Managing bowel issues

MS Plus acknowledges the traditional custodians of the land this podcast is recorded on, the Wurundjeri people of the Kulin Nation. We pay our respects to their Elders past and present. ​

Nicola: Welcome to the MS Education Podcast Series. Thank you for joining me. I'm Nicola Graham, and in each episode, we're going to be joined by an expert to discuss strategies for living well with MS.

Today, we're talking to Bridie Phillips, a nurse with our MS Nurse Advisor Service. Bridie is going to step us through everything we may want to know, and in some cases have been too afraid to ask regarding bowel issues and multiple sclerosis. So welcome, Bridie.

Bridie: Hi Nicola, thanks for inviting me to talk about bowel issues and MS. Unfortunately, talking about bowel issues continues to be an area that people find sensitive to talk about, yet it's an essential normal part of being a human being and vital for our health to manage this function well. There is so much that can be done to help if you're experiencing bowel issues and I really hope that this podcast opens the door to some suggestions.

Nicola: Well, Bridie, how common are bowel issues for people who've got multiple sclerosis and also, as a comparison, how many people in the general population have bowel issues, because it's not something we talk about and it's hard to gauge how common it is.

Bridie: Well, it is actually a common symptom for people with MS, with around 75 percent of people with MS experiencing some sort of bowel issue at some time, and according to a recent article in the BMJ Gut Journal, around 51 percent of people generally have irregular bowels and bowel issues. So, I guess, in that case, people with MS are definitely not alone.

Nicola: That's interesting, Bridie, that half the population are having bowel issues if you like. So, what is a normal bowel function? Do we have to go every day to be considered normal?

Bridie: Thanks, Nicola. That's a great question and I guess the best way to answer that is to talk about normal bowel function and how it actually works. So, bear with me for a minute while we go through it.

The bowel is, believe it or not, a five foot long tube which can also be called the colon or the large intestine, and it's our internal plumbing, so to speak, and it makes up the lower portion of the digestive system. So, the bowel takes the part of our food that can't be used in the body and makes it ready for disposal. So, the food we eat begins its journey at the mouth and proceeds down through the throat and oesophagus to the stomach. Major digestive action starts in the stomach and it's continued in the small or the upper intestine. The food which is moved through the digestive system by a propulsive action called peristalsis, which is muscles contracting, has become mainly waste and water by the time it actually reaches the bowel. By the time the stool reaches the final section of the bowel, called the sigmoid colon, it's lost much of the water that was present in the upper part of the digestive system, so that stool finally reaches the rectum, and on command from the brain, it's consciously eliminated from the body with a bowel movement through the anal canal. So, the rectum, which is the last four to six inches of the digestive tract, signals when a bowel movement's needed, so that remains empty until just before a bowel movement. So, the filling of that rectum sends a message to the brain via the nerves in the rectal wall that a bowel movement is needed and from the rectum the stool passes into the anal canal, guarded by a ring shaped internal and external sphincter muscle. Just prior to being eliminated, the stool is admitted to the anal canal by the internal sphincter muscle. That opens automatically when the rectal wall is stretched by a massive stool.

So, there's a lot of communicating going on with the brain here. The external sphincter on the other hand, that's opened by a conscious decision of the brain so that the bowel movements can be performed at appropriate times. So normal bowel functioning is usually three bowel movements a day, just three times a week. So, everyone's a little bit different. Now, despite the widely recommended one movement a day, physicians agree that such frequency is not necessary. The medical definition of an infrequent bowel movement is less often than once every three days. So, most physicians will agree that a movement less other than once a week is not adequate.

Nicola: Okay, thanks for clarifying that, Bridie, because there's a lot of misunderstanding and misinformation about that. So why do people with MS have bowel issues? What's going on or, what's not going on, so to speak?

Bridie: Okay, so bowel control is an extremely complex process that involves the coordination of many different nerves and muscles, and bowel problems in MS occur as a result of the disruption of messages between the brain and various parts of the digestive system. This causes problems with the sensation in the back passage and control of the muscles at the bottom of the anus and this results in problems like constipation and incontinence.

