An Overview of Constipation in Multiple Sclerosis

One of the more uncomfortable and unpleasant symptoms in multiple sclerosis (MS) is constipation. It can be chronic, in some cases, and it can be painful. It's estimated that between 50 percent to 75 percent of people with MS experience constipation at some point. Still, it tends to be under-reported. This is probably due to many factors, such as:

• Patients not connecting this symptom to MS, so not reporting it to their neurologists
• Patients being focused on more significant symptoms during their neurologist visits
• Patient being too embarrassed to report constipation to their doctors

Constipation includes one or both of the following symptoms:

Constipation that is not managed can result in fecal impaction, which happens when constipation is so severe that the entire rectum becomes filled with a large, hard ball of stool.

There are two components involved in healthy, regular bowel movements:

When the stool slows down on its journey through the intestines (especially the colon, the last part of the large intestine), water is absorbed to make the stool solid. When it slows down too much, too much water is absorbed by the colon and the stool becomes hard and difficult to pass.

There are a few common causes of constipation in people with MS.

In people with MS, lesions may prevent the brain from accurately receiving or transmitting signals that control conscious attempts to have a bowel movement. In other words, you may not be receiving the message that you “have to go,” or you may be unable to effectively relax and push as needed to have a bowel movement. The involuntary movements that keep the stool moving through the lower parts of the digestive tract may also be impaired.

Again, these problems are compounded by the stool being too hard to pass easily, due to prolonged time in the colon.

An important component of intestinal motility (the movement of digested food through the intestines) is physical activity, such as walking. Many people with MS are unable to move around and walk much due to weakness, spasticity, sensory ataxia, or fatigue.

Constipation is a side effect of many of the medications that people with MS take to control symptoms. These include:

• Antidepressants, especially tricyclic antidepressants including Elavil and Endep (amitriptyline), Norpramin (desipramine), Sinequan (doxepin), Tofranil-PM (imipramine), and Pamelor (nortriptyline)
• Painkillers, especially those containing morphine or codeine, as well as other pain-alleviating drugs like Ultram (tramadol)
• Medications for bladder dysfunction called anticholinergics like Detrol tablets and Detrol LA extended-release capsules (tolterodine)
• Medications for spasticity, including Lioresal (baclofen) and Zanaflex (tizanidine)

It's common for people with MS to cut back on water, especially if they experience problems with urinary urgency or nocturia. Some people with MS also reduce fluid intake when they are going out or traveling, as getting to a restroom may be difficult. It's important to drink plenty of water throughout the day if you have MS. Avoid caffeine and alcohol, which act as diuretics and can dehydrate you more.

Diagnosing problematic constipation can be tricky, given that people have varying bowel habits. Your doctor will do a general physical exam and ask you about yours and if they have recently changed.

There are also several tests and procedures used to detect and diagnose bowel problems. Here are a few that may be indicated in someone with MS:

• Anorectal manometry: In this procedure, your doctor inserts a narrow, flexible tube into your anus and rectum and then inflates a small balloon at the tip of the tube. The device is then pulled back through the sphincter muscle. This procedure allows your doctor to measure the coordination of the muscles you use to move your bowels.
• Balloon expulsion test: Often used along with anorectal manometry, this test measures the amount of time it takes for you to push out a balloon that has been filled with water and placed in your rectum.
• Colonic transit study: In this procedure, you may swallow a capsule that contains either a radiopaque marker or a wireless recording device. The progress of the capsule through your colon will be recorded over several days and be visible on X-rays. Your doctor will look for signs of intestinal muscle dysfunction and how well food moves through your colon.

Treatments for constipation include stool softeners, fiber supplements, and rectal suppositories. Laxatives can also be helpful, but discuss options with your doctor before taking them, as some may cause dependency.

In cases of fecal impaction, you may be given an enema, or a doctor or a nurse may have to remove the blockage manually (using a gloved finger).

Constipation is common in MS, but the good news is that there are things you can do to prevent it or at least reduce it. Strategies include:

• Drinking six to eight glasses of water daily
• Incorporating fiber into your diet, including whole grains and a wide variety of fruits and vegetables
• Staying active as much as possible
• Establishing a time each day to use the bathroom; this is called bowel training

Lifestyle strategies are usually effective for managing constipation. If symptoms are frequent or chronic, don't delay seeing your doctor. In some cases, constipation can be a sign of something more serious, like colon cancer.