Managing constipation

What is a healthy bowel movement?

What people think of as a healthy bowel movement tends to be based on personal experience and what they are constipation brought up to believe. In reality, there is a big range of what is considered ‘normal’.

Some people will pass stool every day, but a bowel movement every second day may be your routine, as can opening your bowels every few days, or having up to three bowel movements in a day. An interval of more than three days between going to the loo will cause most people discomfort. Yet for many people with MS, intervals between bowel movements can be a lot longer than three days, and they may also feel the need to strain.

People can mean different things when they talk about constipation. Symptoms include the following. While most people will not have all of these, a combination is possible:

infrequent bowel actions

hard pellet stool

straining

bloating

abdominal pain

sense of incomplete emptying

excessive wind

Providing it is not causing problems, not going for a few days is not a cause for concern.

If you have concerns talk to a health care professional

Bowel problems are among the hardest things to talk about. But if you do have problems, do talk to a health professional – your GP, MS nurse, neurologist or a continence adviser – and try to make yourself understood.

You will need professional help to work through some of the different stages of managing bowel problems. Five general measures for treating constipation

If people with MS are constipated, they are advised to begin with the general measures for treating constipation. These general measures are associated with achieving regular bowel movements.

Good fluid intake

The generally recommended fluid intake is approximately 10 cups (1.5 to 2 litres) per day. People with MS need to maintain a good fluid intake to help treat and prevent constipation, and this will require management of any MS bladder symptoms. Bladder problems in MS can almost always be managed effectively although high fluid intake may require, for example, more frequent visits to the toilet or more frequent self-catheterisation.

Caffeine: Caffeine in tea and coffee may irritate the bladder, and caffeine-laden drinks also have a diuretic effect and may make you fluid-depleted and dehydrated. For some people, however, coffee may stimulate bowel movements, though it is preferable not to rely on caffeine-laden drinks as your main source of fluids. Decaffeinated coffee can stimulate bowel movements almost as effectively as regular coffee, so may be worth a try.

Healthy-eating diet

A healthy-eating diet is recommended for the population as a whole to reduce the risk of heart disease and some cancers. It is also the kind of diet that dietitians generally recommend for people with MS as the best overall recipe for good health. Two main principles of a healthy-eating diet are to cut down on saturated fats and eat ‘five a day’, that is, five portions of fruit and vegetables every day. A healthy-eating diet can help you achieve regular bowel movements.

Fibre: Generally, it is good advice to eat more fibre, found in cereals and in fruit and vegetables. Fibre helps to keep stools bulky, and this can stimulate the bowel. Some people with MS who have mild constipation may respond to high-fibre cereals, perhaps taken with other high-fibre foods like dried fruit, nuts or seeds, for example. For people with severe constipation, however, fibre in unprocessed bran, for example, may not help waste move through the colon any faster and could lead to bloating.

Then it can be preferable to get your fibre from fresh fruit and vegetables, and include high-fibre foods like prunes (or prune juice), figs, other dried fruit, linseeds and nuts in your diet. It can be trial and error to find foods that make your control better or worse.

Activity and exercise

Moderate and appropriate exercise can benefit people with MS, and generally the advice is to tailor exercise to suit the individual. If you are unsure how to start, perhaps because of fatigue, effects of heat or poor mobility, you can get advice from a neuro-physiotherapist or an occupational therapist. Exercise can stimulate the gut, and regular bowel habits are associated with exercise and activity.

Regular and comfortable routine

Try to schedule a regular time to go to the toilet, and make use of the reflex (gastro-colic reflex) that can stimulate a wave of contractions in the bowel. Some advisers say that 20 to 30 minutes after breakfast is the best time. Or you might schedule a regular time after coffee or a hot meal. It can take time to develop your own routine. It is advisable to have things arranged so you can take your time (and have privacy), but not to spend endless time in the toilet straining. If the bowels do not open, try again at the same time next day. If you depend on other people, your bowel care will need to be planned carefully.

A toilet also needs to be fitted out so you can feel comfortable and stable. It is most natural for humans to squat to pass a stool. When sitting on the toilet, try to rest your feet on something about 8 to 10 inches (20 to 30 centimetres) high so your knees are above waist level. Keep your feet about 1.5 to 2 feet (40 to 60 cms) apart.

When going to the loo, relax and breathe normally. Don’t hold your breath and strain, or you will cause your anus to become tense. Bracing your abdominal muscles is best done with your hands on your waist. (As the muscles tighten, you should feel your hands being pushed out sideways.) Concentrate on relaxing the anus to allow the stool to pass. Do not push from above without relaxing the anus below.

Medication review

Together with your doctor, review the drugs that you take. Some types of drugs commonly taken in MS are known to cause constipation, and it may be possible to switch to a similar drug that you find more agreeable, or vary

the dosage. Or you may be able to do something to compensate, like alter your diet, for example. Among the drugs that can cause constipation are:

Drugs used to treat over-active bladder in MS: These are anti-cholinergic drugs, of which there are many, such as oxybutynin (brand name Ditropan) and tolterodine (Detrusitol, Detrol).

Anti-spasticity drugs used to treat muscle stiffness and spasms: These include baclofen (Lioresal).

Anti-depressants: In MS, these are used frequently to treat a number of MS symptoms, as well as depression. Again, there are many different types of anti-depressant drugs from which to select.

A medication review should also include any ‘over-the-counter’ supplements or self-medication you use. Drugs that might contribute to constipation include some medicines to treat heartburn, high blood pressure and heart problems, and painkillers containing codeine. A preparation containing iron (such as a multivitamin tablet) can also be constipating.

Compliments of:MS Society, UK