Bowel problems can also be made worse by other MS symptoms such as fatigue and spasticity. For example, fatigue might lead you to become less active, which then slows down the movement of waste through your colon, or similarly, spasticity might affect the muscle control and time which make going to the toilet more difficult. So, not all bowel symptoms are caused by MS. They can also be caused by other factors. It can be the side effects of the medication you're on, your diet, how much you exercise, and sort of other health conditions like irritable bowel syndrome, which is really common in general public anyway.

Nicola: Yes, and often people need to remember to keep hydrated and also to listen to that signal, don't they Bridie? You know when you get that signal to go to the toilet to make it a priority and, go.

Bridie: Yes absolutely.

Nicola: So, what are the common symptoms of a person with MS who's experiencing bowel issues? I know you mentioned constipation and incontinence.

Bridie: Yes, so the most common bowel symptoms are constipation. So having problems emptying the bowel or incontinence or a lack of control over the bowel opening leading to bowel accidents, but it's actually not uncommon for people with MS to experience bowel issues, both of those constipation and incontinence at the same time. Other presenting symptoms you might have very reduced peristalsis, so the muscles that contract to push the faecal contact through the bowel might be reduced. You can have a loss of sensation in the anus or rectum so you might find that faecal matter or wind might be passed without control, and there also might be some bowel leakage. Sometimes people with MS don't feel the urge to empty when the bowel is full, so sometimes you can get a bit of spasticity of the anal sphincters so that little muscle that is controlled to open and close to let the faeces in and out. It may not do that properly or give you the right messages to go to the toilet and a person might feel like they would like to go to the toilet, but they can't. Or, if the sphincter can't close properly, then the person might actually experience some incontinence or soiling. Sometimes you can have a loss of gastrocolic reflex, and this is where the act of eating helps stimulate the bowel.

And we know that that is strongest after eating breakfast, about 15 to 20 minutes after eating and then you can have a bit of spasticity of the colon, which is a little bit like irritable bowel syndrome, and the symptoms you get from that. I guess the biggest thing to note is that incontinence is a widespread condition and it affects so many Australians, so please don't feel alone or embarrassed to talk about it.

Nicola: Yes, and I think, because people don't talk about it, people don't get a gauge of how common this problem actually is, do they, Bridie?

Bridie: No, no, not at all, and the reality is that bowel function, as I've mentioned, is such an important integral part of our health, and if our bowel isn't working properly, it can make you actually really sick.

So, when you're severely constipated, I often talk to people and say it's a bit like having a compost bin sitting in your gut and you think about the ramifications of that happening and it explains why you feel really unwell and why it’s really important that you address these issues and any feeling of embarrassment, you’ve got to remember that your doctor goes to the toilet, the queen goes to the toilet, everybody else does, it is a normal body functioning that we need to be quite open about.

Nicola: So Bridie, what can a person do to better manage these bowel symptoms that you've mentioned?

Bridie: Okay, so bowel problems can be a source of embarrassment and discomfort, so it's important to work with healthcare professionals to evaluate the cause and to find solutions. So obviously, we need to work out what is going on before we can come up with a really good management plan for it.

So, for predictability of bowel habits, we need to look at things like fluid, dietary fibre, and regular activity. So, the goal is to have a comfortable bowel movement every day or every other day. So mild laxative can sometimes be used if there hasn't been a bowel movement for three to four days. And some other really simple steps to increase bowel regularity. If you eat regularly for regular bowel habits, that's a good tip. Drinking at least six to eight glasses of fluids a day and increasing fluid intake, it's an important first step in avoiding constipation. And we're talking more about straight water here. Caffeine can be a stimulant, so we really need to get the water to be absorbed into the faecal matter. We need to increase our fibre intake to at least 25 to 35 grams per day. Natural fibre can be got through fresh veggies and fruits and cereals and breads made with whole grains and sometimes you can use dietary fibre supplements such as like psyllium or a bulking agent such as Normafibe and they can also really help but please note, if you're increasing your fibre intake, you need to accompany that with a fluid intake because if you have extra fibre without the fluid, it can actually make constipation worse.

