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Bowel management
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Bowel management

Date of issue: July 2012
This factsheet will be updated within three years

1. Introduction
2. How the bowel works
3. Common bowel problems in MS
3.1 Constipation
Causes of constipation
Management of constipation
3.2 Faecal incontinence
Causes of faecal incontinence
Management of faecal incontinence
3.3 Additional factors concerning bowel problems
4. Useful resources
5. References
1. Introduction
Bowel problems are commonly experienced by people with MS. Estimates vary about the number of people affected and the problem is thought to be under-reported. However, it is believed that around half of all people with MS experience bowel problems at some stage1,2. Bowel symptoms can be a source of considerable distress in MS, having an impact on quality of life, including self-esteem, sexuality and limiting ability to work. constipation and difficulty in emptying the bowel faecal incontinence and lack of control over bowel opening. It is not uncommon for people with MS to experience both constipation and Bowel control is an extremely complex process that involves the coordination of many different nerves and muscles. For people with MS, bowel problems are often accompanied by problems with mobility, spasticity and fatigue, which can present additional management difficulties. However, with the right information and support, the majority of bowel problems can be managed Though bowel problems are often difficult to talk about and can cause some embarrassment, there are teams of health professionals dedicated to the management of problems and support for people who experience them. It is important for people to know that they are not alone. The sooner help is sought, the sooner the focus can shift from the problem to the solution. Many hospitals, Primary Care Trusts (PCT), Clinical Commissioning Groups (CCG) and Health Boards now have a continence advisor, or continence nursing service, that deals specifically with bladder and bowel problems. To find these services, contact NHS Choices, or the Bladder and Bowel Foundation (see Section 4 - Useful resources). In some areas, people may be able to refer themselves to continence services, or MS specialist nurses and While bowel problems are a common symptom of MS, there can be other causes such as medication or other underlying conditions. It is therefore essential that any bowel problems are properly assessed by a continence 2. How the bowel works
In normal bowel function, digested food passes from the stomach into the small intestine where essential nutrients are absorbed into the body. The waste left after this process passes into the colon, where water is extracted before the waste is passed to the rectum to be expelled. When waste moves into the rectum, it stretches the rectum, triggering messages to the brain, thus causing an awareness of the need to evacuate - known as the 'call to stool'. The rectum is filled with sensitive nerve endings which can tell the difference between solid or liquid stool, or wind. In MS, these messages may be interrupted, affecting awareness of bowel movements3. Other bowel problems in MS may arise as a result of disruption between messages from the brain to Diagram of the bowel
3. Common bowel problems in MS
3.1 Constipation
Constipation can be defined as: "the passage of hard stools, less frequently than the patient's usual bowel pattern" 4. Constipation is common in the developed world. It is estimated that as much as one fifth of the adult population who consume a western diet, experiences constipation at some stage in their lives5. Although it is not fully understood how and why constipation happens in MS, research has identified a number of contributing factors, which may, or may Causes of constipation
Sluggish bowel/slow transit bowel
In some people with MS, waste travels through the colon more slowly than in those without MS6. This slower transit time is most likely explained by the disruption of messages from the bowel to the brain that occurs in MS, a lessening of general physical activity, lack of fibre in the diet and the use of multiple medications. As digested food moves through the colon, the slow transit of stools increases the amount of water that will be reabsorbed from the waste, making stools much harder, smaller, and more difficult to pass.  Reduced sensation in the back passage (rectum)
Some people with MS have reduced sensation in the rectum. This can lead to a loss in awareness of the need to empty the bowel, so that stool remains in the rectum for longer, allowing more water to be reabsorbed. This results in harder, smaller stools that are more difficult to pass.  Evacuation difficulties
Some people with MS have difficulty passing stool out of the rectum, although it may have travelled normally through the colon. This can mean that the stool stays longer in the rectum leading to constipation, or the rectum may become loaded with soft-formed stool. This can be caused by a lack of coordination of the muscles around the pelvic floor which control bowel emptying.  Lack of fibre in the diet
