Multiple Sclerosis and neurogenic bowel problems; incidence, prevalence, and management; a holistic approach. 2013. ( Before there was more than one trans-anal irrigation manufacturer. )

1. MS and the bowel

2. Multiple Sclerosis
• Is the most common cause of neurological
disability in the under 65s in the UK. There are
• 100,000 pwms
in the UK.
• MS is commonly
diagnosed
between age
20-40yrs
• Symptoms and severity very variable

3. Causes of MS?
• Unknown.
• Genetic predisposition, familial risk, interacts
with environmental factors to trigger
autoimmune response.
• Environmental factors:
• Sunlight, latitude, vitamin D
• Epstein Barre virus (glandular fever) Female
hormones
• Prognosis also affected by smoking & diet,
especially fats

4. What happens in MS?
1. The normally impenetrable
blood-brain barrier (BBB)
breached
2. Activated lymphocytes enter
Central Nervous System (CNS)
• Once within CNS they set off
an ‘inflammatory cascade’
that results in damage to
myelin by body’s own immune
system
• De-myelinated areas may
become scarred – Multiple
Sclerosis means ‘many scars’

5. What is MS?
• Demyelination –
destruction of the
fatty sheath that coats
the nerve.
• Remyelination –
repair of the damage
does occur –
especially in the early
years

6. Brain aspects of multiple sclerosis
(MS). Axial T1-weighted
gadolinium-enhanced MRI in a
patient with MS demonstrates
several intensely enhancing
pericallosal white matter lesions
compatible with active disease
Brain aspects of multiple
sclerosis. Axial diffusion-
weighted MRI in a patient
with MS shows several
hyperintense lesions, a
feature of inflammatory
disease activity.

7. Varied disease patterns
Types of MS
BA C
Adapted from Lublin FD Reingold SC. Neurology 1996;46: 907-11

8. Inflammation and degeneration

10. Lottie:32yrs, works in admin. Recently married.
memory problems, anxiety re work vertigo, dizziness,
relapses Trigeminal
Optic neuritis, diploplia neuralgia
Central motor fatigue
Muscle weakness
Tremor,
Ataxia
Constipation, and faecal urgency
Urinary urgency
Numbness, tingling, loss dexterity
sexual problems related to fatigue & altered sensation
muscle stiffness & spasm, spasticity
Altered sensation & Pain

11. Emily
• 63 years old
• Married
• 3 children
• Part time volunteer work
• Does the books for husband

12. Emily’s worst problem at the
moment:
Can’t get tickets for Mamma Mia

13. Digestion in the large intestine
• Liquid chyme passes from stomach
• Small intestine absorbs nutrients
& fluid – about 8 litres of it daily.
• Large intestine continues to absorb
fluid, forming solid faeces.
• Contents move along by 2
types of muscular contraction-
Haustral churning & Peristalsis.
• Gastro-colic reflex stimulates
• Mass Peristaltic movements
which push faeces into rectum.

14. Defecation.
• Sensory nerves in the rectum
send a message to the spinal
cord, and motor nerves then allow the
internal anal sphincter to relax.
(This is a reflex, not voluntary)
• Nerve message must pass to the brain
to request permission to open the external
anal sphincter, when acceptable.
• If not in the right place, the external
anal sphincter must be consciously
contracted to remain continent.

15. Normal bowel function depends
on:
• Sensory and motor
nerve messages; bowel-
spine- brain -bowel
• Having sensation
• Muscular action
• Muscular control
• Reflexes
• All of these functions are often affected in MS.