Nicola: And I think we should just reiterate that because so many people don't appreciate that, that if you are increasing your fibre, please increase your water.

Bridie: Absolutely. Yes. You hear a lot of people who are taking their fibres and their bulking agents, but they're forgetting that really important liquid to go with it. Please make sure you do.

The other thing is that the bowel can be trained and you need to establish a regular time and schedule for bowel movements with no more than about two to three days between the movements. So, if you try and plan for a bowel movement each day, about half an hour after eating or drinking something warm, the emptying reflex is stronger at that time. So, if you sit on the toilet for about 10 minutes and try and have a bowel movement, gently rocking backwards and forwards can sometimes help. If nothing happens, leave the toilet, try again later. So, know when you're most likely to go to the toilet and try and listen to the signals that indicate that you need to use your bowel and don't ignore it. So, if you are out and about in the shopping centre and you sort of feel like, oh, something's happening, go to the toilet, don't hold on because you want to train your bowel to be able to go at those signals.

Nicola: And earlier on, Bridie, you said that that strongest peristaltic action happens just generally just after breakfast. So that's important for people to be more aware or try and establish a routine that allows them to go to the toilet half an hour after they've had a warm drink or breakfast in the morning if possible.

Bridie: Yes, yes, and ideally, I think everyone would like to go in the morning and feel refreshed for the day and know that they're okay, but everybody's bowels a bit different. You can use stool softeners, enemas, suppositories and laxatives in moderation, and they can help bowel movements, but I would always recommend that you consult a health professional around that because the different types of aperients and things that are out there all have a slightly different mechanism of action and it's really important to understand why you're having trouble going to the toilet to make sure that you're actually on the right combination.

The other thing to note is to know what your medications are and understand which of those could potentially cause constipation. So, if you're on painkillers that have codeine in it, we know codeine is a terrible binding drug for constipation. So, if you're on regular drugs with something like that, you would want to also include an aperient. So really important that you understand your medications.

It's important to keep mobile and do some exercise because obviously that keeps the circulation going, your muscles working really well, and pelvic floor exercises to strengthen muscle tones, not a bad idea.

Toilet positioning. Squatting position is the most effective for evacuation. So that means putting your knees higher than your hips, leaning forward, elbows on your knees, spine straight. It sounds like an exercise class, doesn't it? Bold your abdomen and pop your feet on a stool. You can actually buy squatty potties these days that actually attach to the bottom of the toilet and fold up, so they're designed exactly for this purpose, that you can put your feet on the stools.

Nicola: And I just have a little stool at my toilet just to make sure that my knees get higher than my hips and you're in a comfortable squatting position because we know that that is lends itself to much more easier bowel movements, don't we Bridie?

Bridie: Yes, absolutely. I mean it’s the same with voiding as well, you know, passing urine, it just works better. So, there's a lot of talk about this now, about positioning on the toilet, so if bowel incontinence or trouble pushing the stool out is experienced, sometimes just something simple like a glycerine suppository can be helpful to stimulate bowel activity. It takes about 20 minutes after putting the suppository in for the rectal wall to activate the bowels, so if you feel like there's something there and it's not quite coming through, that could be an option. But again, I would discuss that with a health professional first.

So, the bowels are a bit of creatures of habit and once a regular routine is working, it's really important that you try and maintain it. The other thing, it's really good if you keep a bowel diary, so you've got a record of fluid and food intake, as well as in any changes in bowel habits, so that we can look at Whether dietary or behavioural factors are contributing to those elementary problems, and including the amount of activity and exercise that you do is also really helpful. Putting things down, like if you've got diarrhoea, what you've taken, what's worked, what hasn't, and obviously if you do have diarrhoea, there are medications that can help with that. And there are such things called anal plugs.

So, if you have faecal incontinence, and you are leaking and you want to go out for the day, there are these things called anal plugs. It sounds really bizarre, but a health professional that really understands these problems will be able to speak to you more about that, and also, it's really important to have a proper assessment, even from the GP initially, to see whether you're impacted or constipated, because as I was saying, the treatment can be a little bit different.