Dietary fibre is found in wholegrain foods such as wholemeal bread, weetabix, bran flakes and in fruits and vegetables. Fibre is not digested during its passage through the gut. It absorbs liquid and provides bulk for the stool. A bulky soft-formed stool stimulates the natural movements of the gut and helps to prevent constipation. Many people do not eat enough fibre in their diet and this contributes to constipation. However, individuals with slow colonic transit should not eat very large amounts of fibre as this can lead to even slower  Inadequate fluid intake
Some people with MS try to manage their bladder problems by reducing the amount of fluids they drink. This can lead to dehydration. To compensate, the body will try to reabsorb as much water as possible from food waste, leading to harder stools and increased likelihood of constipation. It is important to drink enough fluid. Current recommendations are 1.5-2.5 litres of fluid a day - about eight full glasses. The exact amount will vary according to weight and height, as the calculation is based on 30ml of fluid per 1kg of body weight7. Pale, straw coloured urine indicates an adequate intake It is worth discussing the amount of fluid needed with a continence advisor or MS specialist nurse, particularly if it causes, or increases, bladder problems.  Reduced mobility
Reduced mobility can lead to lack of exercise and, sometimes, weaker muscles. Exercise and muscle strength are thought to be important as they help increase the muscle contractions within the gut, promoting gut transit and Reduced mobility may create difficulty in getting to a toilet promptly, which can Needing help with toileting - 'performing' at the convenience of carers - can also create constipation problems, which need to be managed.  Medication
Many common MS medications list constipation as a possible side effect,  drugs used for bladder problems such as tolterodine (Detrusitol) and  drugs for pain management such as carbamazepine (Tegretol)  anti-depressants, such as amitriptyline (Triptafen) or imipramine (Tofranil), which may be prescribed for pain relief, and the selective serotonin reuptake inhibitors (SSRI) such as fluoxetine (Prozac) and  some dietary supplements such as iron and calcium tablets.  Other causes
There may be other causes of constipation. For example, many women experience changes in bowel pattern at times of hormonal fluctuation such as menstruation, pregnancy, or after the menopause. Management of constipation
There has been very little research into which management strategies for bowel problems are most successful in multiple sclerosis. Consequently, management is based on the experience of people with MS, as well as continence advisors. The experience of individuals with very similar problems due to other neurological problems, like spinal cord injury, can be helpful8. The main steps for managing constipation are:  Assessment of daily diet
This will particularly look at fibre and fluid intake and may involve keeping a food diary to record the effect of any dietary changes on symptoms. Fibre: Adequate amounts of fibre are necessary to maintain soft-formed
stools. However, the right type of fibre is important. For people with a sluggish bowel, too much wheat-based fibre (eg bran-based breakfast cereals) can slow down the gut even further. Fibre from the recommended five portions of fruit and vegetables per day, with one or two portions of wholegrain foods, should help with constipation. Increases in fibre should be introduced gradually, to minimise unwanted side effects such as bloating and wind, and should be accompanied by sufficient fluids. Fluid: Sufficient fluid intake is important. As discussed, exact amounts vary
from person to person. However, drinking enough to produce pale straw coloured urine throughout the day is a good indication of sufficient fluid intake. Remember, additional fluid is needed in warm weather.  Regular bowel habit
It is important that a continence advisor provides advice on how to develop and practise regular bowel routine. Often people will learn to open their bowels at a specific time of day. The most active time for the reflexes that help empty the bowel is around half an hour after a meal; the response is strongest  Give it time
It is important that people are not rushed when trying to open their bowel. If, after twenty minutes, nothing has happened, the person should stop and try again after the next meal (eating and drinking will stimulate bowel movement),  Posture during bowel opening
The human body's natural posture for bowel opening is to squat. However, this is no longer common in the western world. The nearest approximation is the 'brace and bulge' technique as shown in the diagram below: Whilst sitting on the toilet, the knees are raised so they are higher than the hips (this can be helped by using a footstool, a pile of telephone directories, or something similar); lean forward, resting the elbows on knees, if possible; movement of stools can then be helped by bracing the abdominal muscles and bulging the abdominal wall outwards.  Knees higher than hips  Lean forward  Put elbows on knees  Bulge  Abdominal massage
