Neurogenic bowel dysfunction in patients with multiple sclerosis: prevalence, impact, and management strategies

Abstract

Bowel dysfunction in patients with multiple sclerosis (MS) is highly prevalent. Constipation and fecal incontinence can coexist and alternate, impacting on the patient's quality of life and social interactions, as well as burdening the caregivers. The cost for the health care providers is also significant, with increased number of hospital admissions, treatment-related costs, and hospital appointments. The origin is multifactorial, and includes alteration of neurological pathways, polypharmacy, behavioral elements, and ability to access the toilet. Every patient with MS should be sensitively questioned about bowel function, and red flag symptoms should prompt adequate investigations. Manipulation of life style factors and establishment of a bowel regime should be attempted in the first place, and if this fails, other measures such as biofeedback and transanal irrigation should be included. A stoma can improve quality of life, and is not necessarily a last-ditch option. Antegrade colonic enemas can also be an effective option, whilst neuromodulation has not proved its role yet. Effective treatment of bowel dysfunction improves quality of life, reduces incidence of urinary tract infection, and reduces health care costs.

Keywords: constipation; fecal incontinence; multiple sclerosis; neurogenic bowel dysfunction.

Figure 1

Rectoanal inhibitory reflex (RAIR). Notes: Excitation peak: initial increase in the resting pressure is associated with sudden rectal distension. Excitation latency: duration from the point of excitation peak back to the baseline pressure. Point of maximum relaxation: lowest point of resting pressure secondary to reflex internal anal sphincter relaxation. Recovery time: the duration between maximum relaxation and the point at which the resting pressure recovers to two-thirds its baseline value. Total reflex duration: calculated as the duration from the point of the excitation peak to the point where two-thirds recovery is observed. Figure reproduced from Thiruppathy K, Roy A, Preziosi G, Pannicker J, Emmanuel A. Morphological abnormalities of the recto-anal inhibitory reflex reflects symptom pattern in neurogenic bowel. Dig Dis Sci. 2012;57(7):1908–1914. Copyright 2012 Thiruppathy et al.

Figure 2

Diagram showing the multifactorial origin of constipation. Notes: Adapted from Preziosi G. Pathophysiology of Bowel Dysfunction in Multiple Sclerosis and the potential for targeted treatment [Doctoral thesis]. London, UK: University College London; 2014. Copyright 2014 Preziosi. Abbreviations: FI, fecal incontinence; RAIR, rectoanal inhibitory reflex.

Figure 3

Diagram showing the multifactorial origin of fecal incontinence. Notes: Adapted from Preziosi G. Pathophysiology of Bowel Dysfunction in Multiple Sclerosis and the potential for targeted treatment [Doctoral thesis]. London, UK: University College London; 2014. Copyright 2014 Preziosi. Abbreviation: RAIR, rectoanal inhibitory reflex.

Figure 4

This diagram shows how important it is to tailor treatment, sometimes using a combination of interventions. A stepwise approach is recommended; however, it is paramount to engage patient and caregiver, to understand their preferences and adjust treatment accordingly.