At our support group yesterday the subject of constipation came
up again. Although not the most pleasant subject to discuss, it
continues to be a problem for a lot of members of the group,
especially my wife. The things which have been discussed are
herbal laxatives (Senna Tea, Cascara Sagrada aged Bark capsules,
mineral oil, and castor oil). In addition some members have had
Propulsid prescribed ( my wife included). These items work to
varying degrees for different people. If anyone has any other
suggestions or input for us we would greatly appreciate it.
Our group leader suggested that perhaps sharing her latest
essay, in a continuing series, be with this list. The essay I know
speaks from experience and follows:
PATIENT PERSPECTIVES ON PARKINSON'S
19. CONSTIPATION AND PARKINSON'S
By Donna Dorros
It is ironic that Sid was preparing to write this essay on
constipation, not knowing that it was going to be the cause of
his death.
The reason we had chosen this topic as the next in our series
of essays was that we both felt that more discussion and
information was needed on this subject. It was no surprise to
us, on a recent trip to England, to learn that the #1 medical
concern of Parkinson patients in the United Kingdom was
constipation. This was expressed by members writing in prior
to the annual general meeting of the Parkinson's Disease
Society. We already knew this to be true both from personal
experience and from feedback from hundreds, if not
thousands, of fellow sufferers we had met over the years of
speaking before support groups.
What I have come to understand since Sid's death is that
the problem of constipation in Parkinson's is not well
understood either by doctors or patients. Nor, do they
understand how critical it is that it be well managed.
First of all, in Parkinson's the disease process itself causes
constipation and the most commonly prescribed drugs for
treatment all have constipation as a possible side effect. In
other words, patients have what could be called a "double
whammy" effect.
It might be helpful at this point to define exactly what
constitutes constipation. According to Taber's Cyclopedic
Medical Dictionary it is "A sluggish action of the bowel." The
typical form of constipation which affects most of the general
population from time to time usually responds well to the
conventional forms of treatment. In Parkinson's patients, this
is not necessarily the case because the condition is much more
complex.
In doing a search of the medical literature, I discovered that
in a fairly recent study, it had been determined that
physiological changes take place in Parkinson patients as a
result of the disease process. For one, "abnormal control of the
pelvic floor musculature caused by PD itself may play a
significant role in the constipation of these patients."(1)
Also, "defecatory dysfunction was....significantly more common in
patients being treated with dopaminergic
medications....prevalence appears to correlate with the
duration and severity of PD, not with diet or treatment....In
short-term studies, apomorphine has shown considerable
promise in patients with defecatory dysfunction."(2)
In a follow-up study, it was stated that "There is a
paradoxical puborectalis contraction during straining in PD
patients, thus preventing the normal straightening of the
anorectal angles accentuating the flap valve action and
preventing the onward passage of feces."(3) In this study,
constipation was defined as less frequent bowel movements
rather than difficulty with defecation and may largely be an
expression of delayed colonic transit.
What does all this mean to the average Parkinsonian who
suffers from chronic constipation? As in all aspects of coping
with Parkinson's, you should be an informed and observant
participant in the medical management of the problem.
Together with your doctor, you should develop a strategy
that works for you As each person is on different dosages of
medicine as well as being in a different stage of the disease,
your method of coping with this problem may be unique to
you.
There are a variety of over-the-counter and prescriptive
treatments available for constipation. In using any of these,
patients should work closely with their physicians.
A log of your bowel habits may be helpful in determining if
you have gone too long without a bowel movement and need to
seek further medical treatment. You could have a blockage,
obstruction, or as in Sid's case "acquired megacolon."
"Megacolon is clinically asymptomatic until the late stages
when fecal impaction occurs, and its presence is frequently
unsuspected in neurological disorders....(However), the high
incidence of megacolon in neurologic disorders is out of
proportion to the incidence in the general population."(4)
In the commentary of this study, the authors state:
"Megacolon is a dysfunction of the bowel of unknown origin
giving rise secondarily to characteristic dilatation....the
primary factor is failure of the anal sphincter which should
take place when the rectum contracts." They also stated that
attention to the gastrointestinal tract, particularly the large
bowel, is extremely important in the management of chronic
neurological disorders, such as Parkinson's.(5)
Signals that you may have more than constipation are: a
hardened and distended abdominal cavity after several days of
no bowel movement, which may or may not be accompanied by
vomiting; and decrease output of urine which is darker in color
than normal. Seek immediate medical intervention is this
occurs.
In addition to apomorphine, referred to in the first study
above, there is a new prescription drug which has recently
been FDA approved for use in the United States that might be
of help. It was approved for reflux esophagitis, not
Parkinson's, but it is of interest for its use in decreased motility
in P.D. The name of the drug in the U.S. is PROPULSID.(6)
How strange that the last part of this drug's name is 'SID.'
This essay is a continuation of the series of 18 essays in
PATIENT PERSPECTIVES ON PARKINSON'S which has
already been published in booklet form (purple cover) by the
National Parkinson Foundation and is available free, upon
request.
(1) Edwards LL, Pfeiffer, RF, Quigley, EMM, Hofman Ruth, and Balluff
Mary. Gastrointestinal symptoms in Parkinson's disease. Movement
Disorders 1991;6;2:151- 156.
(2) Ibid.
(3) Edwards L, Quigley EMM, Hofman R, and Pfeiffer RF.
Gastrointestinal symptoms in Parkinson's disease:18-month follow-up
study. Movement Disorders 1993;8;l:83-86.
(4) Lewitan A, Nathanson L, Slade WR. Megacolon and dilation of the
small bowel in parkinsonism. Gastroenterology 1952;17:367-374.
(5) Ibid.
(6) Parkinson's Disease Update. 1993;30:121-123.
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[log in to unmask] (Woody Schneider)
Gaithersburg,MD
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