Abdominal massage can help to encourage movement of waste through the gut3. Abdominal massage techniques can be used with the 'brace and bulge' position during evacuation, as some people find 'brace and bulge' does not work on its own; this technique should be taught by an MS specialist nurse, a continence advisor, or other trained person. Regular use of an abdominal massage technique with the person lying on their back, can also be beneficial; this can either be carried out by a health professional, a partner, or the person  Review of existing medication and dietary supplements
It is possible that existing medication, or dietary supplements, are causing, or contributing to, symptoms. It is therefore important to identify any of these potential factors and to consider alternatives where available. Some, or all, of these steps should enable many people to manage constipation. For some people, additional help may be needed. There are treatments and medicines which can help with different problems. These should be discussed with the MS specialist nurse, or continence advisor, to  Bulk forming laxatives eg ispaghula (Fybogel,Isogel), methylcellulose
(Celevac), sterculia (Normacol). These may be useful where dietary fibre cannot be increased and are used daily, at regular times; a good fluid  Stool softeners eg docusate (Docusol, Norgalax) soften stool, making it
Osmotic laxatives eg macrogol (Movicol) or lactulose (Duphalac,
Lactugal) work by drawing water from the lining of the gut to smooth out  Enemas are fluids inserted into the rectum. 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  Stimulant laxatives eg senna and Bisacodyl. 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. Senna and Bisacodyl 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, thereby alleviating constipation. Stimulant laxatives take between eight and 12 hours to work. If assistance is needed with getting to the toilet it is important to plan the right time to use stimulant laxatives, as difficulties may arise with controlling the bowel.  Suppositories are capsules inserted into the rectum to help lubricate the
stool and to stimulate the back passage to expel the stool.  Trans anal irrigation (also known as anal irrigation or rectal irrigation) eg
Peristeen or Qufora. Trans anal irrigation is a system that can be used in the management of both constipation and faecal incontinence. The system works by introducing warm tap water into the bowel using a catheter or cone whilst the person sits on the toilet. This encourages the muscles in the bowel to contract and push the stool out. The system is only available after assessment by a qualified health professional, who will also teach the method of administration. (For further information see Section 4 - Useful 3.2 Faecal incontinence
Faecal incontinence - having no control over when the bowel opens - can happen in MS for a variety of reasons. This most embarrassing of symptoms is normally treatable, but needs proper assessment and management by a continence advisor or MS specialist nurse. Causes of faecal incontinence
Reduced sensation
Loss of or limited sensation can result in a lack of awareness of the need to empty the bowel. The first line of treatment is to establish a regular bowel habit. Further treatment will depend on the success of this  Constipation
Constipation that causes faecal incontinence is known as 'faecal impaction with overflow'. The rectum fills with hard impacted stools. Watery matter may leak round the sides, causing diarrhoea. Normal treatment is to clear the impaction first, usually with some form of laxative, suppository, or enema. Regular effective emptying of the bowel will help avoid build up of constipated stools and development of faecal impaction. However, this is not always successful. The MS specialist nurse, or continence advisor, may suggest a long-term management plan involving a combination of medicines and other techniques.  Other causes
When bowel control is impaired, excessive fibre in the diet or too much stimulant laxative can result in incontinence. When stool is loose the risk of incontinence is much greater, and gastrointestinal viruses can cause faecal incontinence. It is very important that the cause of any sudden episode of incontinence is correctly identified. Diarrhoea caused by a gastrointestinal virus may, or may not, need medical treatment, but should always be assessed by a GP. Here again, changes to diet and establishing a predictable bowel routine may help. Medication, such as loperamide (see below), may be helpful where all other causes of diarrhoea have been Management of faecal incontinence
Pelvic floor exercises, practised over a period of time, may help
strengthen the muscles around the anus and allow the individual greater control. These exercises are typically taught by a continence advisor.  Loperamide (Imodium) is a medicine that slows down the movement of
the intestine. Loperamide works by making the stools more solid and less frequent. It is essential to follow the advice of a continence specialist or  Trans anal irrigation eg Peristeen, Qufora (see p9)
Biofeedback retraining is a technique available in some specialist
centres. It aims to retrain individual awareness about bowel opening, diet and fluid intake. Biofeedback may be useful for individuals with relapsing  Surgery is an option for a few people with severe bowel incontinence that
