BOWEL MANAGEMENT

INTRODUCTION

The Digestive System 

To help understand how the bowels are affected by a SCI, it’s helpful to understand the anatomy of the human digestive system since the bowel is part of that system.

Small Intestine: Digestion and absorption of food

Colon: Absorption of water and excretion of solid waste material

Rectum: Holds stool for a short time until evacuation happens

Anus: Muscles relax to allow contents from rectum to be released

A bowel movement happens when the rectum (last portion of the bowel) becomes full of stool and nerves send a message via the spinal cord to the brain. When one is ready to empty the bowel, the brain sends a message back down the spinal cord to the bowel, telling the external anal sphincter muscle to relax and open. Stool then passes from the rectum to exit the body. A spinal cord injury changes the way the bowel works due to interruption of messages between the bowel and the brain. The term used to describe this condition is a neurogenic bowel.

WHAT DO I NEED TO KNOW?

Introduction to Neurogenic Bowel 

A neurogenic bowel is the medical term used to describe the condition that affects the bowel after SCI. These are the types of neurogenic bowel:

1. SPASTIC (REFLEXIC) BOWEL, which is from an Upper Motor Neuron (UMN) injury above T12.

2. FLACCID (AREFLEXIC) BOWEL, which is from a Lower Motor Neuron (LMN) injury below T12.

It is important that a person with a SCI understands their bowel type as this will determine their bowel management program. Is it a spastic (UMN) bowel or a flaccid (LMN) bowel?

WHAT CAN I DO?

Part of your rehabilitation program will be about learning whether your bowel is spastic or flaccid so you can try different ways to manage your bowel function that match how your bowel works after SCI. It can take time and trial and error to learn how to effectively manage your bowel function after SCI.

Strategies for Managing a Spastic/Reflexic Bowel (Injuries above T12)

If you have this type of neurogenic bowel you may not feel the need to have a bowel movement, however the reflex that makes you move stool is still there. You can stimulate this reflex by digital stimulation and/or stimulant suppositories (described below). A common bowel routine for someone with a spastic bowel is to empty every other day or 3x/week. A bowel routine should take no longer than 1 hour.

Spastic Bowel Routine Example

● Morning routine: take stimulant laxative in the evening 8-12 hours before bowel routine, insert suppository in the morning after breakfast, wait 10-15 min, transfer to commode chair (if applicable), perform digital stimulation (if needed).

● Evening routine: take stimulant laxative in the morning 8-12 hours before bowel routine, insert suppository in the evening after dinner, wait 10-15 min, transfer to commode chair (if applicable), perform digital stimulation (if needed).

Note:

• Always use plenty of lubricant.
• Be gentle. (If you push or rotate your finger too roughly, you can irritate or tear the lining of the rectum or the anus).
• Assistive devices such as a suppository inserter, finger extension or digital stimulator may be required to assist you in establishing a successful bowel program.
• Use caution as overstimulation can lead to an increase of incontinence and increased mucus production.

Strategies for Managing a Flaccid/Areflexic Bowel (Injuries at or below T12)

A flaccid bowel is the result of an injury below T12. The bowel reflex is lost as the nerve to the rectum is damaged. A person with SCI can’t feel the need to have a bowel movement, the rectum can’t easily empty by itself and the sphincter muscle may relax, staying open. To manage a flaccid bowel the bowels may need to be emptied frequently and is usually done daily but can be done every other day or twice per day.

Flaccid Bowel Routine Example

• Take stimulant laxative 8-12 hours before desired bowel routine. (The goal is to decrease laxative use slowly until none are needed).
• Transfer to a toilet (or commode or raised toilet seat).
• Remove stool from rectum using digital removal with a gloved finger.

Establishing an Effective Bowel Routine 

An effective bowel routine is meant to help regain control of bowel functions after a spinal cord injury by:

• Establishing a routine for a predictable bowel movement at a planned time.
• Having adequate care organized to assist with the bowel routine if needed.
• Ensuring that bowels are completely emptied and that the routine is completed in less than one hour.
• Minimizing or eliminating bowel accidents.
• Keeping bowel-related concerns and problems to a minimum.

It is important to create a routine that increases personal confidence and self-image. Each person’s bowel program should be individualized to fit his or her needs.

Consider the following factors when developing a bowel routine that works for you:

• Fluids: Fluids are crucial to maintaining a healthy bowel routine. Many other factors will not be effective without taking in enough fluids. Drink enough “healthy” fluids to keep stool soft (approx. 2 litres per day). Note that healthy fluids do not include caffeine or alcohol beverages, as these will cause dehydration.
• Diet: Fibre plays a key role in establishing a successful bowel routine. A person with a SCI must learn how fibre impacts their bowel routine as well as which foods affect their bowel routine. The following are common irritants that can result in diarrhea/loose stools.
• Timing: find a time that works best for the person with the SCI; do bowel care at same time each day; bowel care is best done 30 minutes after a meal or hot drink to take advantage of the stomach reflex; a bowel routine should be completed in less than an hour.
• Pre-injury bowel routine: How did your bowel work before your injury? When do you tend to have a bowel movement?
• Positioning: A raised toilet seat or commode, or elevating the feet on a small footstool if you’re using a toilet, can increase the speed of bowel routine, as gravity will assist in bowel emptying.

