MS Constipation Treatment

Special thanks to our sponsors, Viatris & EMD Serono.

What is Constipation?

Constipation is a problem with passing stool. It generally means passing fewer than three bowel movements per week and is usually associated with hard, dry, or lumpy stool that is difficult or painful to pass. It can be accompanied by abdominal bloating and discomfort, tiredness and fatigue, and a loss of appetite. Constipation in a person with MS can also cause increased spasticity (stiffness). The most important factors known to promote constipation are reduced physical activity and inadequate dietary intake of fibers, carbohydrates, and fluids.

Constipation is a common symptom that affects half of individuals living with multiple sclerosis. In some cases, severe constipation is the first sign of multiple sclerosis. Individuals who suffer from constipation may also experience fecal incontinence, or uncontrolled loss of stool that is typically caused by loose stool that leaks around hardened stool that hasn’t passed out of the body. Fecal incontinence can also result from a loss of sensation in the rectum. Diarrhea is usually caused by factors other than MS. Although constipation is common, it does not have to be accepted as a normal part of your daily life. If you experience difficult passing stool, there are several different management options.

An important note before we dive into this discussion is that constipation or fecal incontinence should always be discussed with your neurologist or primary care physician. They will screen for “red flags” such as blood in the stool, unexpected weight loss, or unexplained changes in bowel habits. The presence of any of these symptoms would warrant specialized testing. Your medical team will also look at your medication(s) as a potential cause of bowel dysfunction. Many medications have side effects that impact our bowel habits and sometimes the way medications interact with each other could be the cause.

If your medical team is aware of your symptoms and there are no red flags or pharmacologic adjustments that can be made, you’re ready to take matters into your own hands. When deciding which management option(s) may work for you, let’s first discuss several things that must occur in our bodies to have a successful a bowel movement:

1. The digestive system must be intact and have connections with our brain and nervous system.
2. Hormone levels need to have the right balance to allow movement of the gastrointestinal (GI) tract.
3. The food and fluids we consume must produce the right consistency to create stool that can pass through our system.
4. We need to have access to a toilet and achieve a position and optimal level of relaxation to allow the stool to pass.

Now, let’s break down the top five ways multiple sclerosis can impair this process and what you can do about it.

1. The Digestive System is Not Communicating With the Brain and Nervous System

MS can cause a loss of myelin in the brain or spinal cord, which can prevent or interfere with signals between the bowel and the brain. This can coincide with something called pelvic floor dyssynergia which occurs when your abdominal and rectal wall contraction is not coordinated with pelvic muscle relaxation, which causes constipation.

TRY THIS:

• Relaxation techniques (see more on this below)
• Initiate a team approach with your neurologist and a pelvic floor physical therapist to develop a personalized treatment strategy.

Your neurologist and/or pelvic floor physical therapist may ask you to participate in an internal examination. This is an approach that will allow these experts to assess your pelvic muscle contraction and relaxation. The internal examination is an important part of evaluating the source of bowel dysfunction and can guide your treatment plan. With that being said, if you’re uncomfortable with an internal exam, there are other methods your team can use to evaluate and treat constipation or fecal incontinence.

2. Hormone imbalance from Stress, Menopause, Medication, or Nutrition

TRY THIS: 

• Prioritize getting a full, undisrupted night’s rest
  • Check out this article for Strategies to Improve your ZZZ’s

• Nourish your body with health-focused foods, including fiber and healthy fats, and avoid sugar
• Avoid smoking and alcohol
• Consider supplements and alternative medicines
• Participate in regular exercise, even if it’s only 10 minutes a day

Activity promotes digestion in a number of ways:

1. Activity increases our heart rate and respiratory rate, which improves blood supply and oxygenation to our organs (including our GI tract!) during and after activity
2. Activity increases abdominal contractions, which can support our digestive system in processing and moving stool through our digestive system
3. Activity helps maintain a healthy gut, allowing you to absorb nutrient better

3. Stool That is Hard to Pass or Runny

As mentioned earlier, constipation is common in people with multiple sclerosis because messages between the brain and the bowel can become mixed up, which can slow down the movement of stool through the bowel. A high-fiber diet can help promote bowel movements. Daily recommendations include both soluble and insoluble fiber from a variety of fruits, vegetables, legumes, and grains. Increase servings slowly, and make sure to drink plenty of fluids every day.

There are two types of fiber:

1.     Soluble fiber dissolves in water to form a gel-like material. Soluble fiber is found in oats, peas, beans, apples, citrus fruits, carrots, barley and psyllium.
2.     Insoluble fiber doesn’t dissolve and remains largely the same as it moves through the digestive system, increasing speed of passage. It’s found in wheat bran, vegetables, and whole grains.