And before you can get your bowel into a really good routine, we need to make sure we've got a clean slate and that bowel is clear, so then we can start with a nice clean canvas and then try and establish a routine.

Nicola: So, what happens in a bowel assessment, Bridie?

Bridie: So, as we sort of mentioned, specific problems require specific solutions, so what they do is they look at your general health and your surgical history. They look at your mobility, so is it that you're struggling and you're having accidents because you are getting feeling to go to the toilet, but you can't get there fast enough, so what's the solution around that? Or is some of the issue that you can't clean yourself properly because of issues with your hands and your dexterity. And so, they look at all of that sort of thing.

They look at your medications and they take a list of that and have a look whether any of your medications might be contributing. They look at bowel and a fluid chart and a diet chart and this is where it's really good if you've already kept a bit of a diary and particularly if you're having some issues with, um, some memory. It's really good to have that all written in front of you so you can just present that to your health professional. They look at your social history, how your bowel issues are affecting your life, are you being socially isolated because of it, and what sort of impact this is having on you. They look at your smoking history, they look at your mental health history, they look at your bladder history. Often bladder and bowel and often sexual dysfunction often happen together, so, they will have a look at that. They have a bit of a feel of your abdomen, so they palpate it as we say, and they tap it and they can check for masses and tenderness.

They might do a bit of an anal check, to look for haemorrhoids, prolapses or signs of irritation. You know, sometimes if you're pushing really hard and, and you can't get something out, you may actually have some tears and things like that, so they make sure anal health is really good. They might do a rectal examination. They might do a plain x ray to see if you're impacted or actually see if you've got some faecal loading in your bowel.

And then they might actually refer you for further tests, like if you've got a prolapse, they might do a colonoscopy. They can do tests to check anal sphincter function, and this whole process can actually take a couple of hours, or it might be over a couple of sessions.

But it's really important to get that baseline to enable moving forward with a really good management plan.

Nicola: So, they're really assessing specifically what is affecting you so that they can make a specific plan accordingly.

Bridie: Absolutely. Yes. Yes. And it's so important because everybody's bowel is different, and habits are different. So, yes, it's like a tailored design management plan for your bowel.

Nicola: We are all very unique, aren't we? Yes, so Bridie, who do you talk to get specific help for your specific bowel issue? Where do we go to from here?

Bridie: Alright. First thing I would always recommend is GP. GP can start the ball rolling on a number of levels, including ordering plain x-rays and having a feel of your belly and that sort of thing, getting a bit of a history. And then they can make a decision where that needs to go, whether you need to see a gastroenterologist, talk to the neurologist, you can talk to continence nurses, we’re always available here just to sort of troubleshoot what's going on and make some recommendations where you should go.

There's also continence clinics in public hospitals and local community services, and the National Continence Helpline is a really good free service that can give you on the spot advice as well. I would always recommend a full continence assessment and management plan. But it depends where you want to start. So, if you're going through your GP, they will probably make recommendations from there where to go. There are continence aids available online. I think it's Independence Australia. You can buy pads and things like that in bulk, and they actually deliver.

It's also handy to have the national toilet map and a universal key if you're out and about and you need to use a toilet or you need a key to get into some of the public disabled toilets, you've got that. There's the CAPS scheme, which is the Continent Aids Payment Scheme, can help pay for some of the products that you might be using. NDIS, they can also arrange continent assessment and products. And I guess, if you're through the My Aged Care stream as well, you could probably organise some assessments through there as well. And I guess the biggest thing to remember is that no one needs to struggle with bowel symptoms and have them impact your quality and enjoyment of life. There's help available. So please speak up and get professional advice.

Nicola: Thank you, Bridie. Lots of great information and resources there for our listeners to tap into. So, thanks for your expertise. And remember you can speak to our nurse advisors here at MS on 1800 042 138.

Thanks again, Bridie.

Bridie: You are welcome.

Nicola: For more information on anything we've covered today, please get in touch with MS Connect on free call 1800 042 138 or email [email protected].

And don't forget to find the MS Podcasts on your favourite podcast player such as Apple, Google Play, Spotify, Overcast or you can access the podcast directly from our website ms.org.au.