Bowel program ms

It is important to remember that your daily fluid requirements will increase when you increase your fiber. If you have MS bladder problems you may consciously or subconsciously reduce your fluid intake. If you have MS spasticity or MS fatigue you may have become less active, and that cause constipation.

But it is vital that you incorporate exercise into your daily routine as this improves many MS symptoms, including constipation. Exercise will stimulate your abdominal muscles that in turn stimulate movement in the colon. Some people with MS climb mountains, win medals at the Paralympics or run marathons which is fantastic and inspirational — if you are not that way inclined, regular exercise might simply mean doing an activity that you find fun. Whether it is joining a yoga or tai chi class to encourage bowel movement, or sailing, bowling, horse riding or swimming for a full body workout, take a look at our exercise options for inspiration.

The great thing is that there are exercises to do at all levels which will help with a number of MS symptoms.

The key is for the activities and exercises to be enjoyable and regular so that you will see the positive results to help you to stay motivated. There are also changes you can make and successful treatments which will allow you to manage bowel incontinence and regain control.

There will also be some foods which make you produce a looser stool and this will also take some experimentation to find out which foods irritate and you can avoid. Common examples include:.

Dairy products. Keeping to a healthy weight will alleviate the pressure on your pelvic floor and reduce bowel incontinence. You can also do regular pelvic floor exercises along with a technique called biofeedback,which can help strengthen the muscles used to control the opening and closing of your bowels.

Strategies to reduce anxiety and stress are vital for your health and wellbeing and stress can worsen bowel incontinence. In fact, meditation is so important that it is one of the central elements of the Overcoming Multiple Sclerosis Recovery Program. Making lifestyle changes to help with bowel problems will also help to alleviate any stomach pain felt from constipation or diarrhea.

The OMS Recovery Program incorporates MS diet recommendations that are scientifically researched and will not only help any bowel problems, but other symptoms of MS too. Making sure that you eat plenty of fiber, engage in regular physical activity and drink more water will see improvements with bowel problems. This will relieve any stomach pain or discomfort, making you feel happier and more relaxed.

Participating in sports and fitness is one way of increasing physical activity but even just getting up and going out to school, work or leisure time activities if helpful. However you choose to be active, do it. Activity helps the mind as well as the body….

Sometimes health issues will not allow you to be as active as you once were. For example, if you develop a skin sore and need to be on bed rest, this decrease in activity will slow down the motility of your bowels. This can lead to constipation and other bowel problems.

If your activity level changes for any reason, expect that the bowel program will be affected, too. You may need to make adjustments in other areas to maintain the right bowel consistency for your injury level.

The medications you are taking may have side effects that can influence bowel elimination. For example, pain medications can cause constipation while antibiotics can cause diarrhea. Ask your doctor or pharmacist whenever you start a new medication about how it may affect your bowel function. Sometimes you may be using medications to help the function of your bowels. As with all medications, know the purpose, name, dose, frequency, and any side effects of the medication.

Being very consistent with the medications you take is very important and will help you predict the effect they will have on your bowel program. Your bowel program must be done at regular times in order for it to be successful. Therefore, it is important to use the same method at the same time each day.

Some people find the time, after the morning or evening meal, to be the most convenient and natural time for a bowel movement. This allows you to take advantage of the normal reflex function of the bowel that increases after eating.

The bowel program should last about one hour at most, from insertion of the suppository, if you use one, to clean up. It will take time to establish a regular bowel program and get your system set up on a regular schedule. It will be important to maintain a regular time for the bowel program to happen because your body will eventually get used to elimination at that time.

Try to keep your bowel program time within two hours of your scheduled time. If you skip it or are very late, you will run the risk of experiencing an involuntary bowel movement when stool comes out accidentally.

Sitting up during your bowel program is the best position so gravity can help in the elimination process. If you must be in bed for your bowel program due to illness, skin problems, or other reasons, then lie on your left side.

The large intestine empties to the left side of your stomach so if you must lay down to do the bowel program, laying on your left side works best. Many people use digital stimulation or aids to assist in the bowel program. When designing your own bowel program decide on the aids that you plan to use and stick with them.

The more consistent you are with every aspect of the bowel program the more consistent your results will be. Any change, no matter how small, can have a big impact on your bowel results. Decide how you will do the program and be consistent! Nails, both natural and artificial, should be kept clean and gloves used. Hands should be washed with each glove change. Polished nails should not be chipped or cracked. Fecal incontinence FI is the involuntary loss of stools or flatus for at least 1 month. Like for constipation, it is clinically very important to qualify accompanying stools consistency.