TRY THIS:

•  It’s best to get fiber from food. But if you can’t eat enough fruits and vegetables to make a difference, then opt for fiber supplements, including psyllium, methylcellulose, wheat dextrin, and calcium polycarbophil.
•  For people with MS, it can be tempting to manage bladder problems by reducing fluids. But fiber must have water in order to sweep the colon and move the stool out of your body. Consuming 6-8 cups of water, mineral broths, and/or herbal teas daily can help keep you .
• Magnesium has been clinically used as a laxative for many years. It helps to increase the water content and volume of stool which helps with bowel movements by stimulating the intestinal wall and intestinal propulsive motor activity(5). The best dietary sources of magnesium are tofu, seeds, nuts, and green leafy vegetables.
• Flaxseed is commonly used to improve digestive health or relieve constipation. Flaxseeds contain soluble fiber, which dissolves in water and softens stools, making them easier to pass. Choose ground over whole flaxseed because the ground form is easier to digest. Like other sources of fiber, flaxseed should be taken with plenty of water or other fluids. Flaxseed shouldn’t be taken at the same time as oral medications. As always, talk with your doctor before trying any dietary supplements.
• Probiotics: Many parts of modern life can affect the gut microbiome, including high-stress levels, too little sleep, and eating a Western diet high in processed and high-sugar foods. This change in intestinal microflora may contribute to the rise of autoimmune diseases in humans, but probiotics can have powerful effects on digestion.  Cultured foods, including yogurt, kefir, miso, sauerkraut, kimchi, natto, and kombucha, provide beneficial bacteria that can help heal the gut and boost immune function. Consume at least one serving daily. Build up slowly if side effects occur.

4. Accessibility of Bathrooms

TRY THIS:

•  Download an app on your phone that will help you locate bathrooms on the go.
•  If you are concerned about accidents on the go, create a “go bag” consisting of a full change of clothes, body wipes, disinfectant wipes, and a small garbage bag.

5. Difficulty Relaxing When Going to the Bathrom

TRY THIS:

• Make your bathroom a relaxation station with candles and a squatty potty to help with optimal positioning, and practice diaphragmatic breathing on the toilet (deep belly breaths).
•  Try a bowel massage about 20-30 minutes before you try to have a bowel movement (or while you’re on the toilet if you’re really busy!)

For the massage:

1. Find a relaxed position – on your back if you have time to do this before you’re on the toilet or leaning back with deep breaths if you’re sitting on the toilet
2. Start at your lower right abdomen and perform small, clockwise circles with a moderate amount of pressure
3. Travel the massage up to your rib cage and around to the left side
4. Finally, go down and back around to the right side, ending where you started

The massage should feel good, not painful! You can do this over your clothes or with some lotion directly over your skin.

Bowel retraining programs help train the body to have regular bowel movements at a consistent time each day.

1.     Choose a regular time: Try sitting on the toilet 20–40 minutes after a meal, such as after breakfast or lunch.
2.     Be patient: Training your bowels can take time, so don’t worry if you don’t have a bowel movement right away.
3.     Spend time on the toilet: Sit on the toilet for 10–20 minutes.
4.     Don’t strain: Don’t strain while trying to have a bowel movement.
5.     Repeat: Repeat the process every day until you develop a consistent pattern.

Keep a diary: Keeping a diary of your bowel movements and what you eat and drink may help identify what helps or contributes to constipation.

Lifestyle improvements relieve constipation for many people. But, if constipation continues after making these changes, the next step may be a mild laxative. Laxatives can help relieve constipation; however, regular use of laxatives is not recommended because they can cause problems like diarrhea, dehydration, and damage to the digestive system. Instead, a multi-level strategy that combines medicinal and non-medicinal strategies is recommended. Even though many laxatives are available without a prescription, it’s important to talk to your healthcare team first. They can help decide the safest kind of laxative for you.

 References

1. Arnaud MJ. Mild dehydration: a risk factor of constipation? Eur J Clin Nutr. 2003 Dec;57 Suppl 2:S88-95. doi: 10.1038/sj.ejcn.1601907. PMID: 14681719.
2. Preziosi G, Gordon-Dixon A, Emmanuel A. Neurogenic bowel dysfunction in patients with multiple sclerosis: prevalence, impact, and management strategies. Degener Neurol Neuromuscul Dis. 2018 Dec 6;8:79-90. doi: 10.2147/DNND.S138835. PMID: 30584387; PMCID: PMC6287516.
3. Parikh A, Thevenin C. Physiology, Gastrointestinal Hormonal Control. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537284/
4. Khera, A. J., Chase, J. W., Stillman, B. C., Salzberg, M., Thompson, A. J. V., Basnayake, C., … Kamm, M. A. (2022). Pelvic floor behavioral treatment for fecal incontinence and constipation in quiescent inflammatory bowel disease. Scandinavian Journal of Gastroenterology, 57(7), 807–813. https://doi.org/10.1080/00365521.2022.2039280
5. Mori H, Tack J, Suzuki H. Magnesium Oxide in Constipation. Nutrients. 2021 Jan 28;13(2):421. doi: 10.3390/nu13020421. PMID: 33525523; PMCID: PMC7911806. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7911806/
6. https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/expert-answers/flaxseed/faq-20058354