Monday, 10 April 2017

#ClinicSpeak: anal and pelvic floor function in MS

Have you ever being incontinent in public? #ClinicSpeak #MSBlog 

Patients with MS describe being incontinent of faeces and/or urine in public as being their worst nightmare. Do you agree? 


I have managed several patients over the years that have become socially isolated as a result of this experience; they simply stay at home so as not to experience the embarrassment again. One patient of mine developed a severe anxiety disorder as a result of an episode of faecal incontinence in public. Her anxiety was so bad that she had to see a psychiatrist. She was eventually diagnosed as having a post-traumatic stress disorder. She had intrusive thoughts about the episode and kept having unpleasant flash-backs about the episode. In other words she was reliving the episode over and over again. It took her several years of counselling to overcome the social phobia associated with her anxiety and she eventually was able to start going out again. She now only goes out after having an enema to  clear her lower colon and rectum, and she never eats when she is out so as not to stimulate her gastro-colic reflex. The latter is the reflex urge to defaecate that comes after eating a meal. She also wears pads and carries a change of clothing with her. She once showed me her faecal incontinence emergency pack; it contained wet wipes, clean underwear, spare continence pads and poo bags to dispose of any used items discreetly. Her emergency pack reminded me of what I used to carry around with me when I went out with my daughters before they were potty trained. With regard to her bowel function this particular patient has become a baby or child again. 

The study below documents that in general pwMS with constipation have loss of sphincter tone (strength) at rest and during contraction compared to non-MS patients. In the subgroup of patients with faecal incontinence, rectal sensitivity threshold was lower in patients with MS than in other patients. In other words when faeces enters the rectum the threshold that triggers the defaecation reflex is lower. Finally, patients with MS had a decrease in the difference in resting anal pressure before and after maximum squeeze maneuvers, which suggests post-contraction sphincter spasticity. All this indicates impaired pelvic floor coordination in pwMS. 

Knowing what is wrong with rectal and anal function in patients with bowel problems can help with specific therapies targeting specific symptoms, i.e. constipation, faecal hesitancy (difficult initiating a bowel action), incomplete emptying, faecal urgency, urgency incontinence, overflow diarrhoea, excessive bloating, excessive flatus, etc. 

Bowel function is one of the hidden MS symptoms; patients often suffer in silence and their HCPs often fail to ask about bowel problems. Over the lifetime of the disease the majority of pwMS develop bowel problems so it is important for you to realise that a lot can be done to help you. If you have bowel problems can you please discuss these with your neurologist or MS clinical nurse specialist. 

On the other side of the coin if MS is treated early and effectively before the neuronal pathways that control bowel function are damaged then these issues can hopefully be avoided or at least delayed. 



Marola et al. Anal sphincter dysfunction in multiple sclerosis: an observation manometric study. Open Med (Wars). 2016;11(1):509-517.

Background: Constipation, obstructed defaecation, and faecal incontinence are frequent complaints in multiple sclerosis. The literature on the pathophysiological mechanisms underlying these disorders is scant. 


Methods: Using anorectal manometry, we compared the anorectal function in patients with and without multiple sclerosis. 136 patients referred from our Center for Multiple Sclerosis to the Coloproctology Outpatient Clinic, between January 2005 and December 2011, were enrolled. The patients were divided into four groups: multiple sclerosis patients with constipation (group A); multiple sclerosis patients with faecal incontinence (group B); non-multiple sclerosis patients with constipation (group C); non-multiple sclerosis patients with faecal incontinence (group D). Anorectal manometry was performed to measure: resting anal pressure; maximum squeeze pressure; rectoanal inhibitory reflex; filling pressure and urge pressure. The difference between resting anal pressure before and after maximum squeeze maneuvers was defined as the change in resting anal pressure calculated for each patient.

Results: Group A patients were noted to have greater sphincter hypotonia (reduced tone) at rest and during contraction compared with those in group C (p=0.02); the rectal sensitivity threshold was lower in group B than in group D patients (p=0.02). No voluntary post-contraction sphincter relaxation was observed in either group A or group B patients (p=0.891 and p=0.939, respectively).

Conclusions: The decrease in the difference in resting anal pressure before and after maximum squeeze maneuvers suggests post-contraction sphincter spasticity, indicating impaired pelvic floor coordination in multiple sclerosis patients. A knowledge of manometric alterations in such patients may be clinically relevant in the selection of patients for appropriate treatments and for planning targeted rehabilitation therapy.

10 comments:

  1. I really feel for this lady. How common is this problem? The thought of not being able to control my bowels really scares me.

