in Multiple Sclerosis
Catherine W. Britell, M.D.
Bowel problems are very common in people with MS, but it is often difficult for people to discuss these issues with anybody, including their physician. With the proper care, many bowel difficulties can be prevented, and with the proper knowledge and assistance from a caring professional who understands functional problems associated with MS, nearly all bowel problems can be treated satisfactorily. It should be possible to acheive regular, efficient bowel emptying and maintain continence and dignity.
The types of bowel problems experienced in people who have MS vary, just like other MS symptoms. The most common problem seen is constipation. This may be characterized by hard, dry, pellet-like stools and may be associated with difficult or incomplete emptying. Some individuals may experience some bowel incontinence occasionally;often accompanying constipation and having gone a number of days without a bowel movement. Many people with MS (and also many without MS) experience hemorrhoids. These can get worse and quite painful if you have to sit for a long time straining on the toilet. Sometimes the stool gets stuck in an area of the colon or rectum. This is called an "impaction" and can actually cause runny diarrhea, when the colon is irritated by the impaction and runny stool leaks around the blockage.
These problems are caused by a number of things. First, the "gastro-colic reflex" (that normal urge to empty your bowels after eating...especially after breakfast or hot liquids) may be diminished. Second, the contractions of the gut that move the food along may become incoordinated...just like walking sometimes gets incoordinated. Third, there may be loss of sensation in the anorectal area, decreasing the normal "urge" to defecate. Therefore the person doesn't go to the bathroom when the stool is first in the rectum, and so it sits there and becomes drier and harder and more difficult to get out. Fourth, the anal sphincter can be spastic; not opening up easily to allow stool to pass. Fifth, lack of mobility (sitting in a chair all day) may decrease the rate of movement of the gut contents. Sixth, loss of muscle tone in the abdominal wall may allow the colon to increase in size and the stool to move along more slowly. Seventh, if a person gets depressed, this can also lead to constipation. And finally, many of the medications used to treat spasticity, bladder spasms, and other conditions associated with MS can be constipating.
The best way to treat bowel problems is to avoid them. The first and simplest thing to do is to manage your food and water intake optimally. A high-fiber diet is good for everybody. It lowers cholesterol, decreases the risk of cancer, AND keeps you regular in the bargain. For most people with MS, a little more fiber than usual is going to be necessary to enhance regularity. In general, a breakfast of bran cereal is a good way to start. In addition, it is recommended that a person have 4-6 servings of fruits and vegetables per day. All bread, cereal, and pasta products should be whole-grain. Besides keeping you regular, a predominance of whole grains, vegatebles and fruits in your diet will make it easier to control weight and also stay on a low-fat diet. If you can't eat whole grains and veggies for some reason, then a dietary fiber supplement may be indicated. It's important to remember, however, that particularly using the soluble fiber supplements, adequate water intake is vital...without adequate water, the fiber suplements will actually make matters worse. In general, the recommendation is that one drinks about 2 liters (eight 8-oz glasses) of water or other liquids per day. Plain water is considered the most healthy of these, because it doesn't have caffeine, sugar, artificial flavors, or other chemicals. The third preventive measure is going to the bathroom right after a meal and a hot drink at the same time every day (usually breakfast or supper). Oftentimes, "hanging out" there for 10-15 minutes, reading a magazine, rubbing the tummy a little, will bring about the desired results, even if the "urge" has eluded you. Most people find that a high-fiber diet, plenty of water, and a very-compulsive regular schedule will allow complete bowel emptying with good regularity and avoid accidents.
What do you do when you've already got problems? First, you need to have a relationship with a health care team that understands MS and will help you care for the functional problems you are experiencing. Second, there are some things you should avoid. Regular laxatives are your worst enemy. Your gut will get accustomed (akin to addicted) to them, and you will need bigger and bigger doses to get yourself going. Laxatives also cause cramping and can cause electrolyte imbalances if used chronically. A second thing to avoid is enemas or colonic irrigations. They also cause the bowel to slow down, and will also cause electrolyte imbalance if used regularly.
If, after going on a high-fiber diet, adjusting your drinking habits, and developing a very regular bathroom routine, you're still having problems, it may be time to add one or more medications. Because MS is a multi-system disease, many medications will have unusual side effects in MS patients. For this reason, it's absolutely necessary to discuss any medication you take (even over-the-counter medications) with your MS physician or nurse.
Some medications that have been helpful to varying degrees in people with MS include stool softeners (docusate sodium) and complex poorly-absorbable sugars (lactulose or sorbitol). Recently, selected patients have had some good results with cisapride, a medication that improves stomach emtpying and gut motility.
Sometimes using a suppository can aid in getting the stool started and making evacuation quicker and easier. A bisacodyl suppository after breakfast daily or every other day is often effective in getting things going. Once regularity is established, a glycerine suppository may be all that's needed. One problem with using bisacodyl suppositories is that they sometimes have a prolonged effect and can cause delayed stool leakage in people who have no sphincter control. . If the bisacodyl suppository doesn't work, sometimes a bisacodyl mini-enema is indicated.
Very rarely, somebody with MS has incontinence with runny stools. The first thing to look for in that case is a fecal impaction, which is an obstruction with stool running around it. If this has been ruled out, one needs to look for an infectious cause. If a person has been on antibiotics for a urinary infection, unusual organisms can set up housekeeping in the gut and cause diarrhea. This can be found by examining a stool sample for these bacteria and the toxins they make. If this is present, a course of a special kind of antibiotic will cure the problem. If loose, incontinent stools persist and no infectious cause can be found and corrected, they can be usually be controlled by the addition of soluble fiber and one of a number of medications to slow down gut motility. One should always talk to a physician before taking these medications, however, since they can cause serious complications if used in the wrong circumstances.
On the other end of the spectrum, a rare patient gets repeated fecal impactions in spite of doing all the right things, and this person ends up in the emergency room now and then to have the impaction removed. If this happens frequently, sometimes a colostomy is considered for that patient. In very rare cases, a colostomy is necessary to keep the patient healthy, comfortable, and out of the hospital. Most of the time, however, an understanding physician working together with a skilled and experienced rehabilitation nurse can get the patient "on track" and stop these episodes without resorting to surgery.
In conclusion, it's very important to discuss your bowel issues with your MS physician and nurse. Many of the difficulties people have with bowels can be prevented, and almost all can be treated satisfactorily. You deserve to have secure and dignified bowel control and be able to empty your bowels comfortably and efficiently.