Bowel and Sexual Dysfunction in the Multiple Sclerosis Patient

Philip J. Aliotta

Elimination Issues in Multiple Sclerosis: Bowel Disorders

In the population with multiple sclerosis (MS), bowel dysfunction is underreported. When investigated, 60% of patients with MS experience some form of bowel dysfunction.¹ Constipation is reported to predate diagnosis in many cases and may be an early nonspecific symptom of the disease.²,³ Upper gut symptoms, such as difficulty swallowing, are also widespread.² NARCOMS identifies three types of bowel complaints experienced by patients with MS: 39% have constipation, 11% have fecal incontinence, and 36% have both.⁴ The Bowel Function Questionnaire for MS helps differentiate the three types of bowel dysfunction and comprises 15 items pertaining to constipation, 13 items for fecal incontinence, and 20 items for both constipation and fecal incontinence. It is self-administered. Other questionnaires are Brief Fecal Incontinence Questionnaire, Quality of Life Scoring Tool Relating to Bowel Management (QOL-BM), and the Constipation Symptom Assessment Instrument (PAC-SYM).⁵,⁶ Das Gupta
and Fowler categorized symptoms associated with bowel dysfunction into disorders of elimination (constipation) or storage (incontinence) or a combination of both.⁷,⁸ Constipation is caused by slow colonic transit, abnormal rectal function, and intussusception. It is the most common bowel complaint of people with MS.⁹ Rectal overload and overflow with impaired sensation due to neurogenic bowel in the patient with constipation can lead to fecal incontinence.¹⁰,¹¹

Owing to the variable range of related symptoms and the timing of their occurrence, the term constipation has different meanings for different individuals.¹² Constipation is defined as less than or equal to two bowel movements per week or the need for stimulation (digitally or with the use of laxatives, enemas, or suppositories) more often than once per week.¹³

Fecal incontinence is less difficult to characterize, as it can present with solid or liquid stool or flatus alone. It may be passive, occurring without the patient’ awareness, or urgent (Table 17.1).¹⁴ Bowel problems have been found to be associated with more severe disability, disease progression, genitourinary symptoms, and depression but not necessarily with gender. The bowel problems associated with specific subtypes of MS have not been identified.¹⁵,¹⁶ Time spent on bowel management affects daily activities. It has been reported that 23% of patients spend 16 to 30 minutes per day and approximately 30% spend anywhere form 16 minutes to over 1 hour daily attending to bowel issues. Thirty-five percent of patients with MS report that their bowel management problems stops them from working outside of the home. Fifteen percent identify bowel issues as interfering with personal intimacy.³ The cause of the bowel dysfunction can be multifactorial: due to disease progression, secondary to drug therapies for MS and its associated comorbidities, behavioral problems, or concurrent medical problems.⁷

From a neurological perspective, bulbar and spinal involvement can affect bowel regulation by interfering with afferent sensory or efferent motor pathways. Patients with MS with constipation or fecal incontinence are reported to have delayed somatosensory evoked potentials when
recorded from the brain but normal potentials at the lumbar spine, suggesting higher spinal or cerebral involvement in these patients.¹⁷ Motor spinal pathways show prolongation in cortex to lumbar spine and cortex to pelvic floor striated muscle conduction times. Altered large bowel compliance and prolonged colonic transit time have been associated with demyelinating lesions of the conus medullaris.¹⁸

TABLE 17.1 SYMPTOM PRESENTATION RELATED TO CONSTIPATION¹³

No stool

Decreased bowel movements

Hard, formed stools

Severe flatus

Rectal fullness

Decreased bowel sounds

Distended abdomen

Palpable mass

Headache

Anorexia

Nausea and/or vomiting

Diarrhea related to fecal impaction

Increased fatigue

TABLE 17.2 SYMPTOM PRESENTATION OF FECAL INCONTINENCE¹⁴

Presentation

Timing/Occurrence

Solid with or without flatus

Liquid with or without flatus

Flatus alone

Passive/urgent

Presentation

As stated, the cause of bowel problems in MS is often multifactorial. Patients present with variable complaints and symptoms (Table 17.1). The presence of constipation correlated strongly with the duration of illness, presence of genitourinary symptoms, and use of medications.¹⁴

Chronic constipation accounts for exacerbation and persistence of the presenting symptoms (Table 17.2) and is a source of complications (Table 17.3).

