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When nature's call slows.

WHEN NATURE'S CALL SLOWS

Bowel problems are hardly the stuff of polite dinner conversation, yet studies have shown that up to half of all people with multiple sclerosis have some problem in this area. Too often, however, they tend to suffer in silence, sometimes feeling the problem is too trivial, other times too embarrassed to make an issue of it.

"With so many other things to worry about, I kept letting the problem slide, even though I was extremely uncomfortable," said Kitty Gold of Utah (not her real name). "For years, like a fool, I did nothing. I think I thought nothing could be done. I finally approached my doctor, who did solve the problem in a matter of weeks." The truth is that 9 times out of 10, there is a solution, depending on the nature and the source of the problem.

Sometimes bowel problems can be a direct result of nerve damage. Dr. Randall T. Schapiro, M.D., director of rehabilitation at the MS Center at Fairview Hospital in Minneapolis, indicates that "demyelination in the brain and/or spinal cord can interfere with the nerve transmission necessary for normal defecation. Constipation, and occasionally diarrhea or incontinence can result." Additionally, according to Dr. Norman S. Namerow, a neuro-rehabilitation specialist at the University of California, sudden emptying of the bowels can result from MS spasms. Often, however, bowel problems stem from indirect causes relating to MS. "Inactivity due to fatigue, weakness or spasticity; inadequate fluid intake to counteract bladder incontinence problems or reaction to medication taken to relieve other MS symptoms can all cause distress," Dr. Schapiro says.

In almost all of these cases remedies are available, although often trial and error, and working with your physician or nurse at it, is necessary to arrive at the one that works best for you. The most important thing, say the experts, is not to ignore the problem.

"True, it's not that constipation, for instance, is a major, life-threatening condition," one physician says. "But if you've got it, you've got to recognize it and do something about it. Otherwise it can be painful extra baggage for years. And that's something people with MS don't need.

"Also," he explains, "too many people just don't connect a severe case of constipation with multiple sclerosis. Although irregularity can hit anyone, chronic bowel problems may very well be linked to MS, directly or indirectly, and should be treated accordingly."

If the cause of constipation is the reduction of liquid to reduce bladder accidents, Dr. Namerow recommends at least one quart per day of liquid intake. Phyllis Wiesel-Levison, clinical coordinator of the Medical Rehabilitation Research and Training Center for MS at the Albert Einstein College of Medicine, Bronx, New York says, "Water is the cheapest and the best liquid to take, but just about anything will work, such as coffee, tea or juice."

Along with adequate liquids, a diet with ample fiber and bulk to help move along the contents of the intestine and retain moisture is suggested.

Sandra Shaw (not her real name), had had MS for 10 years when a mild but persistent bout of constipation seemed to be worsening. A thorough bowel exam showed no neurological damage due to MS, and Sandra's doctor prescribed a high fiber diet.

For Sandra, it meant foods rich in bran, and fresh fruits and vegetables, together with two to three quarts of fluids per day -- mostly water. She noticed a difference after a week, and was convinced after a month that the diet was making the difference.

"We recommend unprocessed or miller's bran," Wiesel-Levison says. "It's not delicious, but it works. Two or three tablespoons can be sprinkled on cereal or yogurt, or stirred into fruit juice."

Wiesel-Levison stresses that the Einstein MS Center tries to "stay away from medications, although sometimes a stool softener such as Colace can be helpful. A diet with adequate liquids and fiber is tried before any laxative medications are prescribed."

If inadequate exercise or mobility is the problem, the remedy can be a little tougher. Most of the specialists interviewed agreed with Marie Namey, clinical nurse specialist at the Cleveland Clinic's Mellen Center for MS Treatment and Research, that "any kind of exercise is helpful in keeping the bowel moving properly, even just stretching while you're in bed or a wheelchair. But if you can't exercise or move at all," she says, "then be sure to take adequate liquids and a fiber-rich diet. The combination can work."

Namey says the Mellen Center's strategy is not to hit the patient with a barrage of bowel information right away. "After we first get a history on an individual with MS," she says, "we always ask about bowel functioning. If the person indicates any special problems or concerns, then we schedule the individual for a special education session with a nurse."

That nurse typically asks questions about the person's daily habits, including eating, drinking, and activities. Besides recommending exercise, fluids and fiber, nurses and physicians stress the importance of having regular bowel movements.

