BOWEL MANAGEMENT

After a Spinal Cord Injury (SCI) the connection from the brain to parts of the lower gastrointestinal system is damaged, and the large and small bowel can no longer empty on demand. You may not be able to feel when it’s time to have a bowel movement. It’s possible to manage your bowel function after spinal cord injury through planning, a bowel routine and understanding how different foods affect you. The goal of a bowel routine is to empty the bowel regularly on a scheduled basis to prevent accidents, avoid constipation and assist with overall health.

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. spinal cord injury bowel digestive 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. bowel nervous system control spinal cord injury

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?

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UNDERSTAND YOUR BOWEL

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.

Digital Rectal Stimulation  Digital rectal stimulation is a technique used to stimulate the bowel reflex to start a bowel movement. 1. Gently insert a well lubricated gloved finger (or adaptive device) 1-2 inches into rectum. 2. Rotate finger in a circular motion for 10-30 seconds keeping the finger in contact with the rectal wall to trigger the bowel reflex and muscle contractions. 3. Perform digital stimulation every 5-10 minutes and continue until there is no stool in your lower bowel.

Insertion of Suppository  Check bowels first by gently inserting a well lubricated gloved finger into the rectum. If there is stool present, hook the stool with the gloved finger to remove it. Then place the lubricated, medicated suppository into the rectum against the wall of the bowel. Inserting the suppository may work better when lying down as it may fall out while sitting up on commode or raised toilet seat.
Abdominal massage Can be effective while on the commode or raised toilet seat. This involves massaging or running a firm hand over the lower abdomen in a circular, clockwise motion from right to left to increase bowel activity.

RESOURCE

Digital Stimulation Handout

RESOURCE

Bowel Management Overview Handout

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.
Digital (finger) Removal:  Insert well lubricated gloved index finger into rectum, gently hook and remove stool, repeat every 5 minutes until rectum is emptied.
Consider using a glycerine suppository to help lubricate rectum for easier passage of stool.
bristol stool chart spinal cord injury rehabilitation Keep stool at a firm consistency by balancing diet and possibly the help of medications. See the Bristol Stool Chart for a guide to stool consistency.
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.

Consistency: Diarrhea
Diarrhea: Frequent loose or watery stools that may cause unplanned bowel movements. Tips for Loose Stool:

  • Concentrate on foods that are high in soluble fiber. Examples: squash, oatmeal, Psyllium. Consider foods that harden the stool such as white rice, white bread, pasta, dairy, bananas and applesauce.
  • Avoid foods that irritate your digestive tract. These vary between individuals but may include pears, caffeine, alcohol, chocolate, strong spices or fried foods.
  • Avoid large amounts of sugar, candy, syrup, and sugar free candy, as these products will cause more fluid to accumulate in the gut.
Consistency: Constipation

A common condition where stool may not pass as often, as fast, or as completely as planned. Stool is formed and hard. Tips for Constipation

  • Include extra fiber at all meals. Examples are flax seed, wheat bran, fruits and vegetables with the peel, green leafy vegetables, nuts, whole grain breads and pastas.
  • Avoid high fat foods and foods that harden the stool.
  • Know your medications: Many common medications can constipate. Over the counter allergy, decongestant and anti-diarrheal medicines as well as opioid painkillers and anti-cholinergic drugs used to help manage bladder spasms (Ditropan, Detrol) can cause or exacerbate diarrhea. Talk to your prescribing doctor or pharmacist for tips on how to address these side effects, and ensure you drink an extra glass of water whenever you take these medicines.

Impaction: a partial or complete blockage in the intestine of stool. There may be leakage of liquid stool around the impaction. A stool softener will help soften the stool for easier passage. Avoid foods that harden the stool, eat foods that help soften the stool.

Hemorrhoids/Rectal Bleeding

Hemorrhoids/rectal bleeding is swelling of tissue surrounding the anus. Small amounts of rectal bleeding may be seen in the stool or during bowel care. If you see blood on your stool or toilet paper, you should discuss it with your family doctor for treatment. Frequent AD during bowel routines may also be triggered by hemorrhoids. Strategies to deal with hemorrhoids include softening stool with medication (such as stool softeners) and increasing fluid intake, or doing very gentle digital stimulation using Xylocaine jelly to lubricate the finger or on a suppository. You can also try over the counter medications that can help decrease the swelling and/or pain from hemorrhoids. These products are usually applied after bowel care.