16. • Prevalence of bowel dysfunction is 39%-73% in MS
• People with MS have 2-3 x more admissions for
impaction, megacolon and constipation than other non-
neurological conditions.
• Constipation and faecal incontinence frequently co-exist
Weisel PH et al. (2001) European Journal of Gastroenterology & Hepatology. 12: 441-448
Hinds JP et al. (1990) Prevalence of bowel dysfunction in multiple sclerosis. A population study. Gastroenterology. 98:
1538-1542
Eidelman, B.H.Wald,A., 1990 Sonnenberg et al 1994
The bowel and MS in the literature

17. Pathophysiology of bowel in MS
Bulbar or spinal involvement can interfere with:-
• Bowel transit
• Pelvic floor muscle function and coordination
• Sensitivity of lower bowel to content
• Response to the call to stool
• Mobility to get to toilet
• Reduction in postprandial reflex (gastro-colic reflex)
Hinds JP et al. (1990) Prevalence of bowel dysfunction in multiple sclerosis.
A population study. Gastroenterology. 98: 1538-1542

18. Other possible factors that add to
bowel problems in MS
• Reduced ability to exercise
• Inability to get into a good position
• Reducing fluid intake because of urinary urgency
• Eating a diet low in fibre
• Missing meals, especially breakfast
• Difficulty getting to toilet, or reliance on carers
• Medication e.g. anti-cholinergics and anti-depressants
• Also drugs used for pain in MS, like Amitryptilline, tegretol
• Preferring constipation to faecal incontinence
• Inability to raise intra-abdominal pressure ( bear down)

19. Constipation
• Affects an estimated 50% of people with MS
Wiesel PH, Norton C, Glickmann S, Kamm MA.
Pathophysiology of bowel dysfunction in multiple sclerosis.
European Journal of Gastroenterology and Hepatology 2001;13(4):441-448
Bakke A., Myhr KM, Gronning M, Nyland H.
Bladder, bowel and sexual dysfunction in patients with multiple sclerosis: a cohort study.
Scandinavian Journal of Urology and Nephrology. Supplement. 1996; 179: 61-66

20. Evidence base for management
• There has been little or no research into simple
measures likely to improve bowel problems in MS
patients
• There is no evidence available that an increase in
fibre, fluids or physical exertion is helpful or
improves gut transit times! (Norton, C. 2004)
• Increasing dietary fibre in the absence of
peristalsis increases flatulence and bloating
Weisel PH et al. (2001) European Journal of
Gastroenterology & Hepatology. 12: 441-448

21. Faecal urgency/incontinence
• Fecal incontinence is one of the most
psychologically and socially debilitating
conditions….. It can lead to social isolation,
loss of self-esteem and self-confidence, and
depression. Markland AD, Greer WJ, Vogt A, Redden DT, Goode PS, Burgio KL, et al. Factors impacting
quality of life in women with fecal incontinence. Dis Colon Rectum. Aug 2010;53(8):1148-54.
• I have many patients who don’t describe
themselves as having faecal incontinence, but
whose lives are ruled & limited by urgency &
the threat of incontinence.

22. Faecal incontinence
• Occurs in 51% - 60% of MS patients but does
not correlate with disease severity/disability
• Can correlate with the duration of the disease
and spinal cord involvement
• Most frequently caused through reduced
rectal sensation and anal squeeze pressure
• Can co-exist with constipation
• Can have spinal reflex bowel

23. MS
• In MS, lesions
can occur at any
level of the spine

24. Working up from the basics.
Ignorance about normal bowel health is just as
prevalent in Ms population as in general
population, so I always start with the basics.

25. Natural approaches:
• Drinks – plenty of non-caffienated drinks, & try prune juice
• Fruit and veg daily – all bran etc is no substitute!
• 2 dessert spoons of Linseed daily on food or swig it down with juice - has
bulking, stimulating, and slippery properties and contains omega 3 oils
that are important in MS.
• with 1 ripe pear daily
• Ortisan fruit cubes ( made from figs and senna)
• Try to go soon after you first eat and drink in the morning.
• Try raising your feet on a stool/ piles of books, leaning forward, and
deep breathing whilst on the toilet. Also massaging abdomen along &
down.

26. Medication
• Fibregel or normacol with plenty of water bulks up the stool, but does
not help it to travel faster. You would need to add a stimulant to do this.
• Add Senna – bowel stimulant; take 2 at night
• Movicol – stops the water being absorbed from the stool. ½ a sachet,
then increase as necessary – up to 8 sachets in a jug for severe
impaction. Can be used with senna or bisacodyl. Too much causes sloppy
stools.
• Bisacodyl (stimulant laxative) orally and/or in suppository
• Suppositories – glycerine to only soften stool, bisacodyl to help move it
out. Takes about an hour. Sometimes putting it in stimulates the bowel,
some people need a laxative too. For some just digital (gloved finger)
ano-rectal stimulation can trigger bowel to move.