Evaluation

Bowel problems in MS are multifactorial, and aside from the presentation of constipation with or without flatus, fecal incontinence with or without liquid stools, or flatus alone, assessment should include an assessment of the physical limitations, psychosocial challenges, work environment assessment, dietary habits, fluid hydration, as well as an evaluation of bladder control.

TABLE 17.3 COMPLICATIONS OF CONSTIPATION¹¹

Hemorrhoidal irritation

Rectal prolapse

Anal fissures

Pain

Bleeding

Excessive secretion of mucus

TABLE 17.4 ASSESSMENT OF BOWEL FUNCTION¹³

Muscle tone and Strength

Cognitive and communication abilities

Ability to chew and swallow

Past bowel history

Eating habits

Motor skills and degree of independence

Environment

Personal assistance

Medication

Bladder management

Patient’s perception of the problem

Various scales exist to assess for fecal incontinence. These scales, i.e., Pescatori,¹⁹ Wexner,²⁰ American Medical Systems Score,²¹ correlate well with careful clinical impression and severity.¹⁴ The application of questionnaires for fecal incontinence and quality-of-life assessment has a positive impact because they include the improvement not only of individual clinical practice but also of evaluating the effectiveness of treatments and the functioning of health services.²²

In addition to the general assessment of bowel habits and function (Table 17.4), measurement of gut transit time provides a measure of large bowel function. Radiopaque markers can be used to evaluate gut transit. Other tests include anorectal manometry, balloon expulsion testing, and electrical rectal sensory testing, and evacuation proctography has been used to assess pelvic floor coordination and distal colonic innervation, to rule out megarectum, and to assess slow or incomplete rectal emptying and sphincter function.¹²

Medications must be reviewed, as most medications used for bladder overactivity, i.e., anticholinergics, can cause and or exacerbate bowel problems (Table 17.5).

Past medical and surgical history must be obtained and reviewed. Previous bowel surgeries, pelvic surgeries, radiation therapy, underlying medical disease of the colon, i.e., Crohn disease, diverticulosis with or without diverticulitis, ulcerative colitis, and irritable bowel syndrome must be evaluated. If diarrhea is the chief complaint, a search for the causes of diarrhea is required (Table 17.6). In women, obstetric history may contribute to bowel disturbances. A focused physical examination should be performed, including abdominal examination, pelvic/perineal assessment, and rectal examination. A rectal examination assesses external sphincter pressure and resting anal tone. Stool for occult blood can be obtained. Laboratory assessment includes blood glucose, electrolytes, calcium, and thyroid function tests.⁵ Emotional factors and behavioral changes may influence toileting habits directly or through altered autonomic control of gut function.¹² As part of the history, diet and lifestyle play an important role in understanding bowel dysfunction. Having a poor diet is often cited as the reason why people have constipation, but there are many factors that can contribute to the development of this problem.

TABLE 17.5 AGENTS THAT CAUSE CONSTIPATION²³

▪ Oral contraceptives

▪ Opioid pain relievers

▪ Anticholinergic agents

▪ Antispasmodics

▪ Tricyclic antidepressants

▪ Calcium channel blockers

▪ Sympathomimetics

▪ Antipsychotics

▪ Diuretics

▪ Antihypertensives

▪ Antihistamines

▪ Antacids (containing calcium and aluminum)

▪ Calcium supplements

▪ Iron supplements

▪ Antidiarrheal agents (loperamide, attapulgite)

▪ Anticonvulsants

▪ Nonsteroidal anti-inflammatory drugs

▪ Miscellaneous compounds, including octreotide, polystyrene resins, cholestyramine

Measurement of gut transit time provides a measure of large bowel function. Radiopaque markers can be used to evaluate gut transit. Anorectal manometry, balloon expulsion testing, and electrical rectal sensory testing, and evacuation proctography has been used to assess pelvic floor coordination and distal colonic innervation, to rule out megarectum, and to assess slow or incomplete rectal emptying and sphincter function.¹²

The Bristol stool scale (Figure 17.1) is a diagnostic medical tool designed to classify the form of human feces into seven categories. It is used in both clinical and experimental fields. It is sometimes also referred to as the Bristol stool chart (BSC), Bristol stool form scale, or BSF scale.²⁴

