Managing constipation

This is often the key to managing constipation. Drink 6 to 8 glasses or cups of fluid a day. Drink more if the weather’s hot or you’re exercising.  

Apart from your first pee of the day (which is often darker), pee should be pale yellow. Darker pee means ‘drink more’.   

You may be tempted to drink less if you also have a bladder problem, or your MS makes getting to the toilet difficult. But this can make constipation worse. Talk to your MS nurse, GP or bladder and bowel nurse about how to manage this.  

Fibre makes your poo have more bulk. That makes it easier for it to move along your bowel. But be sure to drink enough. If you don't, your poo can get too hard and won’t move easily.    

• have at least five pieces of fruit or vegetables a day (and ideally more). It can be tinned, dried, frozen or come as a juice. Eat a mix, not just one type of fruit or veg.   
• ditch white rice, regular pasta and white bread 
• instead eat brown rice, whole-wheat pasta and wholemeal bread. These have more fibre in them 
• for breakfast choose whole-grain cereals. These include porridge, Shredded Wheat, bran flakes, Weetabix or muesli (but without added sugar in it) 
• snack on nuts, seeds and dried fruit. Or add them to meals, along with lentils or any kind of peas or beans. Baked beans are rich in fibre too
• some people add a tablespoon of linseeds (also called flaxseeds) to food or a yoghurt.    

When you add fibre to your diet, go slowly. If you suddenly eat more fibre, you’ll get bloated and full of wind.    

Because fibre soaks up water in your bowel, you’ll need to drink more. Without enough fluids, your poo will be hard and your constipation won’t get better.   

Fibre doesn’t make things better for everyone   

Some people find fibre, bran in particular, makes their constipation worse, especially if they don’t drink more. For these people fibre might slow their gut down, or cause diarrhoea. It can make Irritable Bowel Syndrome (IBS) worse, too. Get advice from a doctor, dietician or MS nurse or bladder and bowel nurse. 

Your other MS symptoms might make it a challenge to stay active. But moving more stops your bowels getting sluggish. Exercise that uses your stomach muscles will strengthen the muscle in your bowel and help it push poo along. 

Check out our exercises 

If you use a wheelchair, there are exercises you can do, too.

These are also called bulking agents. Fibre in these soaks up water in your bowel. This makes your poo bigger and heavier. A bulkier poo stimulates your bowels to squeeze more, so it moves along quicker.   

These laxatives may take two to three days to work. Examples are ispaghula husk (also called psyllium). Brand names are Isogel or Fybogel, sachets of high fibre, fruit-flavoured powder. There’s also methylcellulose (brand name Celevac) and sterculia (Nomacol).   

Bulk-forming laxatives are the gentlest on your body and the safest to use long term.

These draw water into your bowels from the rest of your body, and keep it there. This softens your poo.  

They may take two or three days to work. Examples are lactulose (its brand names are Duphalac and Lactugal) and polyethylene glycol (also known as PEG or macrogol). Brand names are Laxido and Movicol.  

Too much causes diarrhoea, so follow advice from a health care professional. It can take a few weeks to get the dose right. Some people need two sachets a day, others manage with one every two days. 

These make muscles in your gut squeeze more, moving poo along faster.   

These take 6 to 12 hours to work. Examples include bisacodyl (brand name Dulcolax), sodium picosulfate (brand name Dulcolax Pico) and senna (brand name Senokot).   

Some health care professionals think senna shouldn’t be used for longer than a week. But for some people with MS senna can be a good long-term solution. Some people using senna will find it works less over time. It should only be used long term on advice from a health care professional. 

These laxatives also let water into your poo to make it less hard. Often stool softeners aren’t enough on their own, so you use them with a stimulant laxative.   

Stool softeners include arachis oil and docusate sodium. Brand names are DulcoEase and Dioctyl.   

You can also get stool softening gels to use as mini-enemas called Docusol or Norgalax.

The type of laxative to take will depend on what exactly is causing your constipation. Different types of laxative can also be tailored to how your individual body works. Your health care professional will advise which laxative is best for your problem.  

A bulking agent on its own may make constipation worse. So you might use one together with another type such as the prescription-only laxative prucalopride (Resolor). 

MS might mean you can’t get to a toilet fast enough. Or it stops you knowing when the laxative is about to work and that you need to empty your bowels. So people using laxatives often feel they need to stay close to a toilet to avoid bowel accidents.   

It’s not a good idea to treat yourself over a long time with over-the-counter laxatives. The longer you use them, the less they tend to work. And overdoing laxatives can cause bowel accidents. Let your GP, MS nurse or continence nurse advise you on what to use, and how to tailor your use of them.   

Some laxatives you can take as a suppository. These let you decide when to empty your bowels, and they work faster. For example, bisacodyl (Dulcolax) tablets take 6 to 12 hours to work. But the suppository version takes 10-45 minutes.  

