Multiple Sclerosis Centers of Excellence
Bowel Dysfunction in Multiple Sclerosis
Lynne Walker, BSN, CRRN, MSCN
The symptoms of multiple sclerosis (MS) are unpredictable and vary from person to person. A common symptom that affects approximately 68% of people with MS is bowel dysfunction. People can experience bowel dysfunction when demyelination in the central nervous system (CNS) interferes with nerve transmission needed for normal bowel function. This demyelination can affect muscle groups, which are needed to produce normal bowel function. Other factors like slowed transit time of the intestines, muscle weakness, fatigue and lack of exercise can also contribute to the problem. Medications like sedatives/tranquilizers, diuretics, narcotics/analgesics, antidepressants, anticholinergics, antacids, iron supplements, and antihypertensives that are used to manage symptoms of urinary problems or depression might also alter bowel functions. In addition, many people with multiple sclerosis want to decrease their bladder incontinence by inappropriately limiting their fluid intake, which in turn increases their risk for constipation.
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The reasons for bowel dysfunction vary, but the usual bowel problems reported by people with MS are constipation, diarrhea and fecal incontinence.
- Constipation is the most frequently reported problem. The definition of constipation is infrequent (two bowel movements or less per week) or difficult elimination of stool. Slowed transit time, altered fecal composition, decreased ability to expel feces and altered ability to acknowledge the urge to defecate may all cause constipation.
- Diarrhea is less common than constipation and may even be a result of constipation. The definition of diarrhea is abnormal fluid stools. If hardened stool is retained, diarrhea may occur around the mass.
- Fecal incontinence is the involuntary passage of stool. Contributing factors include sphincter dysfunction, sensory loss in the rectum, medications and dietary problems.
The treatment for bowel dysfunction includes patient assessment, interventions, medications, and bowel reflexes. Following these four steps can aid in helping the patient experience a more normal bowel program.
Step 1: Assessment of the person’s history is the beginning of the treatment for bowel dysfunction, which includes:
- Frequency and type of bowel movements
- Usual time of day pattern
- Reliance on laxatives or enemas
- Current medications
- Comorbid medical conditions that may affect medications
- If assistance is needed for toileting, consider when help is available.
Step 2: Interventions should be designed to develop and maintain consistent emptying of the bowel. Use the following guide for dietary and fluid changes:
- A consistent habit and time of emptying (usually 1 to 3 days)
- Predictable bowel emptying
- Maintain a balance of stool that is easy to pass
- Provide for sufficient hydration with 1.5 to 2 liters per day of non-caffeinated, non-alcoholic fluids.
- Include 25 to 30 grams per day of dietary fiber. (*See Dietary Fiber)
- An exercise program shortens transit time through the gastrointestinal (GI) tract. Walking and active exercise are best, but when that is not possible, encourage as much activity as the person can do.
A dietary supplement that can aid in bowel emptying is a combination of several food products high in dietary fiber* blended together.
The “bowel recipe” to maintain consistent emptying of the bowel.
1 cup applesauce
1 cup unprocessed bran
½ cup of 100% prune juice
Dosage: 1 tablespoon at bedtime with an 8 ounce glass of water. Refrigerate mixture between uses. A dose in the morning can be added as needed.
*Dietary Fiber is an important component of bowel management to encourage consistent bowel emptying. Dietary fiber is beneficial in the management of both constipation and diarrhea. It's bulking action helps alleviate diarrhea and its softening action helps to prevent constipation. Fiber functions by binding water in the intestines in the form of a gel to prevent over absorption by the large intestines. This ensures that feces is bulky, soft and does not have delayed transit time. Delayed transit time generally results in constipation.
Chief dietary sources of fiber: whole grain breads and cereals, leafy vegetables, legumes, nuts and fruits. Increased fiber intake needs to be gradually introduced to allow the GI tract time to adapt. Too rapid an increase may result in flatulence, distention and diarrhea.
Step 3: Medications may be necessary if dietary and fluid changes are not adequate.
- Suppositories – act on colonic mucosa to produce peristalsis to initiate reflex emptying of the bowel (e.g. Glycerin, Dulcolax, and mini-enemas).
- Stool softeners – adjust stool consistency; usually the effects of stool softeners take several days after initial use (e.g. Dialose, Colace, and Surfak).
- Softeners with a laxative component may be used when additional softening or peristaltic stimulus is needed. They need to be given approximately 12 hours before the desired results (e.g. Dialose Plus, Pericolace, and Senokot).
- Bulking formers – these agents add substance to the stool by increasing its bulk and water content (e.g. Metamucil, Fibercon, and Citrucel, etc.).
- Osmotic laxatives such as Sorbitol, Milk of Magnesia and Lactulose act in both the small and large intestines to attract and retain water in the intestinal lumen increasing intraluminal pressure. These drugs may be an option for bowels that do not respond to other drugs.
