A common area of dysfunction in MS is the lower intestine or “bowels”, affecting approximately 50% of people with the disease ¹.

     One form this dysfunction can take is bowel incontinence, or inability to control bowel movements. People who experience this symptom often fear they could have an “accident” at any time, without much warning. The opposite but not un33related form is constipation. Many people with MS experience both of these issues on a regular basis ².

     Normal bowel function depends on a network of signaling throughout the central nervous system (CNS) connecting the lower digestive tract to the brain. If this signaling is disrupted as in MS, the bowel may not get the go-ahead to empty at the desired time. This can cause a range of symptoms, especially with additional MS-related problems in the area, such as reduced sensation in the rectum (and thus recognition of the urge to go) or reduced control of the outer anal sphincter (the muscle at the end of the anal canal). If stool becomes loose for any reason (e.g., overuse of laxatives or gastrointestinal infections or irritable bowel causing diarrhea), bowel accidents are more likely because it is more difficult to feel and control the loose stool.

     Ironically, one of the most common causes of bowel incontinence is constipation. When a hard plug of impacted stool builds up in the lower intestine, a loose, watery, diarrhea-like fluid can pass around it and leak out when the inner anal sphincter finally opens and the pelvic floor relaxes to allow the muscles in the rectum to push the stool out – something known as “overflow incontinence.” Constipation can be worsened by inadequate fluid intake, a common problem among individuals dealing with bladder incontinence, which is can occur with bowel incontinence, as both result from impaired nerve signaling between the brain and pelvic area.

     Steps that may be helpful:

·       Keeping a journal of bowel activity and symptoms, along with the food and beverages consumed and other potentially relevant behaviors (especially medication use, regardless of an obvious relationship to bowel function) is often recommended. Patterns may emerge that can provide useful clues regarding needed modifications. There are related smart phone apps available to help monitor bowel function, such as the Bristol Stool Chart app, that help track information that can be shared with healthcare professionals.

·       Establish a bowel management routine by emptying your bowels at a regular time that suits you.

·       Consuming enough fiber or fluids to avoid constipation ³, while avoiding spicy foods, high-lactose (fluid) dairy products, caffeine, artificial sweeteners, and individual triggers for irritable bowel may help reduce bowel urgency. If starting with a low-fiber diet, it is recommended to gradually add fiber, i.e., a new source or upgrade every few days – while drinking plenty of water – until a goal amount of about 40 g per day is reached. The general recommendation for total daily water intake is 1 ml per kg body weight per hour (½ oz per lb body weight; when working in the heat or exercising intensely, add 1 cup (8 oz or 240 ml) of water every 15-20 minutes; when running a fever, add at least a cup each hour.

·       In more difficult cases, it may help to follow an elimination diet with gradual reintroduction of foods to determine what might be problematic. Journaling this process can be helpful.

·       Medications can contribute to bowel incontinence or constipation, either due to direct actions or side effects. Some may have a stimulant or irritant effect leading to bowel contractions – including certain laxatives – while others may slow down digestion, leading to constipation (and possibly a higher risk of incontinence). It may be helpful to work with the prescribing physician to determine what adjustments can be made, and/or to investigate what natural and potentially gentler alternatives may be used.

·      Pelvic floor exercises such as “Kegels” may strengthen the muscles around the anus and enable greater control. Though often encouraged for women, people of any gender can add them to their daily routine.

Kegel exercises:

−    To identify the pelvic floor muscles being used, stop urination or defecation midway and be aware of the location of and action leading to the sensation.

−       Repeat the action on an empty bladder or bowels – imagine sitting on a marble and tighten the pelvic muscles as if lifting the marble.

−     Do these for three seconds at a time, then relax for a count of three. Repeat three times a day. Aim for at least three sets of 10 to 15 repetitions a day.

−  Once the muscles and technique have been identified, the exercises can be done in any position, though it may be easiest lying down. When the muscles get stronger, try doing Kegel exercises while sitting, standing, or walking.

−       For best results, it is important to focus on tightening only the pelvic floor muscles and not flex the outer muscles in the abdomen, thighs, or buttocks. No less vital is to remember to breathe freely during the exercises.

−      Do not use Kegel exercises to start and stop normal bladder or bowel activity, as this can lead to incomplete emptying, which increases the risk of infection.

·  Biofeedback retraining is a technique available in some specialist centers. It aims to retrain awareness about bowel opening, diet, and fluid intake. It can include sessions on how the digestive tract works, dietary changes, bowel and muscle retraining, behavioral therapy, and psychological support. A “continence advisor” can discuss biofeedback retraining in more detail.

·  Transanal irrigation involves introducing warm tap water into the bowel via the anus using a catheter or cone while sitting on the toilet. The water helps to wash feces out of the bowel and encourages the bowel muscles to contract and push the stool out. Assessment and training with a suitable healthcare professional is essential before using transanal irrigation. There are a number of systems currently available on prescription, including Peristeen.

·       For immediate support while working on a solution, there is a wide variety of discreet incontinence guards available and organizations and websites that can help make the most appropriate choice. Pads and adult diapers are the most commonly used options to help to deal with bowel accidents. Anal plugs can be used like tampons – they can be easily inserted into the rectum like a suppository to help control leakage of feces; the plug can be left in place for up to 12 hours after which it is easily removed. It is important to be assessed by a continence nurse or appropriate healthcare professional before trying it. Some incontinence products may be eligible for a medical discount – a continence service can perform the relevant assessment and determine qualification.

·       Caring for the skin around the anus is important if incontinence is a problem. Barrier creams, such as those used for diaper rash or specifically for incontinence, can be useful in preventing discomfort, soreness, and damage – it is best to start using them as soon as the incontinence is identified, rather than waiting for a skin problem to develop. Carefully washing and patting dry the area if the skin is soiled after a bowel movement, wearing loose cotton underwear that allows skin to breathe, and avoiding perfumed soaps, creams, and lotions can all help.

·   Herbal remedies may also help. Among those considered to be non-irritating, peppermint is thought to be beneficial against constipation ⁴.

·      Homeopathy offers a range of proposed remedies for constipation, including opium, alumina, silica, Nux vomica, and sulfur ⁵.

References

1.   Lin SD, Butler JE, Boswell-Ruys CL, et al. The frequency of bowel and bladder problems in multiple sclerosis and its relation to fatigue: A single centre experience. PLoS One. 2019;14(9):e0222731. doi:10.1371/journal.pone.0222731

2.  Gulick EE. Neurogenic Bowel Dysfunction Over the Course of Multiple Sclerosis: A Review. Int J MS Care. Sep-Oct 2022;24(5):209-217. doi:10.7224/1537-2073.2021-007

3.   Coggrave M, Norton C, Cody JD. Management of faecal incontinence and constipation in adults with central neurological diseases. Cochrane Database Syst Rev. Jan 13 2014;2014(1):CD002115. doi:10.1002/14651858.CD002115.pub5

4.   Kazemi A, Iraji A, Esmaealzadeh N, Salehi M, Hashempur MH. Peppermint and menthol: a review on their biochemistry, pharmacological activities, clinical applications, and safety considerations. Crit Rev Food Sci Nutr. Jan 3 2024:1-26. doi:10.1080/10408398.2023.2296991

5.   Whitmarsh TE. Homeopathy in multiple sclerosis. Complement Ther Nurs Midwifery. Feb 2003;9(1):5-9. doi:10.1016/S1353-6117(02)00105-1