Bowel issues in NMOSD

Bowel issues in NMOSD – Transverse myelitis

Transverse myelitis (TM) is inflammation of the spinal cord.  Any inflammation here causes swelling which presses on the nerves in the spine and disrupts the messages.  The last two nerves on the spinal cord control bladder and bowel.  Any swelling about this can affect the bowel, causing loss of sensation in the rectum and/or control of the anal sphincter resulting in constipation and/or incontinence.

The bowel has 2 major functions:
* Digesting food and absorbing nutrients into the blood stream.
* Eliminating waste products at a convenient and appropriate time.

The digestive system includes the mouth, oesophagus, stomach, small and large intestines (known as the bowel). The end of the large bowel is a section known as the rectum. This pouch is where faeces are temporarily stored prior to emptying. Sensors in the rectum send messages to the brain making you feel the urge to go to the toilet. These nerve endings are sensitive enough to distinguish between wind, solids and liquids.  Bowel habits vary from person-to-person.

Constipation
Constipation is defined as passing hard stools with excessive effort usually less than three times a week. Being constipated can cause discomfort, flatulence, bloating, tiredness, fatigue and loss of appetite.  In NMOSD, the bowel movements are slow. The longer the faeces is in the large bowel, the dryer it becomes making it more difficult to pass. Sensory loss in the rectum can also contribute to constipation as the person is unaware of the need to open bowels and the faeces dries and hardens. Weakness of the anal sphincter and pelvic floor can contribute to this issue. Occasionally, the watery, partially formed stools that build-up behind the hard stools causes diarrhoea alternating with constipation.

What can I do to help myself?
What you eat and drink has a massive impact on your bowel. Eating regularly helps the bowel as it keeps it stimulated. Skipping meals has the opposite effect and makes the bowel sluggish.
* Ensure you drink plenty of fluids. Current guidelines recommend 6-8 glasses of water per day but juice, cordial, skimmed milk and decaffeinated tea/coffee are fine.
* Try to establish a good routine by going to the toilet about 30 minutes after breakfast as this is when the urge to open your bowels is strongest.
* Take regular exercise as this strengthens the muscles and contractions within the bowel. Even walking for 15 minutes a day will help.
* Correct posture – How you sit on the toilet can affect how easily you are able to empty your bowels. The correct position for doing this is with your knees higher than you hips. You can easily do         this by resting your feet on a step or small stool. Make sure you get enough fibre in your diet as this helps push the contents of the bowel along. Eat more fibre.

There are two kinds of fibre, soluble and insoluble, both are important. Soluble is from fruit like bananas or apples, nuts, grains such as oatmeal, root veg such as carrots and potatoes and beans/pulses. Soluble fibre helps to bulk your poo and keep it soft whilst also having benefits for your heart. Insoluble fibre, found in wholemeal rice and bread also bulks and is important in moving the contents of the bowel along.

Management – Medication
A good diet high in fibre with plenty of fluids is the key to preventing constipation. Sometimes however these are not enough and medications are required.
Laxatives – often bought over the counter, should only be used as a short term solution:
* Bulk forming laxatives – such as Fybogel work like fibre you get from your diet by increasing the bulk of the faeces, however you need to drink 2 litres of fluid a day for this to work well.
* Stool softeners – such as docusate work by softening the faeces, making it easier to pass.
* Osmotic laxatives – such as Movicol work by delivering fluid to the large bowel that cannot be absorbed by the gut. It is then absorbed by the stool making it softer. It is important that these are       taken exactly as per instructions or they will not work.
* Stimulant laxatives– such as senna cause stronger contractions in the bowel pushing the faeces along.

Continence Products
There are several products available to help with bowel incontinence. Most are available on the NHS but you would need a referral from your doctor or nurse to access the continence team in your area for assessment and advice.
* Anal plugs – these are used to help stop leakage from the anus. There are two types available: a soft expanding foam plug which swells when it comes into contact with liquid; and a soft silicone design with two discs which sit either side of the anus and are connected with a thin tube of silicone and effectively seals the anus until the next time you need to open your bowel. These can be used for 12 hours or more depending on the type.
* Anal irrigation – uses warm water to ‘flush out’ the hardened faeces which can become stuck in the large colon. This is quite useful for people who have limited or no sensation in the rectum or for those unable to push the faeces out. It can be used every other day to prevent build up.
* Continence pads – are a commonly used method to control anal leaking and are available on the NHS. Manufacturers of these products will quite often send samples out to try. Many are very discreet and washable varieties are available.

Other help available
‘Just can’t wait’ toilet cards
These are available from the bladder and bowel foundation at a cost of £5. These can be shown to allow you to go to the front of the queue at public toilets.
Radar Keys:
These keys unlock the 9000 disable toilets located at public areas, restaurants, pubs and office blocks around the country. You can obtain one for approx £5 from your local authority or specialist disabled centres

Useful Links
www.continence-foundation.org.uk
www.bladderandbowelfoundation.org
Radar key
‘Just can’t wait’ toilet card
More information on bowel incontinence
Can I get products on the NHS?
TM Society
Spinal Cord Injury Association (SIA)

If you try any product or idea that helps you in some way please let us know, even if it only reduces the symptoms a little, it may help others too. Please let us know on nmo.advice@thewaltoncentre.nhs.uk