cannot be managed in any other way. Surgery offered is normally a colostomy, which involves bringing the end of the bowel out through the wall of the abdomen, so waste is collected in a special bag. While for some people this can be a positive decision, it needs to be carefully discussed with the surgeon and continence advisor or MS specialist nurse. 3.3 Additional factors concerning bowel problems
There are a number of other factors that deserve consideration by people  Skin care
Caring for the skin around the anus is important. Barrier creams, such as Cavilon, can be useful in preventing discomfort if incontinence is a problem. Carefully washing and drying the area if the skin is soiled after a bowel movement, wearing loose cotton underwear that allows skin to breathe and avoiding perfumed soaps, creams and lotions, can all help. A continence advisor or MS specialist nurse will be able to advise.  Containing the problem
When all other ways of improving continence have been tried, pads and pants can help to deal with faecal incontinence. The Peristeen anal plug may help some individuals to retain stool. A continence advisor and organisations, such as Promocon, will offer guidance on the most appropriate continence products (see Section 4 - Useful resources). Commodes and bedpans are worth considering if urgency is a problem.  National Key card scheme
Disability Rights UK operates the National Key Scheme (NKS) that was previously run by RADAR. The NKS allows people with disability to use
around 9,000 accessible toilets throughout the country. Keys are available, for a small charge, directly from Disability Rights UK (see Section 4 - Useful resources), or in some cases from local authorities. A guide of NKS toilet locations is also available to purchase via the Disability Rights UK  Urgency cards
Urgency cards may prove useful as they explain why a person may need to use a toilet quickly. The 'Just Can't Wait' cards can be presented to give immediate access to a toilet when there are long queues, or if an individual needs to use a shop's facilities. Cards are available from the Bladder and Bowel Foundation (see Section 4 - Useful resources).  Mobile phone apps
Mobile phone apps have been developed to help locate the nearest toilet. For example, the National Key Scheme (NKS) app can show the location of the nearest NKS toilet. Coloplast provide a free app to help locate the nearest wheelchair accessible facilities. See Section 4 - Useful resources 4. Useful resources
Bladder and Bowel Foundation is a charity providing information and
support for all types of bladder and bowel related problems, for individuals, their families, carers and health professionals. They have a confidential helpline (0845 345 0165) staffed by specialist continence nurses and Website: email: Coloplast Limited. Manufacturer of Peristeen and other healthcare products
and services. For further information about Peristeen Anal Irrigation, call 0800 Colostomy Association. Charity offering support and care for people
contemplating or having undergone an operation, such as a colostomy. It provides a helpline (0800 328 4257) and has a network of regional support Website: Disability Rights UK, formed through a merger of RADAR, Disability Alliance
and National Centre for Independent Living, is a national organisation led by disabled people. They operate the National Key Scheme (NKS) that was NHS Choices. Website operated by the NHS, providing information on
medical conditions, healthy living, health news and regional health services. PromoCon. A national service, working as part of the Disabled Living charity,
offering product information, advice and practical solutions to both professionals and people affected by bladder or bowel problems, including a 5. References
1. Wiesel P, et al. Pathophysiology of bowel dysfunction in multiple sclerosis. European Journal of Gastroenterology and Hepatology 2001;13(4):441-448. 2. Bakke A, et al. Bladder, bowel and sexual dysfunction in patients with multiple sclerosis: a cohort study. Scandinavian Journal of Urology and Nephrology 1996; (Suppl) 179: 61-66. 3. MS Trust. Bowel dysfunction. In: MS Trust: Multiple sclerosis: information for health and social care professionals. Letchworth Garden City: MS Trust; 2011. 4. National Prescribing Centre. The management of constipation. Prescribing Nurse Bulletin 5. Cook T, et al. The conservative management of constipation in adults. Journal of the Association of Chartered Physiotherapists in Women’s Health 1999;85:24-8. 6. Norton C. Bowel management in multiple sclerosis. Gastrointestinal Nursing 2004;2(6):31- 7. British Dietetic Association 2007. Fluid – why you need it and how to get enough. [cited July 2012]. 8. Multidisciplinary Association of Spinal Cord Injury Professionals. Guidelines for Management of Neurogenic Bowel Dysfunction after Spinal Cord Injury. MASCIP: Middlesex; April 2009. 9. McClurg D, et al. Abdominal massage for the alleviation of constipation symptoms in people with multiple sclerosis: a randomized controlled feasibility study. Multiple Sclerosis 2011;17(2);223-33. 10. Wiesel P, et al. Gut focused behavioural treatment (biofeedback) for constipation and faecal incontinence in multiple sclerosis. Journal of Neurology, Neurosurgery and Psychiatry 2000; 69(2):240-243. Please contact the MS Trust Information Team if you would like any further information about reference sources used in the production of this publication.


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