"It's important to start making a ritual of emptying the bowels at the same time each day," Namerow says. "Half an hour after eating breakfast is a good time, since there's usually a reflexive action of the bowel at that time. But you can choose any time that seems right for you. The important thing is to sit there each day at the same time, regardless of whether you have success or not."

Namerow and others stress that it is not necessary to have a bowel movement every day. Every two or three days is quite acceptable, especially if the bowels function regularly at those intervals. More than a week between bowel movements, however, indicates a problem in which you run the risk of the stool drying out and hardening too much.

"Using a suppository the night before or first thing in the morning often can help to establish daily bowel routine," Namerow says. "Hot beverages als also may help."

Doctors and nurses focus on natural remedies such as these for bowel problems. They like to use medication as a last resort, because some drugs can actually be part of the problem.

"Medications that help to counter MS bladder problems of urgency and frequency may relax the bowels as well as the bladder," Wiesel-Levison says, "reducing the urge to pass tools and resulting in drier, harder stools.

"Among these drugs are oxybutynin chloride and propantheline bromide. Codeine and other narcotics also can be constipating."

Much less frequent but more unnerving is the problem of incontinence: lack of bowel control. Besides the possibility that an MS spasm could trigger an involuntary emptying of the bowels, as mentioned earlier, MS-related numbness occasionally masks the urge to defecate.

There are some techniques that help. Even those who suffer from incontinence seem to do best on a well-balanced diet that includes adequate fiber and fluids. There are also some medications which relieve bowel spasms and thereby limit bowel accidents.

If incontinence is the problem, or if other problems are becoming more serious, your physician may recommend bowel maintenance with regular glycerine or tap water enemas. This method is used basically to empty the bowels mechanically in order to eliminate the possibility of recurring constipation or incontinence. "However," Namey cautions, "repeated use of enemas can lead to a permanent breakdown of normal bowel functioning. Be sure to consult you physician before embarking on this course.

One way or another," she stresses, "there are enough avenues open so that you should be able to maintain your bowels so you can go out to shop, work, or visit with friends without the discomfort of constipation or the fear that you may have an embarrassing accident."

Dr. Marci Catanzaro, Ph.D, associate professor of nursing at the University of Washington, is optimistic about where bowel problem control is heading.

"While a number of older individuals are still just living with their bowel problems, younger people--the age group with the most MS--are becoming aware of the value of fiber and bulk in their diet and the dangers of using too many laxatives. Within just the past 10 years, young people with chronic bowel problems have begun to disappear, and today it's rare to see anyone under the age of 50 suffering from overuse of laxatives.

"Let's take one of the worst case scenarios," Dr. Catanzaro continues. "I know of one woman about 30 years old with MS who has suffered from incontinence because of a numbness in her abdominal area. She resorted to adult waterproof pants so she could go about her daily tasks without fear of accidents.

"What do we do in a case like this? First hospitalization may be needed for a short period to monitor the pattern of bowel and bladder functioning. Then we start the individual on an adequate intake of fluids. To this we add a daily suppository, a good breakfast with adequate fiber, hot morning beverage and an attempt to have a bowel movement at the same time each day. Just about anyone on this regimen who persists with it should be able to manage."

Gladys King's story provides an optimistic note: The 34-year-old mother of a two-year-old has had MS for five years. "I've had bowel problems from time to time for most of that period," she says, "and mostly constipation. But in the last two years, they have gotten worse.

"A few years ago, many of my symptoms worsened, including those affecting my bladder and bowels. Then I went into a wheelchair most of the time and I became so uncomfortable from constipation that it seemed to make everything I did so much more difficult."

Mrs. King (not her real name) finally consulted a specialist out of desperation. She reports that now she is essentially regular in her bowel habits. "I'm really amazed," she says. "I was examined, and then put on a regimen of Metamucil and the mild laxative Senokot, together with a higher fiber diet. It took only two to three days before things got better," she recalls. "Now my bowels are regulara and the pain from impacted stools and the straining to eliminate is gone. Moreover, the treatment hasn't been that unpleasant. Although I'm eating more cereals and fruits than I used to, my diet isn't very different from before."

"The important thing to remember," emphasizes Dr. Catanzaro encouragingly, "is that there's usually something that can be done to give nature a helping hand."
COPYRIGHT 1990 National Multiple Sclerosis Society
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Copyright 1990, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Title Annotation:includes personal success story; multiple sclerosis and bowel problems
Author:Frames, Robin
Publication:Inside MS
Date:Sep 22, 1990
Words:1744
Previous Article:Small grants, big goals: innovative research program focuses on MS care and quality of life.
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