Constipation

Kathrynne Holden, M.S., R.D.

What is constipation and why does it occur so frequently with Parkinson’s?

Constipation is defined as having fewer than three bowel movements per week. It occurs among many people with PD. Possible reasons include:

1) PD may cause some degeneration of the nerves of the GI tract.These nerves control “peristalsis” – the rhythmic movement of the GI tract, including the colon. When they are affected, peristalsis slows down. Slowed peristalsis of the colon means that the stool moves very slowly, becoming dry and hard

2) Medications used to treat PD (levodopa, dopamine agonists, selegeline, amantadine, anticholinergics, and others) can also cause constipation, again by affecting peristalsis.

3) People with PD often have a craving for sweets, which contribute to constipation by replacing the high-fiber foods that help to soften the stool and speed peristalsis.

4) Very few people drink enough fluids, which are needed to help keep the stool soft and bulky.

Why is constipation a cause for concern? Isn’t it mainly just a nuisance?

At first, constipation may seem more of a nuisance than a real concern. However, there are several concerns, all of which have occurred in some people with PD.

• A person who is frequently constipated, over a long period of time, may develop hemorrhoids, a condition in which part of the tissues lining the anus slip outside, becoming enlarged and painful.

• Another concern is the possibility of bowel impaction, also known as fecalimpaction — a condition where dry, hard feces accumulate in the colon and cannot be passed. Sometimes watery feces may pass around the impaction, as diarrhea, leading the person to believe s/he is not constipated. Bowel impaction can be very painful, and may require hospitalization. In extremecases, surgery may be necessary.

• Still another consideration is that chronic constipation can raise the risk for colorectal cancer.

If constipation is caused by medications or by PD, how can it be controlled?

It’s important to get enough fiber and fluids each day. Besides helping to prevent constipation, fiber can help lower blood pressure and cholesterol, prevent many chronic diseases, and often aids people with diabetes in controlling their blood sugar. Fluids, especially water, work hand-in-hand with fiber to keep the stool bulky.

What does fiber do?

Fiber, along with water, keeps our bowels working smoothly. Insoluble fiber works like a partner with water. Each bit of fiber soaks up water like a little sponge and swells up to many times its size. All these little water-soaked sponges add bulk to the stool, making it soft and easy to pass.They also exercise the muscles of the intestine, so they stay strong and healthy. More frequent bowel movements are often the result.This not only helps prevent constipation, it can also prevent or ease hemorrhoids. These occur when we strain to pass the stool. Fiber may also lower the risk of colon and rectal cancers.

Why can’t I just use laxatives?

Many people prefer laxatives, which are powerful, but work in a different way. Laxatives stimulate the nerve endings of the colon, causing rapid removal of bowel contents. Over time, stimulant laxatives damage the lining of the colon, causing even greater difficulty with constipation.

What sources of fiber are best?

Fiber is found only in plant foods. Foods highest in insoluble fiber are whole grains, cooked dried beans, and fruits and vegetables with edible skins. Wheat bran is an excellent source of insoluble fiber. People who experience constipation should aim for 25 to 35 grams of fiber daily.

If you’re not used to eating whole-grain foods, or apples and potatoes with the skin, it’s best to increase the fiber content gradually. Bloating and gas can occur as the system tries to get used to the unusual load of fiber. Products like Beano have helped many people enjoy a fiber-rich diet. If it’s difficult for you to get enough fiber daily, consider using a product such as Unifiber, which can be added to foods or liquids, and even tube feedings.

What about fluids?

Fluids are just as influential as fiber. Without fluid, fiber particles remain dry and harden, actually making constipation worse. Four to eight glasses of water per day, plus juices, milk, and other beverages are necessary.

What if fiber and fluids aren’t sufficient to manage constipation?

• Diet should be your first treatment for constipation. However, sometimes peristalsis (muscle action in the large intestine) is slowed enough in Parkinson’s disease that other therapies may be indicated. If you get plenty of fiber and fluids, yet still have fewer than three bowel movements per week, it may be necessary to take further steps.

• A remedy used in some hospitals is called the Prune Juice Cocktail. Mix together:

1/2 cup applesauce

2 tablespoons wheat bran (“miller’s bran”)

4-6 oz prune juice

Store in refrigerator.Take a tablespoonful per day at first, gradually increasing until you find the amount that works best. Most people find this mixture quite palatable.

• Some patients report that a serving of prunes or prune juice including pulp 2-3 times per week is beneficial.

• It may be helpful to combine these two suggestions – have a daily spoonful or two of Prune Juice Cocktail, and 2-4 times per week, have a serving of cooked prunes.

• Ask your doctor about a fiber supplement, such as Metamucil, Citrucel, or Unifiber. Metamucil and Citrucel can be stirred into liquids, and are found in most drug stores and grocery stores. Unifiber can be mixed with liquids or stirred into thicker foods, like mayonnaise, applesauce, cooked cereals, and other foods; and if needed, can also be used in tube feedings. Your pharmacist can order Unifiber if not in stock or phone Niche Pharmaceuticals, Inc., Roanoke, Texas 76262, 1-800-677-0355.

• Manual “belly massage” from the bottom of the ribcage to the top of the pubic bone, performed 2-3 times daily, sends mechanical signals to the bowel to “keep things moving.”

• Train yourself to “honor the urge” to have a bowel movement. It may not always occur first thing in the morning or only at home! Likewise, be aware that the natural position for evacuating the bowel is squatting. Raised toilet seat devices may aid mobility, but are not ideal for bowel function.Try hiking your feet up on a small bench while sitting on the toilet.

• Ask your physician about using an over-the-counter stool softener such as Colace or Pericolace. If bowel motility is good but stool is dry and hard to pass, some health practitioners also advise occasional use of infant-sized glycerin suppositories to soften stool in the lower colon and reduce straining.

If you’ve tried all these solutions and still have a problem with constipation, you may need to consult your physician to see if prescription medications or referral to a specialist is indicated.