A suppository is made of a firm jelly-like substance shaped like a bullet. Some are simple glycerin without any medication; others include a laxative. You cover it in lubricant, then push it into your bottom where it melts. Some come with an applicator to help you get it inside. Or it might come as a liquid that’s inside an applicator. You put that inside your bottom and squeeze the liquid out. 

Put a suppository inside your bottom about half an hour before you want to go to the toilet.  

These use a small amount of stool softener which comes in a little tube. You put it inside your bottom, then squeeze out the softener. It works in 5 to 20 minutes, so you need to stay near a toilet.  

Brand names include Enemeez, Norgalax and Micralax.   

If two different types of laxatives haven’t worked, there are two prescription-only alternatives:    

• prucalopride (brand name Resolor). This type of laxative stimulates nerves in the muscles that line your bowel. This makes poo move along it quicker. This drug isn’t recommended on the NHS in Scotland.  
• lubiprostone (brand name Amitiza). It’s not a laxative, but makes your bowel keep more water in it to soften your poo  

Some MS medications can cause constipation. Drugs for these MS symptoms can cause constipation:   

• muscle spasms and stiffness drugs, such as baclofen (Lioresal) and gabapentin (Neurontin)    
• pain medication, such as pregabalin (brand names are Lyrica, Alzain, Lecaent and Rewisca) and gabapentin (Neurontin). Also any painkiller with codeine in it (including Co-codamol, Nurofen Plus and Solpadeine Max or Plus), or any with morphine in it (like Oramorph)   
• bladder drugs like oxybutynin (Ditropan) and tolterodine (Detrusitol or Detrol)   
• depression meds such as amitriptyline (Lentizol, Tryptizol, Domical and Elavil), fluoxetine (Prozac) and citalopram (Cipramil)   

Always speak to your doctor before you stop taking a drug. Explore with your health care professional whether any drugs you're taking are making your constipation worse.   

You can ask for a Medicines Use Review with the pharmacist who gives you your prescriptions. They’ll check if taking these drugs, especially several together, might give you bowel problems.  

In Scotland ask for a Medicines Care Review instead. You may need to ask at several pharmacies until you find one that offers this service.        

You use your finger to make the muscle in your rectum squeeze so that it pushes poo out. You put a gloved finger, lubricated with water-based gel, into your bottom, then slowly turn it around making a circle. You keep your finger touching the lining of your rectum. A carer might also be able to do this for you.  

Do this for up to 20 seconds, then pull your finger out to let a poo happen. You do this a few times every five to ten minutes until you’ve passed all your poo.   

Stop if nothing happens after three tries. Carry out a ‘manual evacuation’ instead.   

It’s best to do digital stimulation (or manual evacuation) sitting over the toilet (or a commode or shower chair with a built-in toilet seat). That's because being upright helps poo move down into your rectum.   

Manual evacuation is when you use your finger to empty your bowel. Before you do this you need a specially trained nurse to teach you how to do it.     

With manual evacuation you stick a gloved, lubricated finger into your bottom. You use this hooked finger to break up or to take out the poo, flushing it down the toilet. If you’re on a bed, you collect the solid poo in a container, then flush it away.  

If the poo isn’t solid enough to be flushed, or the sheet gets poo on it, double bag it (put one plastic bag inside another to stop it leaking). You can then put this with the normal household rubbish.    

You can do manual evacuation over a toilet or commode, or lying on a bed. You’ll need to cover the bed with a disposable protective sheet while you do this. A nurse can prescribe these for you.  For more advice on getting rid of this kind of waste, speak to your bladder and bowel service.  

If your finger or hand control isn’t good, someone else can do manual evacuation for you. This can be a District Nurse or your family carer (once they’ve had training).  

Digital stimulation or manual evacuation is easiest if your poo is around 3 to 4 on the Bristol Stool Chart.  

See the Bristol Stool Chart at the Bladder and Bowel Organisation website

A second line treatment is one doctors try if other first line treatments haven't worked. There's only one second line treatment for constipation caused by MS. It’s called transanal irrigation (TAI). You try this if gentler first line treatments don't work.   

Transanal irrigation (TAI) is when you wash your bottom out with water to make you poo. It makes it less likely that you get constipated or have faecal incontinence (poo leakage).   

TAI lets you decide when and where you poo. It means you spend less time managing your bowel issues.   

You use a pump system or one that works using gravity to push tap water into your bowel. The water is body temperature warm. You use enough to reach past your rectum. This encourages muscles there to squeeze out poo.   

You sit on the toilet (or a commode), then put a tube (catheter) with a balloon up your bottom to get the water up there. Or instead of a tube you use a silicone cone (with no balloon).  

The small balloon in the catheter blows up when it’s inside your rectum. This stops it falling out and seals the water in. If you use a system with a cone, you hold the cone in place.   

With the balloon or cone in place, you insert the amount of water your health professional has recommended. As the water gently stretches the wall of your rectum, it makes you want to open and empty your bowel.  

When you take the tube or cone out, muscles in your bowel squeeze, your bowel opens and water flushes poo out into the toilet. If you need to, you can repeat if it doesn't work the first time.  

