Constipation

Many people with multiple sclerosis experience bowel problems. One common problem is constipation which is 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.

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 fatigue, and a loss of appetite.

It's 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 it takes for waste to travel through the colon (known as transit time), the harder and smaller your stools become.
• Reduced sensation in the back passage (rectum) can lead to a loss in awareness that you need to empty your bowel, so that stools remain in the back passage for longer. This can make constipation worse and potentially result in overflow incontinence. This is where loose, diarrhoea-like fluid passes around a hard plug of impacted stool.
• Weakness or lack of coordination of the anal muscles, 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 back passage – which might have been caused by excessive straining on the toilet, during childbirth or because of heavy lifting – can also cause difficulties.

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.

The aim of managing constipation is to produce stools that are not too hard or soft, and allow you to empty your bowels more easily (and effectively) on a regular basis. Some tips for improving constipation include:

Eating regularly is good stimulation for your 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.

Making sure you have enough fibre in your diet can 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.

Adequate amounts of fibre in your diet 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 (eg bran-based breakfast cereals). Soluble fibre dissolves in water and becomes a gel-like substance when it reaches your stomach. Insoluble fibre on the other hand doesn't dissolve and remains largely the same as it goes through your digestive system.

Fibre from the recommended five portions of fruit and vegetables per day, with one or two portions of wholegrain foods, can help ease constipation. The fruit and vegetables may be fresh, frozen, tinned or dried. You can also increase the fibre in your diet by adding a tablespoon of linseeds or flaxseeds to your food. For people experiencing constipation, too much insoluble fibre (wheat or grains) can slow down the gut even further, so when increasing your fibre intake it can be useful to increase soluble fibre first (fruit and vegetables) and then increase insoluble fibre more slowly.

Any fibre should be increased gradually to avoid abdominal bloating or wind, and fluids should be increased alongside this. 

You can use a bowel diary to record any changes as you gradually alter your diet and monitor the effects these changes have.

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 which leads to harder stools.

Current recommendations are to drink at least 1.5 litres of fluid a day or about six to eight full glasses – ideally water rather than tea or coffee which can have a dehydrating effect. Your urine should be pale or straw-coloured; if it's a darker yellow than this, it can be an indication that you're dehydrated.

There are some foods and drinks that can overstimulate bowel activity or draw excess fluid into the colon. These include:

• alcohol
• drinks containing caffeine including tea, coffee, cola, hot chocolate
• prunes and figs
• food that contains the sweetener sorbitol increase likelihood of constipation.

Exercise is thought to be important as it helps to increase the muscle contractions within your gut, promoting transit of waste along the bowel and improving your ability to empty your bowels.

Reduced mobility and a lack of exercise can lead to weaker muscles and difficulty getting to the toilet, which can also lead to constipation. Staying as active as possible and finding and maintaining an exercise regime that works for you is really important. If you have limited mobility and maintaining a regular exercise regime is difficult for you, even standing for short periods during the week can help with constipation.

It's best to speak to a physiotherapist if you're considering a new exercise regime as they can advise on exercises that will best suit you and your ability.

The human body's natural posture for bowel opening is to squat. The nearest approximation is the 'brace and bulge' technique described below.

• Knees higher than hips.
• Lean forward.
• Put elbows on knees.
• Bulge abdomen.
• Straighten spine.

Whilst sitting on the toilet, raise your knees so they're higher than your hips (you can use a footstool, or something similar to help); keep your feet flat on the footstool and your back straight; lean forward, resting your elbows on knees, if possible. Movement of faeces can then be helped by bracing the abdominal muscles and bulging the abdominal wall outwards.

It's important to give yourself time when trying to open your bowels. Try to find time when you're not rushing to do other things and use a toilet where you feel comfortable and relaxed. Try not to force it and make sure you're not straining while you're on the toilet.

If, after ten minutes, nothing has happened, stop and try again after your next meal or the next day. Establishing a routine for emptying your bowels at a regular time that suits you is really valuable in managing constipation. Health professionals often call this a bowel management routine.

It's possible that medicines you're 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.

Abdominal massage before or whilst opening your bowels can help to encourage movement of stool through the gut ready to be pushed out. 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. The massage is best done in a semi reclined position for approximately ten minutes. Regular use of an abdominal massage technique whilst lying on your back can also be beneficial.

Many common over the counter laxatives are licensed for short-term use only and they can become less effective if taken in the long-term. They're usually taken orally either as a tablet or a sachet of powder that you mix with water and drink. It's important to work together with your MS specialist nurse or continence advisor to find the approach that works best for you. This might involve a little bit of trial and error to begin with.

• Bulk forming laxatives work in the same way as dietary fibre, increasing the bulk of stools. They may be useful if dietary fibre can't be increased and are used daily at regular times. A good fluid intake is essential. Overuse can result in sluggish stool transit. Examples of bulk forming laxatives include ispaghula (Fybogel, Isogel), methylcellulose (Celevac) and sterculia (Normacol).
• Osmotic laxatives make the faeces softer by drawing water from the lining of the gut to smooth out the faeces and make it easier to pass. Macrogol (Movicol, Laxido) or lactulose (Duphalac, Lactugal) are examples of osmotic laxatives.
• Stool softeners soften the stools by increasing their fluid content, making them easier to pass. Docusate (Docusol, Norgalax) is one example of a stool softener. 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.
• Stimulant laxatives 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 8–12 hours to work. If you need help getting to the toilet it is important to plan the right time to use stimulant laxatives, so that you know you can get to the toilet at the right time. Senna and bisacodyl are both stimulant laxatives.

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.

• Suppositories are solid bullet-shaped medications inserted into the rectum to help lubricate the faeces and to stimulate the rectum to expel the stool. Several different types are available.
• Enemas are 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.

Transanal irrigation, also known as rectal irrigation, involves introducing warm tap water into the bowel via the anus using a catheter or cone whilst you sit on the toilet. The water helps to wash faeces out of the bowel and encourages the muscles in the bowel to contract and push the faeces out. It can be useful if you've been unable to successfully manage your bowel with medication and toileting alone. There are a number of systems currently available on prescription, including Peristeen, Qufora, Aquaflush and Irypump. Assessment and training with a suitable healthcare professional is essential before using transanal irrigation. 

All of the treatment options listed above can be used as part of your bowel management routine which helps you to open your bowel regularly to avoid constipation.

• Bladder and Bowel Community - a charity providing information and support for people with all types of bladder and bowel related problems
• Continence Product Advisor - a website providing evidence based information on a wide range of continence products
• Bladder and Bowel UK - a charity offering advice, support and practical help for people with bladder and bowel problems, including information resources and a confidential helpline