- Enemas - a liquid solution in a hand held bottle/device that is inserted into the rectum to stimulate the colon to contract or to soften stool for easier elimination (e.g. Ducusol, Fleet, Naturplex).
Laxatives are oral stimulants that provide a chemical irritant to the bowel. Laxatives can become habit forming so should be used cautiously (e.g. Pericolace, Milk of Magnesia, Senna, and Dulcolax).
In addition, routine use of large-volume enemas can result in overdistended bowel. Changes in the bowel program may be needed, but changes should be one change at a time. Allow a 5 to 7 day trial period for each bowel program intervention.
Step 4: Routine reflexes can aid in managing bowel function. There are several methods to stimulate a routine reflex to empty the bowel. Stimulation techniques include mini-enemas and/or digital stimulation. After using one of these stimulation techniques the reflex to empty takes approximately 30 to 45 minutes. It is important that these stimulation techniques be used at the same time of day to help the body develop routine reflexes. It is most common to initiate this protocol after breakfast. Generally, the gastrocolic and duodenalcolic reflexes occur between 30 to 45 minutes after ingestion of a meal or drinking a hot beverage. The natural timing of reflexes needs to be considered when developing a bowel toileting routine.
- Mini-enemas are lower volume enemas that have an osmotic laxative effect that can promote stool evacuation (e.g. Enemeez, Ducusol).
- Digital stimulation is used to induce reflex contraction of the colon and relaxation of the anal sphincter muscle to facilitate defecation. A gentle clockwise rotation of the index finger against the anal sphincter wall for several minutes at a time can promote stool expulsion. This type of stimulation might need to be repeated until the bowel evacuation is completed.
Step 5: Colostomy is considered after the above interventions are ineffective in developing normal bowel function. A colostomy is a surgical operation that creates an opening from the colon to the surface of the body to function as an anus. The fecal matter is deposited in a bag that is on the outside of the body. This is not an uncommon medical procedure for some people with severe disease and/or slowed transit time. A colostomy can actually provide the much needed relief for patients and simplify care by caregivers.
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- Maintain regular mealtimes.
- Positioning aids help with elimination. An upright position allows gravity to assist in peristalsis and stool expulsion. In addition, having knees higher than the hips and feet flat on a surface (e.g. a small step-stool might work well) helps increase abdominal pressure to facilitate defecation. It also straightens the angle between the rectum and the anal canal to promote rectal emptying.
- Abdominal massage can also stimulate peristalsis. Massage the right groin upward, across and down to left groin.
- Breathing techniques can increase intra-abdominal pressure. By taking slow, deep breaths combined with abdominal muscle contractions (or leaning forward) help perform a Valsalva maneuver increasing rectal emptying.
Below is a guideline for medication dosages that are commonly used for bowel problems. This is only a guide, and should not be used until after a full patient assessment and disease evaluation is completed by a health care provider. The following list of recommendations will vary from patient to patient. For specific information on dosing refer to the pharmaceutical guidelines.
- Glycerin – daily or every other day
- Dulcolax – daily or every other day
- Mini-enemas – daily or every other day
- Bulk forming agents:
- Metamucil – 1 to 2 teaspoons daily, mixed in a glass of water or juice and followed by another 8 ounce glass of liquid.
- Fibercon – 2 tablets, 1 to 4 times per day. Follow with this dose with an 8 ounce glass of water.
- Citrucel – 1 tablespoon, 1 to 3 times daily mixed in 8 ounces of juice or water.
- Stool softeners:
- Dialose – 50 to 200 mg daily
- Colace – 100 to 400 mg daily
- Surfak – 1 every morning
- Softeners with a laxative component:
- Dialose Plus – 1 daily
- Pericolace – 1 to 2 every night
- Senokot – 0.5 to 2 grams once or twice per day
- Senna – 2 pills 1 to 2 times per day
- Dulcolax – 10 to 30 mg at bedtime
- Osmotic laxatives:
- Sorbitol – 1 to 2 grams per kilogram of body weight daily
- Lactulose – 30 ml every night
- Milk of Magnesia – 15 to 30 ml daily as needed
There are varieties of reasons people may experience a change in bowel patterns. People with MS will experience bowel problems at a higher rate than people without MS. Some of the reasons for bowel dysfunction include demyelination of the CNS, slowed transit times, muscle weakness, fatigue, lack of exercise and medications. The most common problems include constipation, diarrhea, and fecal incontinence. The treatment for bowel dysfunction includes patient assessment, interventions, medications, bowel reflexes, and colostomy. Treatments will vary from individual to individual and should be discussed with a primary care provider. In addition, a change in bowel patterns may not be due to multiple sclerosis. It is important that a full evaluation be considered for each case.
Date posted: May 2006
Last updated: July 2014