Constipation

Some Parkinson’s gastrointestinal (GI) issues are caused by your symptoms and/or the medications used to treat them.

The most common complaints are constipation, slow gastric emptying, cramping and bloating.

The good news is that there are easy lifestyle changes that you can make to prevent and manage these issues and their impacts on your quality of life.

Constipation & GI issues

GI symptoms can significantly impact the quality of life for anyone. Constipation is one of the earliest and most persistent symptoms of Parkinson’s. It causes bloating, discomfort, and nausea and can interfere with the absorption, effectiveness and reliability of your PD medications.

Some people don’t recognise constipation as a problem because it is ‘normal’ for them to have less frequent bowel movements, e.g. waiting a week or longer.

However, GI symptoms are often present years or even decades before Parkinson’s motor symptoms start and they continue to affect people throughout their Parkinson’s progression.

What is constipation?

Everyone is slightly different, but most health care professionals say constipation is when you have less than three bowel movements a week. However, your goal should be to maintain a daily poo.

You may feel the need to strain on the toilet or feel like you haven’t completely emptied your bowels, even after going. Constipation may make you feel bloated and nauseous even though you may not have eaten much.

Why is constipation a problem?

Parkinson’s affects the muscles of the bowel and causes a slower movement of waste through your GI system (aka transit time). This slow movement of the digestive tract causes more water to be reabsorbed and stools harden.

Anal muscles may also contract instead of relax making it difficult to empty the bowel. Not emptying the bowels may affect uptake of medication (e.g., levodopa is absorbed from the small intestine before it can cross the blood-brain barrier).

Changes in chewing and swallowing may also affect your eating and drinking habits.

If left untreated, constipation can lead to:

nausea and lethargy which can further reduce appetite and thirst
bladder issues like urinary frequency, incontinence, and urgency
severe constipation, diarrhoea and bowel incontinence
bowel obstruction in the worst cases, which left untreated could be fatal.

How do I know if I am constipated?

A stool is made up of your digested food, proteins, bacteria, salts, and other things produced and released by your intestines. After you go to the toilet, what you see is the result of your diet, fluid intake, medications and lifestyle. So, what your poo looks like can be a really important thing to tell your care team.

The Bristol Stool Chart, Bristol Poo Chart or Bristol Stool Form Scale is a medical aid designed to classify faeces into seven groups. This chart is used by your care team and it is a great tool for anyone wanting to monitor and improve their bowel movements. The types of stool you see on the chart depends on the time poo spends in the colon. You can use the Chart to check what your poos are telling you, it shows seven different categories:

Rabbit droppings: Separate hard lumps, like nuts (hard to pass)
Bunch of grapes: Sausage-shaped, but lumpy
Corn on the cob: Like a sausage or snake with cracks on its surface
Sausage: Like a sausage or snake, smooth and soft
Chicken nuggets: Soft blobs with clear-cut edges (easy to pass)
Porridge: Fluffy pieces with ragged edges, a mushy stool
Gravy: Watery, no solid pieces (entirely liquid)

Every person will have different bowel habits, but the important thing is that your stools are soft and easy to pass.

Steps to prevent constipation

It is recommended to have at least 2L of fluids per day.
Eat a balanced diet. As a guide, getting the recommended 30 grams of fibre per day if you are male or 25g if female. Be careful not to bulk bowels up with fibre too much if your GI tract is really slow.
Getting moving will help you get moving… exercise is great for constipation.
In people with Parkinson‘s, increasing your fibre intake may actually bulk up your poos and cause further constipation.
Aim to eat 5 serves of vegetables and 2 serves of fruit a day. Smoothies are a great way to sneak them all in.
If advised, choose a breakfast cereal high in fibre (e.g., All Bran, Weetbix).
Gradually add wholegrains into your diet (e.g. use wholegrain or wholemeal bread and wraps, swap to brown rice instead of white, instead of white flour choose flour high in fibre).
Add nuts and seeds into your diet. Put them into salads, on your yogurt and cereal or have small handfuls as a snack.
Add lentils and other legumes into casseroles, bolognaise and soups.
Drink at least 1.5 to 2 litres (6 to 8 glasses) of fluid daily unless advised otherwise by the doctor. The best drink is water.
Your thirst mechanism may be impaired due to PD symptoms so set a timer or use other cues to remember to drink.
Limit caffeine, alcohol, and sugary drinks as they can cause bladder irritation.
Eat smaller meals throughout the day to allow more time for digestion.
Develop good toileting habits. Go as soon as you get the urge as this is the most effective time to completely empty the bowel (e.g. most people get the urge first thing in the morning or following a meal when eating something has stimulated movement in the bowel).
Be aware of the correct sitting position on the toilet. Sit on the toilet, elbows on knees, lean forward and support your feet with a footstool. Relax and bulge out your tummy, relax the back passage and let go — do not hold your breath.
Exercise also plays an important role in the prevention and management of constipation. Aim to exercise more than 30 minutes per day and if possible, vary the types of exercise you do.

Medication

When hydration, diet and exercise are not enough, laxatives may be recommended by your health professional. Laxatives are medicines which help you pass a bowel action. They can make the bowel action softer and easier to expel or they may increase the motility of the bowel.

Laxatives are not regarded as the first step in the management of constipation, but they may be necessary if the steps outlined above have little or no result. The ideal laxative for an individual will depend on which of the factors are causing the problem. Talk to your Nurse, GP or neurologist before taking any laxatives.

Your Care

Remember, the management of constipation for people living with Parkinson‘s is a forever problem.

The first step to improving your bowel control is to have a full continence assessment carried out by a health professional.

If your constipation is severe or acute help should be sought from your GP, a Practice Nurse, or a Parkinson’s Nurse specialist.

For more information, contact the Continence Foundation of Australia’s National Continence Helpline at 1800 33 00 66. The Continence Foundation of Australia is a peak body for awareness, education, and advocacy for those with continence and their carers. www.continence.org.au

For more information:
www.invisibledisabilities.com.au
www.continence.org.au
www.bladderbowel.gov.au
www.toiletmap.gov.au

This Infosheet was kindly reviewed by the Australian Neuroscience Nurses Association and Continence Foundation Australia.

References

Bristol Stool Chart. Continence Foundation of Australia webpage

Adams-Carr, K. L., Bestwick, J. P., Shribman, S., Lees, A., Schrag, A., & Noyce, A. J. (2016). Constipation preceding Parkinson’s disease: A systematic review and meta-analysis. Journal of Neurology, Neurosurgery & Psychiatry, 87(7), 710-718. https://doi.org/10.1136/jnnp-2015-311680

Heaton, K W & Lewis, S J 1997, ‘Stool form scale as a useful guide to intestinal transit time’. Scandinavian Journal of Gastroenterology, vol.32, no.9, pp.920 – 924. Retrieved on 2/3/2007.

Yao, L., Liang, W., Chen, J., Wang, Q., & Huang, X. (2023). Constipation in Parkinson’s Disease: A Systematic Review and Meta-Analysis. European Neurology, 86(1), 34-44. https://doi.org/10.1159/000527513