You do TAI at home, usually without help from a health care professional. It takes about 20-35 minutes. For the best results you usually do it every 24 or 48 hours.  

TAI stops you getting constipated (or being incontinent) for two days. To start with, you may have to use it every day for the first week. Then ideally you just use it every other day. You can do it yourself or someone can help you.  

A health care professional will decide if TAI is right for you. You can only get a TAI system when first line treatments haven't worked (like drugs or changes to what you eat and drink).   

You get the TAI system on prescription from your GP or a specialist nurse like one from a bladder and bowel service. Before trying it, a doctor or nurse must examine you and teach you how to use it. You'll get a visit from a nurse. They make sure you know how to use it. But they don’t need to be in the room when you use it for the first time.   

To make TAI work, you need to be motivated. It can take up to two months before you feel confident using it.  

You may need to use TAI along with laxatives and digital stimulation (using a finger to encourage you to poo), at least for the first few months. 

TAI won’t work for everyone. Some people give up because it takes quite a bit of time (20 minutes to an hour). But it’s changed lots of people’s lives. It lets them stay in work, go on holiday, and so on. It’s safe and works long-term.   

The TAI systems with a catheter are called Peristeen© and Navina©. The ones that use a cone are Qufora©, Irypump© and Aquaflush©.  

You might see TAI called rectal or anal irrigation. 

This is retraining your bowels. You use tools to improve how muscles work together when you poo. This includes your sphincter and muscles in your belly and around your bowels. Biofeedback might also help you get better at feeling when your rectum is full.    

Only a few centres offer biofeedback. But it might help some people with MS-related bowel problems, especially if their MS isn’t too advanced.   

Electrical stimulation of the nerves involves sending a low level electric current along nerves that connect with your bowels. This can change how the muscles there behave, helping with constipation (and incontinence). This is called neuro-modulation. It can be done in two ways by stimulating either:   

• the sacral nerve. This nerve is at the base of your spine in your lower back   
• or the tibial nerve. This nerve runs up your leg to your lower spine   

Stimulating the sacral nerve (sacral neuromodulation)    

This is also called sacral nerve stimulation (SNM). During minor surgery you have an implant fitted under the skin over your sacral nerve. This is at the bottom of your spine, at the top of your buttocks.     

A wire in the implant – powered by a battery – sends mild electrical impulses to your sacral nerve. This nerve is linked to your sphincter, pelvic floor muscles and bowel. The impulses make the nerve behave more normally.    

A two week trial will see if this treatment works for you before you have the implant permanently put in.     

There are now implants that are safe for MRI scanners if you need a scan of your spine.   

Stimulating the tibial nerve   

If you send a low-level electrical current along your tibial nerve, it can help with bowel problems. The tibial nerve goes up your leg from your ankle to the bottom of your spine. There it works on a nerve that’s linked to your bowel to make it behave more normally.     

There are two ways of stimulating the tibial nerve:   

• Percutaneous Tibial Nerve Stimulation (PTNS)   
• Transcutaneous Tibial Nerve Stimulation (TTNS)    

Percutaneous Tibial Nerve Stimulation (PTNS)     

In Percutaneous Tibial Nerve Stimulation (PTNS) a needle is stuck into the skin above your ankle, near the tibial nerve. An electrode is stuck on your foot. The needle and electrode are connected to a stimulator device.    

A mild electrical current goes up your leg along your tibial nerve to the bottom of your spine. There it works on a nerve that’s linked to your bowels to make it behave more normally. This includes relieving constipation. You may get this treatment at home or in a clinic. It might take several months before you get the best results. 

Transcutaneous Tibial Nerve Stimulation (TTNS)   

With Transcutaneous Tibial Nerve Stimulation (TTNS), instead of the electrode going through your skin, they stick self-adhesive electrode pads on your skin.   

How well does stimulating nerves with electric current work?    

Studies are looking at how well PTNS, TTNS and stimulating the sacral nerve work in MS. That’s why there are no official guidelines for using them to treat MS bowel problems. It's the reason stimulating nerves isn’t offered by all hospitals or bladder and bowel services.     

But we do have studies that show stimulating nerves helps with constipation in general. A 2024 analysis of 11 studies of people who have long-term constipation (but not MS) showed that PTNS and TTNS can help. Using PTNS might cut how many bowel accidents you have. But other studies have found it made little difference, so more studies are needed.   

In abdominal massage you press firmly on your stomach to encourage a poo. For ten minutes you make a movement in a circle with the palm of your hand or fist, moving from right to left.    

It’s thought this stimulates your bowel to squeeze poo faster through it. It might make it softer as well. The evidence for abdominal massage shows that if it works, it doesn't have a strong effect. So abdominal massage won’t be offered to everyone with constipation. But it might be worth trying as an option on top of other treatments.   

Abdominal massage isn't right for all types of constipation. So before you try this, a doctor or nurse needs to check why you’re constipated. If it’s right for you, a trained person must teach you the massage.