Regaining the Simple Pleasure of Regularity

by Christina Medvescek on Mon, 2003-09-01 15:45

It’s a subject that lends itself easily to jokes, but when it happens to you, it’s no laughing matter. Constipation is a real pain in the you-know-what.

Constipation is defined not by how frequently you move your bowels, but by whether the stools are hard, dry and difficult to pass. It’s not necessary to have a daily bowel movement. If you’re only going every couple of days, but can complete the task without straining, then you’re not constipated.

Does ALS cause constipation?

Diane Huberty
Diane Huberty

Although not a symptom of the disease, constipation is a common side effect of ALS for several reasons, says Diane Huberty of Fort Wayne, Ind., a retired neuroscience nurse who has ALS.

Decreased movement: Inactivity slows down peristalsis — the smooth muscle contractions that move waste through the intestines. "Anything that changes the speed with which foods move through the large intestine causes problems," Huberty says. The longer waste sits, the more water it loses to body absorption and the harder it becomes. This problem is further aggravated if you don’t go when you feel the urge, perhaps because you’re waiting for assistance or to use your home toilet.

Swallowing problems: To prevent choking, many people don’t eat nutritiously or drink enough liquids, both of which make stools harder. People with ALS sometimes drink less to minimize their bathroom visits as well.

Muscle weakness: As respiratory, chest and stomach muscles weaken, it becomes difficult to "take a deep breath and bear down, something we don’t even realize is important in having a bowel movement until we cannot do it," Huberty says.

Diet, routine, position and laxatives are the best ways to keep things moving smoothly.

Diet is the first defense

Fiber and fluids are the key ingredients in an anti-constipation diet, but they must be taken together.

Fiber is simply indigestible bulk that absorbs water in the colon (helping waste product stay softer) and fattens up the stool (helping stimulate involuntary muscles to move it along). Obviously, fiber can’t do its job if there isn’t enough fluid present; in fact, it can be counterproductive.

Gentle dietary fiber can be found in raw fruits and vegetable like apples, strawberries, lettuce and celery. Because this type of fiber is at least partially digestible, it has a mild effect on peristalsis. The fiber found in bran, seeds or high-fiber cereal or bars is completely indigestible, and so acts more vigorously. Without adequate fluid, this type of fiber can become cementlike and cause additional constipation. When muscle weakness is severe, this type also can make the stools too bulky to pass.

If swallowing problems make it hard to drink enough fluid, consider thickening your drinks into slushes or milkshakes, or using a no-taste thickener such as Thick-It. Many natural sources of fiber, such as fresh fruits, already contain fluid, so you get both at once.

The same dietary principles — fiber and fluids — also apply in tube feeding. Check with your doctor about using a high-fiber formula.

A good routine, a good position

Greg Carter
Greg Carter

The body is a creature of habit, so if you can get used to going at a certain time, you increase your chances of regular success.

Greg Carter, co-director of the MDA/ALS Center at the University of Washington Medical Center in Seattle, suggests these steps for creating a reliable bowel routine:

1. Pick a time of day and stick with it. Peristalsis is naturally stimulated about 20 to 45 minutes after a light meal, and is usually strongest after breakfast (although lunch and dinner work as well). Choose a time when you’ll have at least 15 uninterrupted minutes on the commode.

2. Drink a hot beverage, preferably with caffeine, to stimulate your bowels.

3. Get on the toilet and insert a Dulcolax suppository, then lightly circle the skin around the anus (on the outside) to trigger the colon to move.

In chronic constipation, the colon may have become distended and lost muscle tone. It can take up to six weeks to establish a normal bowel routine in this case, so be patient.

Position on the toilet is also important. Sitting upright, especially with your feet off the floor, does little to help with elimination. Squatting is better. This position opens up the muscles of the pelvic area, angles the bottom for the best mechanical advantage, braces abdominal muscles and pushes the thighs into the abdomen to provide extra force.

To achieve a reasonable and safe squat on the toilet, rest your feet on a footrest that’s about a foot off the ground, such as a stool or walker rung, then lean forward. For additional force, hug a pillow to your abdomen. If you use a hygiene or toileting sling that holds you over the toilet, ensure that your buttocks are the lowest part of your body. This position usually results in a bowel movement in about one-tenth the time required when lying down and using a bedpan.

Diagram of helpful toilet position
A squatting position, with the body leaning forward and feet resting off the ground, is best for moving the bowels.

Lowdown on laxatives

Basically, there are three kinds of laxatives:

Bulk or fiber laxatives, such as Metamucil or Citrucel, are essentially a concentrated form of dietary fiber.

Stool softeners, like Colace, keep water content high or lubricate the stools.

Stimulants, such as Senokot, increase involuntary muscle contractions, moving the stool along quickly.

People with ALS should exercise caution with bulk or fiber laxatives, especially if swallowing is difficult. Without adequate fluid intake, fiber laxatives can swell up in the throat, esophagus or intestine, creating a dangerous blockage. They also can gum up a feeding tube unless adequately flushed with water. Follow package directions carefully.

Carter recommends a daily capful of MiraLax (available by prescription) in eight ounces of water. This strong "osmotic" laxative pulls water into the intestines and helps soften stool.

Tahseen Mozaffar, co-director of the MDA/ALS Center at the University of California at Irvine, says that when adding fiber doesn’t do the trick, he may prescribe Mestinon, a drug used to relieve muscle fatigue in ALS patients. A common side effect of Mestinon is increased bowel movements, "which works fine with people who are constipated," he says.

Stimulant laxatives, while working quickly, can result in dependence if overused — in other words, you can’t go without them. But if nothing else will keep you regular, this may be your best option, so consult your doctor.

Carter says he’s heard positive reports about an herbal stimulant laxative tea called Smooth Move (made by Traditional Medicinals and available in health food stores or online). Patients report using it on a weekly or monthly basis with good results.

Mineral oil and enemas should be used only occasionally. Mineral oil can interfere with the absorption of some vitamins, and enemas distend the bowel, which can eventually cause loss of bowel tone.

One final tip: "Comfort is important in order to concentrate on the job at hand," says Huberty, noting that shrunken buttocks muscles can get sore on a hard seat. Her padded toilet seat has been "a real lifesaver!"

Christina Medvescek
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