TABLE 17.6 CAUSES OF DIARRHEA¹³

Fecal impaction

Diet/irritating foods-dietary intolerance

Inflammatory bowel disease

Stress/anxiety

Medications

Overuse of laxatives/stool softeners

Interruption in the neural pathways

Impaired cortical awareness of urge to defecate

Sensory loss in perineum and rectum

It was developed as a clinical assessment tool and is widely used as a research tool to evaluate the effectiveness of treatments for various diseases of the bowel, as well as a clinical communication aid.²⁵

Constipation

Rome IV Criteria for Constipation. This is used in patients with complaints of constipation for at least 3 months with symptoms onset >6 months.

Do not use in patients with gastrointestinal (GI) bleeding, unexplained iron deficiency anemia, unintentional weight loss, palpable abdominal mass, family history of colon cancer, or symptom onset >5 years and not yet screened for colon cancer, or sudden/acute inset of new change in bowel habit.

Rome IV criteria define constipation as any two of the following criteria²⁴,²⁶,²⁷:

Straining: for greater than one-fourth (25%) of defecations
Lumpy or hard stools: type 1 or 2 on the Bristol Stool Form Scale; for greater than one-fourth (25%) of defecations
Sensation of incomplete evacuation: for greater than one-fourth (25%) of defecations
Sensation of anorectal obstruction/blockage: for greater than one-fourth (25%) of defecations
Manual maneuvers to facilitate defecation, that is, digital evacuation, pelvic floor support; for greater than one-fourth (25%) of defecations
Less than three spontaneous bowel movements per week

Figure 17.1. Bristol Stool Chart. See eBook for color figure.

Interpretation:

• Types 1-2 indicate constipation,

• Types 3-4 are ideal stools as they are easier to pass, and

• Types 5-7 may indicate diarrhea and urgency.

Reprinted with permission from Baskin LS. Handbook of Pediatric Urology. 3rd ed. Philadelphia, PA: Wolters Kluwer; 2018. Figure 10-1.

The lifestyle factors that increase chances of becoming constipated include:

Not eating enough foods that are high in fiber
Not drinking enough liquids
Not getting enough exercise
Not maintaining a healthy weight

Fecal Incontinence

Demyelinating lesions and reflexive activity cause frequent diarrhea leading to recurrent emptying of the rectum.²⁸ Patients need to be assessed for their ability to sense rectal fullness and when they need to defecate.¹⁰

Fecal incontinence is caused by a reduced sensation of rectal filling, poor pelvic floor muscle control, reduced rectal compliance, and weakness of the anal sphincter.⁷,⁸,⁹

Case Study

A patient with a neurogenic bladder in follow-up presented with the lower GI complaints of bowel irregularities now exacerbated by the bladder therapy. Her symptoms included severe constipation of up to 6 to 7 days longer then her initial presentation with flatulence, cramping, and increasing malaise, culminating with massive, often unexpected, bowel movements. Stools were described as a mix of hard lumps both large and medium seen initially with lumps and formed stool. There is no hematochezia. Her stool pattern is consistent with Bristol types 1 and 2 (Figure 17.1). These episodes of constipation were followed by intermittent attacks of diarrhea, which could last 1 to 2 days before “settling down to my normal routine.” Laboratory data reviewed were normal. Medications were re-evaluated. On pelvic examination, a small rectocele and fecal impaction was noted. Abdominal flat plate x-ray demonstrated severe constipation (Figure 17.2). Neurological examination was intact.

Figure 17.2. Abdominal flat plate x-ray: severe constipation.

Treatment

An important aspect of treating bowel disturbances in the patient with MS is to recognize that, with MS, disease progression, exacerbations, and remissions affect bowel function. Revisiting the problem at regular intervals is necessary to best maintain consistency and predictable outcomes for the patient, reduce unwanted secondary effects of medications on bowel regularity and adequacy of bowel movements, and reduce secondary effects from constipation, fecal incontinence, or both. The first line of treatment for constipation with incontinence is lifestyle modification (Table 17.7) or a bowel training program.

A bowel training program should:

Normalize stool consistency
Establish a regular pattern of defecation
Stimulate rectal emptying before rectal overload and overflow leading to incontinence
Avoid diarrhea, constipation, and incontinence as side effects
Improve quality of life