It can be a long process to find a bowel routine that works for you, and your bowel function can change depending on what you eat, drink, levels of stress in your life and many other factors. It’s important to revisit these factors above if you are having trouble maintaining a routine that works for you, and reach out for help. See the “Who Can Help Me” section below for ideas.

SELF MANAGEMENT AND PROBLEM SOLVING

Over time, you will adapt your bowel program to changes in your body and your lifestyle, and as you learn more, you will become more skilled in your self-care. From time to time, you may encounter problems with your bowel program. Constipation, bowel accidents, hemorrhoids and other problems can have a major impact on your daily life.

When you’re having a problem and you’re not sure what to do, the best option is to use this problem-solving approach to tackle it:

Step 1: Identify the problem. Start by getting a clear picture of what’s wrong. If you’re having problems with constipation or bowel accidents, pay attention to when they happen and what seems to cause them. If you have problems with hemorrhoids, make sure you know where they are, and how severe they are.

Step 2: Gather information. Try to get a better understanding of what may be causing your problem, and some different ways you might try to solve it. This may involve doing research or consulting health care providers. You may also find it helpful to speak with peers, people who have had similar experiences. Make sure you evaluate the reliability of the information you find, and try not to rely on information from only one source.

Step 3: List possible solutions. Based on the information you find, list some things you might try. To deal with constipation, you might want to adjust your diet and drink more water. For hemorrhoids, you may want to keep your stool soft and take special care when doing digital stimulation.

Step 4: Try one & evaluate the results. Using your list of solutions, choose the one that seems best and give it a try. It’s important to make only one change one at a time so you can tell whether it works or not. Make sure you keep track of what you do and what the results are. If you solve the problem, that’s great! If not, you may want to go back to step 3 and choose another option. Problem-solving can involve lots of trial and error.

Step 5: Know when to ask for help. Don’t try to take everything on by yourself. You can ask your health care team for information and help with your problem-solving, as your needs change over time.

TROUBLE SHOOTING YOUR BOWEL ROUTINE

Even with a well-practiced bowel routine, many factors can throw things off or signal that you may need to make changes to your bowel routine.

● Medication: Side effects of some medications can interfere with a bowel routine. For example, some medicines (such as codeine, Ditropan) can cause constipation, while others (including some antibiotics) can cause diarrhea. Learn how the side effects of medication can affect the bowel program.

● Illness: A case of the flu, a cold or an intestinal infection may affect a bowel routine. Even if the digestive system is not directly affected, eating habits, fluid intake or mobility may change, which can alter a bowel routine.

● Activity level: Regular movement or activity can help to manage bowels e.g. exercise, weight shifting, range of motion exercises. These help to move the stool through the colon and avoid constipation.

● Age: Along with aging often comes decreased activity and muscle tone of the bowel resulting in slower movement of stool.

● Weather: Hot weather increases the evaporation of body fluids, which can lead to dehydration and constipation.

DEALING WITH BOWEL COMPLICATIONS

Inevitably you will encounter complications with your bowel routines, some you will be able to take care of yourself but others will require assistance from your health care professionals.

Bowel Accidents:

Unplanned bowel movements may happen for various reasons. It is important to determine the cause for possible solutions.

WHO CAN I TALK TO ABOUT THIS?

CONCLUSION 

Management of bowels after SCI involves planning and scheduling. Keeping the bowels emptied on a regularly scheduled basis to avoid accidents is the goal of a well-designed bowel routine.

 Key points for establishing an effective bowel routine:

● Establish a regular routine by keeping with the same frequency, same time of day and same method.

● Time, comfort, privacy, relaxation, and good positioning help facilitate a productive bowel movement.

● Take advantage of the stomach reflex which moves the bowel at 30-40min after eating (this reflex is usually strongest after the morning meal).

● Keep it simple by making one change at a time as needed, allowing 3-5 bowel days to see effect.

● Be patient as training the bowel takes time. It is helpful to keep a bowel journal while making changes.

RESOURCES

• My Bowel Care Program – A worksheet from Spinal Cord Essentials for tracking your bowel movements.
• Diet and Bowel Management – A handout from Spinal Cord Essentials on diet and managing your bowel.
• Autonomic Dysreflexia – Jump to the LivingWithSCI.ca page on AD.

Videos

• SCi-U: Neurogenic Bowel
• Managing a Spastic Bowel
• Managing a Flaccid Bowel
• Insertion of Suppository
• SCI-U Diet and Eating Habits 
• SCI-U: The Perfect Program
• SCI-U Dealing with Diarrhea
• SCI-U: Dealing with Constipation
• SCI-U Dealing with Hemrrhoids
• Bowel Problem Solving