation treated?
Many of the common over the counter laxatives are licensed for short-term use only and can become less effective if taken in the long-term. So it is important to work together with your MS specialist nurse, or continence advisor, to find the approach that works best for you.
Bulk forming laxatives include ispaghula (Fybogel,Isogel), methylcellulose (Celevac), sterculia (Normacol). These may be useful where dietary fibre cannot be increased and are used daily at regular times. A good fluid intake is essential. Overuse can result in sluggish stool transit.
Osmotic laxatives eg macrogol (Movicol, Laxido) or lactulose (Duphalac, Lactugal) work by drawing water from the lining of the gut to smooth out the stool and make it easier to pass.
Stool softeners eg docusate (Docusol, Norgalax) soften stool, making it easier to pass.
Stimulant laxatives eg senna and bisacodyl. A stool softener used on its own may not always be sufficient and a stimulant laxative may also be needed, especially in the case of a sluggish bowel. Senna and bisacodyl cause the muscles of the colon to contract more often, and with greater force. When the colon contracts, it moves the gut contents along more effectively. Stimulant laxatives take between eight and 12 hours to work. If you need help getting to the toilet it is important to plan the right time to use stimulant laxatives, so you that you know you can get to the toilet at the right time.
These suppositories and enemas are used to lubricate the stool to make it easier to pass or to stimulate the bowel to empty. They are an important part of a bowel management routine as they allow you to choose when to open your bowels.
These are solid bullet-shaped medications inserted into the rectum to help lubricate the stool and to stimulate the rectum to expel the stool. Several different types are available.
Fluids inserted into the rectum to stimulate emptying. Mini enemas can be inserted by an individual on a regular basis to help the bowel to empty. Larger volume enemas are usually given by a health professional and are used on an occasional basis only.
This uses warm tap water introduced into the bowel via the anus using a catheter or cone whilst the person sits on the toilet. The water helps to wash stool out of the bowel and encourages the muscles in the bowel to contract and push the stool out. It can be useful where someone has been unable to successfully manage their bowel with medication and toileting alone. Two systems are currently available on prescription (Peristeen or Qufora) but more are becoming available. Assessment and training with a suitable healthcare professional is essential before using transanal irrigation.
Last updated: 06 July 2017
Last reviewed: 10 March 2015
This page will be reviewed within three years