Constipation

What is constipation?

Constipation is a common symptom in MS, however a reluctance to report this symptom makes it difficult to assess just how many MS patients are affected.

However research suggests that 50-75% experience either constipation or faecal incontinence, sometimes a combination of the two. It is also documented that many MS patients also suffer IBS (Irritable Bowel Syndrome).

Constipation can be defined as ….

• Two or fewer bowel movements per week
• Straining for at least a quarter of the time
• Lumpy/hard stool for at least a quarter of the time
• A sensation of incomplete evacuation for at least a quarter of the time

Bowel control involves a complex and delicate coordination of many different nerves and muscles. In order to control bowel actions, it is necessary to be aware of the need to ‘go’. This awareness occurs when the faeces move into the rectum causing the rectum to expand. The finely tuned nerve endings are able to differentiate between whether the stool is solid, liquid or wind. However in MS the messages are often either lost or incomplete, leaving a situation in which it may be difficult to differentiate between the calls.

What causes constipation in MS?

Many MS patients take prescribed drugs such as some antidepressants, painkillers (especially the opiate based drugs), or drugs prescribed to help control bladder dysfunction particularly anti-cholinergics. These have many side-effects, constipation being one of them. Causes of constipation may vary from person to person including MS-related neurological damage, not drinking enough water (to avoid bladder difficulties) and limited physical activity due to weakness, fatigue, and spasticity.

How is constipation treated or managed?

There are many ways of approaching constipation management whether be it by conventional medical intervention or alternative remedies or self- management.

Treatments for mild constipation may include eating a high-fibre diet, drinking 2 litres of water each day, regular exercise for those who are mobile and developing a regular time of day for opening the bowels (the urge is strongest about half an hour after a meal and in the morning)

For more chronic constipation the following may be prescribed:

a) Bulk forming agents
When taken with water, these natural laxatives increase the bulk of waste matter in the bowel, making it easier to eliminate. They also soften the stools so that they are passed more easily. Bulk forming laxatives containing natural fibre include: Ispaghula husk or Fybogel®. This can work in the majority of people within 24 hours, also bran and sterculia.

b) Motility enhancers
These stimulate contractions of the muscles in the colon to reduce the time it takes for the passage of waste material through the bowel. These tend to work within 8-12 hours. Examples of motility enhancers are: Senna e.g. Senokot ® tablets or other preparations. This is a natural ingredient that has been used for centuries as a constipation remedy and its efficacy and tolerability are well documented. Senna works only on the colon, which is where constipation occurs. It usually works within 8-12 hours.

c) Other Stimulant Laxatives
Docusate Sodium is available in capsule and oral liquid form. Brands available are: Dioctyl® and Docusol ®

d) Osmotic laxatives
These act by promoting fluid retention in the bowel to keep the stools moist and easier to pass. Examples include:- magnesium sulphate e.g. Epsom Salts ®, lactulose or lactitol (synthetic sugars); another example being Movicol ® a powder which is mixed with water to make a drink.

e)  Other Treatments
As a last resort constipation may require the routine use of rectal suppositories or enemas. Enemas are only used if no other medication is working as overuse can lead to the bowel becoming dependent and not working properly without them. One such example is glycerol – this works by drawing fluid into the bowel, softening the stool and so easing constipation. As the glycerol suppository breaks down, it moistens and lubricates the passage of the stool. Inserted rectally, the suppository can also produce a mild stimulatory effect in the bowel. Glycerol suppositories can work in 15-60 minutes.

ALTERNATIVE REMEDIES.

These can include abdominal massage, biofeedback; also Reflexology and Acupuncture also have some convincing, albeit early, scientific evidence for effectiveness.

Some MS patients may consider the following :

a) Herbal Remedies

These include:-
Aloe, Cascara, Linseed, Psyllium, Senna, Alder Buckthorn, Basil, Buckthorn, Rhubarb, Chlorophyll, Linseed oil, Bladderwrack, Dandelion, Fenugreek.

b) Homeopathic Remedies.

These include :-
Bryonia, Calcarea carbonica, Causticum, Graphites, Lycopodium, Nux vomica, Sepia, Silicea (also called Silica) and Sulphur.

PERSONAL EXPERIENCES.

“This can be really embarrassing but as I lost all my dignity in childbirth anyway things couldn’t get much worse! I was seriously constipated followed by the biggest clearout ever. My GP gave me Novacol® to help with the constipation because after 20mins. of extreme exertion every day I was rewarded with a tiny rabbit pellet. However, since taking this, things are softer.”

“I don’t suffer too badly from constipation because I’m relatively mobile, drink lots of water and eat high fibre foods. However, I find if I go on holidays, the change of routine and diet can often make me constipated. Therefore regardless of whether I’m at home or away, I make –up a mixture of linseeds, pumpkin seeds, and various other seeds e.g. sunflower, which I sprinkle on my cereal every morning. When I’m away I take extra linseeds with me because a gel forms around them in the gut so easing the passage of food at a moderate pace and I don’t end up ‘running’ to the loo.”

“It’s as if my bottom has forgotten how to work properly, I had a few problems with constipation and all the pushing caused a little fissure. My GP gave me lactulose which works just fine.”

"I have Progressive MS and have really struggled with constipation; it reached a very serious point and I went to the doctors to get some investigations started. I have had a Colonoscopy, which failed and then a Barium enema which also failed to reach a conclusion.

The plan now is to repeat the Barium after a more aggressive preparation; although the concerns were that it may be cancer, it increasingly looks like it was impaction. This has been so severe that at times, I've prayed to meet my maker!

I don't rely on or take medicine and have tried many of the good things in life i.e. ispaghula, colonics, linseeds, roughage, tons of water, etc., etc.

My wife sort of remembered something about Linseeds and soaking them. What we are did was fill a glass, about a quarter full with Linseeds, then half fill the glass with boiling water; this was then left overnight and the next day a gel was produced. I have then been drinking the whole mixture and hey presto - I'm in action!

No dashing to the toilet, no cramp, no tiredness, things 'just happen'.

Absolutely marvellous!! "

© Multiple Sclerosis Resource Centre (MSRC)