27. Working up to:
• ?enemas
• Peristeen anal irrigation system
• Peristeen with laxative
• Also available;
• Aralax ‘magic bullet’ suppository, 7.5mg bisacodyl special
formulation – not on normal drug tariff, have to persuade GP
(expensive) must use dialachemist.com 0800 0086366
• If all else fails, and after specialist consultation - Elective
colostomy
• Consider stress of surgery on MS

28. Working on:Urgency / faecal
incontinence
• Urgency and faecal incontinence can be caused by MS problems, but
remember that there are other causes too. See:
• http://www.healthhype.com/urgency-to-have-a-bowel-movement-and-
urge-fecal-incontinence
• to learn about other problems like intolerance of FODMAP foods,
(Fermentable Oligo-, Di-, and Mono-saccharides, And Polyol - are short-
chain carbohydrates that are osmotically active, and fermentable, and
occur in fruits, milk products & some other foods.)
• IBS and other conditions.

29. Faecal incontinence
• Get bowels into a routine using all the previous info
• Identify any foods which increase urgency. See website above. Learn the
foods that ‘bind’
• Consider anticholinergic medication, with advice of continence adviser.
Be aware of possible side-effects
• Although immodium is used by some people for loose stool diarrhoea,
it’s not good to use this if you get constipation. For occasional use, use
the liquid form, so you can use small and exact doses.
• Anal plugs available on prescription – try a sample from the company
first; not everyone finds them useful or can tolerate them.
• Peristeen anal irrigation can be used to flush the descending colon every
morning so then you know you won’t be caught short.

30. From my training to GPS….
‘…and if after due diligence, no balance can be
struck between constipation and faecal
incontinence, or incontinence and lack of
control dominates, trans-anal irrigation.’

31. Benefits to PWMS of Peristeen
• Ability to lead a more normal life
• To go out without fear of faecal incontinence
• To work, to go out to normal venues, have a
social life, attend family gatherings….
• To overcome severe constipation
• To reduce carer strain & improve relationships
• To feel clean
• Drug free approach

32. Potential obstacles to using
Peristeen in MS
• Obstacles before starting:
• GP fundholders – sometimes don’t want to
pay for it. Perceived as v.expensive.
• Pre-emptive letter to GP, history of problem
and all previous treatments tried, along with
real human cost of the problem
• Can also supply evidence base, cost of
unplanned admission with impaction/UTI
• UTIs can be caused by constipation

34. Potential obstacles
• Dexterity and strength – check ability to blow
up the balloon, and handle the kit.
• Consider type of transfer & mobility – how do
they use the toilet? Which way will they do it?
• Cognitive and memory problems – always
supply written aswell as verbal instructions.

35. • Potential problems with spasm – ejecting
catheter. Try again, use child size catheter;
use after taking any prescribed muscle
relaxants. Possibly do 2 smaller flushes.
• Getting caught out – 2nd bowel movement
later in the day – try the 2 smaller flushes

36. Using Peristeen in advanced disability
• formal or informal carers can
assist using a toileting sling,
rotastand, or standing hoist.
• Educating other healthcare staff –
risk aversion. Compare consequences
of current situation with possible cited risk
• District nurses can be involved and oversee
• Can be hugely liberating, and massively improve
quality of life.

37. Web resources for MS
• http://www.nhs.uk/Conditions/Multiple-
sclerosis/Pages/Introduction.aspx NHS overview
• http://www.mssociety.org.uk/ clear, reliable info on MS, symptoms, etc
• http://www.mstrust.org.uk/ for health professionals & people with MS
• http://shift.ms/ social networking site for younger people with MS
• http://www.overcomingmultiplesclerosis.org/
Very inspiring and educational site explaining all the lifestyle measures you can do to stay well with MS; research based.