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  2. I think this sort of issue highlights how MS is almost unique in terms of the number and range of problems it offers up. Incontinence is a significant 'disease' in itself, but add in memory issues, spasticity, eye sight problems, pain..... I think of MS a lot and realise that 'someone up there really didn't like me'. I would have been the best diabetic in the world. Asthma - no problem. Eczema - walk in the park. MS is off the scale in what it can and does do. The problem with many neuros is they treat the symptoms as if treating a different person. Mobility problems? Get a wheelchair. Incontinence problems? Wear a diaper. Double vision? Black out one lens of your glasses. It all sounds nice, but would you want to sit all day in a wheelchair, wearing a diaper, and only seeing out if one eye? For healthy people out there - do no get MS!

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    Replies
    1. That is why MS is a syndrome rather than a simple 'disease'.

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  3. Yes, I've had bowel incontinence before. I don't have a car so it's not so easy for me to nip home or go to a supermarket toilet when have the urge to go. I get the bus or walk. When I walk it seems to stimulate my bowels, it gets things moving.

    Unfortunately I had severe constipation for many months a few years ago and this has made has weakened my muscles. Meaning I can't hold it in for too long.

    I try and eat a very good diet. I am on DMF and I know this can cause gastro problems.

    The Bowel and Bladder foundation website has free downloadable fact sheets and booklets which are helpful on sphincter exercises, hints and tips on travelling confidently with a bladder or bowel issue. Also a bowel diary.

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  4. I have IBS and worked out that I could stimulate my bowel by drinking coffee at certain times, and calm the urgency with antihistamine at others if I needed to. MS is another matter though and really put a spanner in the works, but I am lucky, it has so far only happened at home. That feeling of not being able to feel the muscles you desperately need to squeeze is horrifying, you know what is about to happen. I keep the same kit in my car.
    But, for me it is the choking that is my worst nightmare, because in the panic of trying to relax my throat and breath, and failing, I know that unless it resolves itself quickly, I will have seen my kids for the last time. It doesn't help that I have lost consciousness through lack of oxygen before (anaphylaxis 20 years ago), that is my moment I relive over and over.
    But for today, my bowel is ok, the bladder is another matter. :-(

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  5. I have had several occurences of bowel incontinence, and I can tell you from experience, that one of the worst things about it is the embarrassment - it stinks and you can't cover up the smell.

    You trigger a disgust reaction in other people - of course, it's a survival instinct - but it's really unpleasant - as is dealing with the consequences.

    Diapers are all very well - but ask yourself the question - would you want to wear one - just in case - at 50? And it still doesn't deal with the smell and as for the consequences - well, you really need a shower, not just a change of pants.

    But I find that quite often, the solutions offered really are unpleasant (daily self-administered enema, anyone?) - but that's the thing - you wouldn't like it, but it's not you doing it, it's me - so that's alright then.

    It's not, it's the 21st century, you need to be offering better solutions.

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  6. My worst nightmare. Currently I worry more about wetting myself, but i will no doub 'progress' to worrying about my bowels as well. If i am going out I take wipes and clean underwear and dehydrate myself prior to leaving starting the previous night. I am never entirely relaxed when out and don't enjoy myself like i used to because i constantly think of the toilet. Where are they? Can i make it in time? Is it accesible? My life is dominated by bladder concerns outside of the house ... and yet, so far, i have never had an accident. I fully understand the patient above being diagnosed with PTSD.

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  7. I suffer from this problem as well. Believe me nothing is more horrifying in public than a bowel accident. There is no hiding it. It's not something my Neuro seems comfortable discussing, however I have been blessed with a uro/gyn PT who is wonderful. She is my hope at the moment as I struggle with this issue. I find myself not participating in things because of this worry.

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  8. Magnesium, Magnesium, Magnesium, Magnesium: 4 time a day in total 400 - 600 mg elementair Magnesium. Magnesium is a salt. Magnesiumoxide contains 60% elemental Magnesium. Each Magnesiumsalt contains a different % elemental Magnesium, for instance only 7% and it is usually not stated on the bottle.

    Magnesium regulates bowel movement.

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  9. I have progressive MS (or whatever it is called these days). Im my case what was believed to be constipation by a 111 GP (on a weekend) was actually acute appendicitis. As a result, I was not sent to hospital and my appendix probably ruptured the following day. Long story short, as a result of this I went from EDSS 3.5 to 6.5 in less than 3 weeks (working climbing up ladders etc to permently being housebound in a wheelchair). Beware and don't hesitate to call for help immediately if required.

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