Patients with MS ranked bowel problems as the third most bothersome symptom after fatigue and issues with mobility. The experience of constipation will vary amongst patients with MS and the variables will be factors related to the extent of difficulty to evacuate, such as how long does the person need to spend on the toilet, if they need perineal or rectal stimulation, and if they regularly have problems with impaction requiring manual evacuation.

In a survey, it was found that a third of MS sufferers spend at least 30 minutes for their bowel toileting, 19 but in clinical experience it is not uncommon, particularly but not necessarily in the most disabled patients, that toileting takes most of the day in designated days of the week. In fact, some patients might hardly ever leave the house because of repeated attempts to open their bowels, or for the fear of FI. It only takes one occurrence of an episode of FI, no matter the initial reason, to propagate enough anxiety which may lead to isolation and self-imposed restrictions in order to avoid the risk of what an individual will see as embarrassment, shame, and humiliation if it were to happen.

Anxiety disorders and depression are mental states that become a part of the presenting complaint once NBD starts to manifest, and they are improved along with successful treatment. As such, these feelings may also contribute to patients presenting late, having persevered, endured, and managed the symptoms with gradual adaptation even as symptoms have progressed over time. Caregivers may inadvertently enable this behavior as they also adapt to the effects of NBD in order to be supportive and to avoid causing them distress, especially when the caregiver is a family member.

Ultimately, these patients are likely to become socially withdrawn, including reluctance to go and connect with friends or family, take holidays, and may become housebound as with each venture there is the need to plan access to toileting facilities.

Other concurrent symptoms, such as hemorrhoids, abdominal pain, fecal impaction, rectal bleeding, rectal prolapse, anal fissure, abdominal bloating, nausea, autonomic dysreflexia, and prolonged evacuation, can complicate NBD contributing to impaired quality of life 25 — 30 and aggravate the physical impact of NBD.

Food restrictions, in an attempt to avoid incontinence, can lead to weight loss. On the other hand, the inability to work can lead to a nutritionally poor diet. Effective treatment of NBD is indeed associated with a reduction in need for hospitalization, physician visits, number of urinary tract infections, and need for surgery, 33 with expected cost reductions. Normal bowel function is multifactorial and relies not only on the anatomical integrity of the bowel and its innervation, but also on hormonal factors and adequate nutrition, which in turn will affect consistency of intra-luminal content.

Furthermore, the ability to access the toilet and a behavioral component are essential in maintaining normal bowel function. Schematically, once the stools have reached the large bowel, effective colonic transit will allow manipulation of stool consistency, reabsorbing water and secreting mucous to form the stools. Mass colonic contractions will deliver the stools in the rectum, which acts as a reservoir.

Essential physiological attributes for effective rectal function are good compliance and ability to sense its luminal content. The rectoanal inhibitory reflex RAIR, Figure 1 will ensure that rectal content is identified at somatic level and released if and when it is perceived to be a socially acceptable time. Notes: Excitation peak: initial increase in the resting pressure is associated with sudden rectal distension. Excitation latency: duration from the point of excitation peak back to the baseline pressure.

Point of maximum relaxation: lowest point of resting pressure secondary to reflex internal anal sphincter relaxation. Recovery time: the duration between maximum relaxation and the point at which the resting pressure recovers to two-thirds its baseline value. Total reflex duration: calculated as the duration from the point of the excitation peak to the point where two-thirds recovery is observed.

Morphological abnormalities of the recto-anal inhibitory reflex reflects symptom pattern in neurogenic bowel.

Dig Dis Sci. Copyright Thiruppathy et al. The areas of the brain thought to be involved in gut function include the cingulate cortex, insula, thalamus, somato-sensory cortex, and prefrontal cortex.

The extrinsic innervation pathway to the bowel involves somatic and visceral sensorial fibers. Somatic afferents are via the pudendal nerve which innervates the external anal sphincter and provides anal sensation. Parasympathetic nerves of the sacral plexus S2—S4 are responsible for rectal sensation. Proximal colonic innervation is from the vagus nerve for the parasympathetic stimulating and sensorial component, whilst the thoracic spinal cord T5—L2 supplies inhibitory sympathetic fiber to the colon and rectum.

The internal anal sphincter has tonic sympathetic activity which helps to maintain the resting tone of the anal canal. The intrinsic pathway is called the enteric nervous system ENS which has two components: the myenteric plexus, which controls the smooth muscles of the gut, and the submucosal plexus, which regulates the secreto-motor and sensory components of gut function.

The ENS works to coordinate peristalsis, secretion, and absorption of luminal content within the gut. The spinal cord conducts signals from gut to brain and vice versa within the dorsal column and spinothalamic tracts. The act of defecation is the result of a coordinated reflex activity at spinal cord level, which is modulated and influenced by the cortex. However, the disease process can affect these pathways directly and at multiple levels. The role of the spinal cord in maintaining normal bowel function is evident, as NBD is almost invariably present in patients with a spinal cord injury SCI.

