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Bowel Management in Multiple Sclerosis

Megan K. Raverty, MD

Bowel function is not something most people want to bring up in casual conversation. The topic might be uncomfortable or embarrassing, especially when things aren’t working as they should. But having a conversation about bowel function with your MS team is very important in helping you manage your symptoms and improve your function.

Most people with MS who experience bowel problems have constipation, or report feeling “bound up” and have difficulty with regular bowel movements. The reason for this is related to your central nervous system (CNS), which is your brain and spinal cord. Together, the CNS speeds up or slows down the digestive process in your bowels. When the communication between your CNS and your bowels is disrupted, as it is in MS, the bowels tend to “slow down” and constipation can result.

Fortunately, there are many approaches and medications that can help with MS related constipation. For some people with MS, managing their bowels is as straightforward as making time to have a bowel movement at the same time every day. This is best done after a meal because this is when your gut becomes more active and begins the digestion process. Sometimes, people need more help with managing constipation, which is called a bowel program.

Simply put, a bowel program is a combination of medications and routines that helps a person with MS related constipation have bowel movements regularly and lessens the chance of incontinence, or accidents. The first part of a successful bowel program is maintaining a regular, healthy diet including consistent amounts of fruits, vegetables, and fiber as these can affect how quickly or slowly your bowels move. Consultation with a registered dietician, a person who is trained to help people manage their diets to meet their health goals, can be valuable in managing your bowels. They can give you suggestions specific to your needs and situation that can help keep your bowels regular.

When diet changes alone aren’t enough, medications can be added to a bowel program. Medications for a bowel program tend to fall into one of two major types: oral or rectal. Oral medications are most commonly used. Oral medications might be in pill form, or as a powder that is mixed with liquid which you drink. Oral medications can be taken by mouth or given through a feeding tube if a person with MS is unable to swallow. The goal of these medicines is to speed up bowels (a “stimulant”) or to keep stools from becoming too hard (a “softener”). Some people may only need one type of oral bowel medication, while others may use a combination of several types.

While many people have success with oral medications alone, others might need rectal suppositories or enemas. A suppository is a round or cone-shaped medication that is put into the rectum, or end of your intestine where stool exits. An enema is a liquid that is put into the rectum. The goal of both types of medications is to stimulate or speed up the bowels so that you have a bowel movement shortly after they are used. If an enema or suppository is needed, the time of day that it is given is important. The bowels are most likely to move after a meal, so most people use an enema or suppository after breakfast or dinner. While which time of day works best for a bowel program can be different for different people, being consistent with the time of day is important. Taking your medications at the same time each day improves your chances of success and makes accidents less likely over time. Think of it as “training” your bowels to move at a certain time each day, and taking your medications as prescribed to match that time.

While constipation is the most common pattern of bowel dysfunction in people with MS, the opposite can also be true and bowel function can actually “speed up”, causing loose stools, diarrhea, and incontinence. Sometimes, loose stools are caused by foods in your diet. Common foods that can contribute to loose stools are spicy foods, fatty or fried foods, certain fruits high in a type of sugar called fructose, and foods or drinks that have caffeine in them, such as chocolate, coffee, and alcohol. In this case, simply avoiding these foods can be helpful. Additionally, fiber can be helpful in making stools less loose.

Loose stools or diarrhea can also be caused by taking too many bowel medications. In that case, it is helpful to talk to your medical team about how to manage your medications to avoid loose stools while still having regular bowel movements and avoiding constipation. If this doesn’t help, in some cases, other medications can also be prescribed to help slow down your bowels. However, you should talk to your provider before starting any over-the-counter medications to slow down your bowels, because these can cause constipation if not used correctly.

While both constipation and loose stools can happen in people with MS, it is important to note if you have changes to your particular pattern. That is, if you usually have constipation and are now having loose stools, this can mean something else is causing it or you are not on the right bowel program. Your health care team can help you figure out the cause and make changes if needed.

In summary, while changes in bowel function related to MS may be frustrating or embarrassing to talk about, a conversation with your MS team is an important one to have. There is no “one size fits all” solution to managing bowel function in MS but working closely with your providers can help you find a way to manage these issues in a way that works best with your life.