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C H A P T E R 1 7
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
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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
TABLE 17.1
Symptom Presentation Related to Constipation
13
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
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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
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
TABLE 17.2
Complications of Constipation
11
Hemorrhoidal irritation
Rectal prolapse
Anal fissures
Pain
Bleeding
Excessive secretion of mucus
Chronic constipation accounts for exacerbation and
persistence of the presenting symptoms (Table 17.2) and is a
source of complications (Table 17.3).
TABLE 17.3
Symptom Presentation of Fecal Incontinence
14
Presentation Timing/Occurrence
Solid with or without flatus
Liquid with or without flatus
Flatus alone
Passive/urgent
Passive/urgent
Passive/urgent
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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.
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
TABLE 17.4
Assessment of Bowel Function
13
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
Medications must be reviewed, as most medications used for
bladder overactivity, i.e., anticholinergics, can cause and or
exacerbate bowel problems (Table 17.5).
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TABLE 17.5
Agents That Cause Constipation
23
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
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
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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 17.6
Causes of Diarrhea
13
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
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
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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.
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.
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Rome IV criteria define constipation as any two of the
following criteria
24,26,27
:
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 onefourth (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 onefourth (25%) of defecations
Less than three spontaneous bowel movements per week
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.
7-9
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