Most studies have focused on measuring alterations on the end organ, particularly the anorectal unit. Anal sphincter has been observed to be weak, and anorectal sensation has been shown to be reduced in some patients with bowel symptoms.

Rectal compliance is a measure of the ability of the rectum to distend, and its alterations are well documented cause of both FI 43 and constipation.

Crucial evidence in demonstrating the role of the spinal cord in determining bowel symptoms in patients with MS came from a study which showed that rectal compliance was altered in a predictable manner, depending on the clinical degree of spinal cord disease, and that patients with higher EDSS had a rectal compliance similar to that of patient with a supraconal SCI.

On the contrary, patients with low disability had rectal compliance similar to that of normal controls. Rectal sensation and the RAIR both depend on rectal distension and are thus related to rectal compliance.

Alterations of these three elements have been studied separately, but might in fact act in synergy. Pelvic floor dyssynergia occurs when abdominal and rectal wall contraction are not coordinated with pelvic floor relaxation, resulting in the inability to evacuate the rectum, and is commonly observed in patients with functional constipation.

The same might apply to MS patients, but it could also be a pelvic floor manifestation of spasticity and incoordination, and parallel to bladder detrusor dyssynergia. Improvement of pelvic floor dyssynergia can normalize colonic transit in idiopathic constipation, 52 and this goes to show how the function of the anorectal unit is clearly integrated with large bowel motility.

With regards to the activity of the more proximal large bowel, slow colonic transit is a feature which has been repeatedly observed. It is possible that this is secondary to anismus, but could be secondary to unopposed sympathetic inhibitory outflow due to spinal cord plaques 53 , 54 or secondary to a dampened gastrocolic reflex. Notes: Adapted from Preziosi G. Pathophysiology of Bowel Dysfunction in Multiple Sclerosis and the potential for targeted treatment [Doctoral thesis].

Copyright Preziosi. It is well documented that FI is considered a taboo topic by both patients and physicians, as observed in the general population. To compound this, bowel symptoms can be perceived to be less relevant within the bigger picture of their disease.

We have described the potential neuropathological mechanisms underlying bowel symptoms, but it should be always in the mind of the assessing physician or nurse its multifactorial nature and the need for a holistic assessment. Bowel function before MS diagnosis needs to be explored, including any history of an eating disorder. An assessment of diet and nutritional status includes evaluation of fluid intake, which is often restricted in order to prevent bladder symptoms.

Coexistent symptoms of foregut dysmotility should also be sought, asking for symptoms of early satiety and abdominal distension. Comorbidities should be carefully evaluated, including diabetes and a history of obstetric injuries. Given the common neurological pathways of pelvic organs, urogenital dysfunction needs to be adequately assessed. It should also be noted that a higher incidence of inflammatory bowel disease is observed in patients with MS.

A detailed drug history could reveal the use of constipating agents, particularly anti-muscarinic drugs and drugs used for spasticity such as baclofen. Polypharmacy in general can be a cause of constipation, whilst metformin, statins, and antibiotics might be responsible for loose stools.

In some patients, the need to open the bowels can present as abdominal pain and occasionally as the worsening of symptoms of spasticity. Evaluation of frequency of a bowel action and time spent in the toilet are important as well as stool consistency, and the Bristol stool chart can be useful.

Behavioral aspects need questioning, including multiple attempts to empty the bowel and toilet awareness, which is a need for the patient who is constantly mapping the presence of toilets, for example, on the route to work. Patients might complain of difficulty with wiping clean, which is a sign of incomplete rectal emptying. Symptoms of FI, including urgency, are often undisclosed and should be sensitively explored. Bowel symptoms in MS patients cover a spectrum, which includes at one end the extreme symptoms of obstinate constipation and at the other of complete passive FI.

In many patients, both constipation and incontinence can be present, and in fact correlated, as reduced rectal sensitivity will not provide any awareness of rectal fullness, with subsequent sudden onset of urgency resulting in FI.

With regards to physical examination, digital rectal examination DRE is crucial. It could reveal any complication of bowel dysfunction, such as hemorrhoids or fissures, as well as allowing to assess for the presence of hard stools or fecal impaction which are signs not only of constipation but is also causative of overflow diarrhea.

DRE also allows a crude assessment of anal sensation, as well as anal tone and squeeze pressure. Specialist tests are indicated in patients with severe or persistent symptoms. They include tests of anorectal physiology, which will give an accurate measure of somatovisceral anorectal sensation and anal sphincter pressures, colonic transit time studies, and endoanal ultrasound assessing integrity of the anal sphincters. MRI proctography is occasionally used to evaluate the presence of enteroceles or pelvic floor dyssynergia.