Autonomic Dysreflexia (AD)
AD is a complication of spinal cord injuries at T6 and above, and it may occur during routine or unplanned bowel movements.  It involves a sudden rise in blood pressure (BP) in response to an irritating stimulus – it is how your body responds to something that would normally cause you pain below the level of your injury. AD can be a medical emergency if not treated immediately. Bowel movements and bowel routines are a known trigger of AD, particularly a full bowel, digital stimulation or while stool is passing.  It can also be triggered by the presence of hemorrhoids. Symptoms of AD may include: headache, sweating and chills, increased blood pressure above your normal. Note: If a person with a SCI becomes dysreflexic during their bowel routine, stop procedure and treat AD, and make sure to report to your physician if you have never experienced this before. Troubleshooting bowel-related AD triggers:

  • Digital stimulation: Try adding Xylocaine jelly, a topical anesthetic used like a lubricant, if digital stimulation causes AD.
  • Full bowel: Work on increasing the frequency of your bowel routine and maintaining soft stool by drinking more water, and making dietary changes.
  • Hemorrhoids: It is best to have a physician determine whether your hemorrhoids need to be treated in order to minimize them as a trigger of AD.
Dealing with Accidents

Managing your bowel routine can be one of the more challenging things to master after spinal cord injury, and it’s normal to deal with a few unplanned bowel movements on occasion. Unfortunately, it can be embarassing, and it’s important to your skin health and dignity to be able to deal with an accident promptly. One way to ensure you have what you need to get clean after an unexpected bowel movement is to carry a small kit with everything you need – it can stay in your purse, backpack or vehicle for when you need it. Your kit could contain:

  • Wet wipes in an airtight container or ziploc bag
  • A change of clothes in a neutral colour
  • Extra plastic bags for dirty clothes
  • A pair of vinyl gloves
  • Any supplies you usually need for your bowel routine

Video:

SCI-U: Dealing with Diarrhea

Downloadable Resource

Troubleshooting Frequent Bowel Accidents

WHO CAN I TALK TO ABOUT THIS?

Family Physician
Your family physician is your primary partner in looking after your everyday medical needs after SCI. Physicians can help identify complications early and help determine whether you are experiencing difficulties related to bowel management or another health issue that needs medical attention. They can refer you for more specialized help from GF Strong Rehabilitation Centre with your concerns, prescribe medications that might help support your bowel management.
Physiatrist (Rehabilitation Medicine Specialist)
Physiatrists, or rehabilitation medicine specialists, are most familiar with how your spinal cord injury affects your body systems, such as your gastrointestinal system, and they recommend all individuals with SCI see their Physiatrist at least every 1-2 years. If you are struggling with your bowel function or you have other spinal cord injury related concerns that are affecting your bowel care, it’s important to consult your Physiatrist.
Nurses
GF Strong Rehabilitation Centre has a Clinical Resource Nurse who is an expert in techniques and tools for managing neurogenic bowel. You can get a referral to GF Strong through your family physician to see the Clinical Resource Nurse for support with your bowel management. Some health authorities have outpatient nurses at community and home health nursing clinics who may be familiar in managing neurogenic bowel. Ensure that you work with someone who has experience dealing with neurogenic bowel before making changes to your routine.
Occupational Therapists
Occupational Therapists (OTs) can provide valuable suggestions for tools you can use to better manage your bowel function. For example, occupational therapists have created devices to assist those with low finger dexterity to perform their own digital stimulation, or applicators for suppositories for people without wrist function. Occupational therapists can be found at GF Strong Rehabilitation Centre or a rehabilitation centre near you. They are also available through most health authorities by referral from your family doctor.
Dietitian
Having a balanced diet that is high in fibre and includes sufficient water intake is crucial to managing a neurogenic bowel after SCI. A Dietitian can identify how to improve your fibre and fluid intake and identify problem foods or eating habits that may contribute to unplanned bowel movements. Dietitians can be found through health authorities and community health clinics, sometimes through your family doctor’s office, or through HealthLinkBC’s Dietitian Services, available by dialing 8-1-1 from anywhere in BC.
SCI BC Infoline
Spinal Cord Injury BC’s Infoline is here to connect you to resources and support for anything spinal cord injury related, including Bowel Management. If you have questions, want to talk to a person with SCI about their routine or specific products, or you need to find help with a specific problem, contact SCI BC’s Infoline information specialists today. Infoline receives thousands of questions from people with spinal cord injury each year and is staffed by people with SCI and other disabilities with expertise in social work and rehab counselling. Phone: 1-800-689-2477 (Monday to Friday, 9am-5pm) Email: info@sci-bc.ca

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.

 

SUMMARY OF RESOURCES

Videos:

This website contains general information about medical conditions and treatments. All information, content, and material of this website is for informational purposes only and are not intended to serve as a substitute for the consultation, diagnosis, and/or medical treatment of a qualified physician or healthcare provider. (c) 2018 Spinal Cord Injury BC