Accurate quantification of symptoms includes the use of a bowel diary for 2 weeks, which will avoid recollection bias and give both the physician and patient a realistic evaluation of frequency of symptoms. The Wexner Constipation and Incontinence scores give a good quantitative assessment and have been employed before with MS patients.

Other questionnaires, such as the St Marks Score, is more useful in a research setting. At present, the management of bowel dysfunction in MS patients remains unsatisfactory, 63 and much of the evidence available on the treatment of NBD comes from studies in patients with a SCI, with whom MS patients share many similarities.

Whether treatment has failed or not attempted yet, the aim is to develop a routine that works for the patient. The first step is to engage the patient and the primary caregiver in a process that might require trial and failure, with the understanding that any intervention might worsen symptoms and might not have a long-lasting effect.

Whilst occasionally success can be quickly and easily obtained with a laxative or anti-diarrheal prescription, the patient and caregivers, as well as the physician or nurse treating patients with MS, need to understand that improvement might require time, titration of medications, and changes in lifestyle. In other words, both health care practitioners and patients need to agree on embarking in a journey, and that it unlikely that one single visit will successfully address symptoms.

Manipulation of stool consistency if necessary is very important and can be achieved by modulating water and fiber intake. The balance to strike is between having enough fiber to have soft formed stools, preventing incontinence and constipation, and at the same time avoiding bloating, which can occur with excessive fiber intake or with the use of laxatives, in the presence of pan-gut dysmotility.

The presence of the latter can be only presumed but not always be established in the clinical setting, hence the importance of explaining this to the patient, so that fiber intake can be adjusted accordingly during the development of a bowel regime. A cautious use of a constipating agent can often significantly improve FI. The patient could then move to the tablet form, if more convenient, at the established dose. Anti-diarrheal agents should be available to be used as required when traveling or for social engagements.

Excessive caffeine, alcohol, or foodstuffs containing sorbitol can also cause loose stools. Strategies to maximize bowel emptying will prevent fecal impaction as well as incontinence and include maximization of laxative effect where required. Additional measures might include abdominal massage, using the heel of the palm in a right to left circular motion.

It should be remembered that addressing constipation will often ameliorate symptoms of FI if present, and so we will look at overall available treatment modality, rather than looking at treatment of a specific symptom. Scant evidence exists on the use of laxatives, mostly from studies of neurological condition or idiopathic bowel symptoms; however, clinical experience dictates that a laxative regime needs to be tailor made, as many variables affects their efficacy.

So regardless of the evidence, more than one laxative might need to be attempted before satisfactory effects are obtained. Therefore, it is important to explain to the patient, potential lack of beneficial effect as well as side effects, such as bloating or diarrhea, and that any occurrence should not be considered as a failure of treatment, but rather an important step of the trial and error process.

It is also important to underline that a positive effect from a laxative can be subjective, and could increase frequency of bowel action, amelioration of ancillary symptoms, or improved feeling of evacuation. The use of the osmotic agent lactulose should be cautious and used only in patients with very mild symptoms.

In fact, given the likely presence of pan-gut dysmotility, it is likely to cause or aggravate symptoms of bloating, due to fermentation and production of methane, as well as being ineffective. Polyethylene glycol equally acts as osmotic agent but does not rely on bacterial fermentation for its activation.

In patients with PD, it has proved to relieve constipation. A stimulant laxative such as bisacodyl has been shown to be very effective in patients with chronic idiopathic constipation. In clinical experience, these laxatives can work in MS patients when used in a stepwise approach in the order in which they have been mentioned.

The use of rectal stimulants or digitation can be employed. Bisacodyl suppositories act as rectal stimulants, having a very rapid onset of action as shown in patients with a spinal cord injury.

On average, laxatives take around 8 hours to have an effect. Therefore, within a bowel regime, they are taken in the evening, so that optimal effect can be achieved in the following morning. Efficacy will be maximized by the mass contractions, typical of the morning rising, and the gastro-colic reflex, as a result of breakfast and a hot drink. However, due to variability in gut transit time, the effects can be unpredictable.

Both patient and caregiver should observe this and implement a regime accordingly. A combination of different laxatives might be more effective, with or without the addition of a rectal suppository.

Prucalopride is a highly selective 5-HT4 agonist that has been shown to be effective in patients with chronic constipation. In non-neurogenic constipation, it increases colonic motility and thus improves colonic transit time, and can be considered as second-line treatment for constipation in patients with MS.