Bowel Management


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Fact Sheet: Bowel Management in Spinal Cord Injury Effect Of Spinal Cord Injury On Bowel Control Spinal cord injury (SCI) affects all of the things that are learned in toilet training, i.e., the ability to know when a bowel movement is about to occur (sensation) and the ability to prevent a bowel movement (BM) from occuring until the time and place appropriate (motor control of the rectal sphincter). It does not affect the movement of food through the intestinal tract from the stomach to the large intestine. Loss of bowel control is usually more of a social problem than a serious medical complication. Therefore, even though it can be devastating to a patient, the physician may not be very concerned. Goal Of Bowel Management The goal of a bowel program is to have regular bowel movements at a predictable time and frequency with a minimum of "accidents." This is not the same as "bowel control" and there is always the potential for accidents, especially when diarrhea occurs. Ideally, a bowel program should not take more than 30-60 minutes to complete. Initial Training There is no plan that will work for everyone. Each person must be treated individually, taking into consideration the following factors: 1. Diet: The amount, type and frequency of eating will affect the bowel program. Regular eating habits and a high fiber diet are recommended. Foods which are known to cause diarrhea should be avoided. 2. Frequency of BM: "Normal" frequency varies from several times a day to once or twice a week. The usual plan is to start with an every other day schedule, then modify as needed depending on the response. An individual's previous bowel history can be helpful. It is not wise to wait longer than three days for a BM because the longer stool remains in the colon, the more water will be reabsorbed and constipation may result. 3. Sensation: Individuals should watch carefully for subtle messages from the body which might precede an "accident" or indicate that a "bowel program" is needed, such as, sweating, "goose bumps," a sense of fullness in the lower abdomen, a general feeling of restlessness. 4. Timing: The time of day for the BM is dependent on the individual's daily schedule. However, it is important to be consistent - schedule for the same time of day every time. 5. Position: Except with high quadriplegics, the sitting position is preferred so that gravity can assist bowel emptying. 6. Stimulation: It is usually necessary to provide some type of stimulus to initiate the bowel movement. This can be rectal stimulation with a gloved finger, a suppository (such as Dulcolax or Glycerine), Therevac mini-enema, or an enema. Rectal stimulation with gloved finger must be done gently in order to avoid damaging the delicate membranes lining the rectum. 7. Enemas: Enemas are strongly discouraged for routine use. It is often difficult to retain enema fluid or to expel all of the fluid. Regular enema use causes loss of elasticity of the bowel wall, resulting in bowel sluggishness and increased problem with impaction. Solutions used for enemas can also cause irritation of the bowel lining. 8. Fiber: Fiber is the indigestible part of food and is an essential part of any good diet because it helps to retain water in the stool and keep it from getting too hard. It is found especially in vegetables, fresh fruit and whole wheat breads. Additional fiber can be obtained from bran cereals (preferably whole bran) or by adding 2-4 tablespoons of unprocessed bran flakes (available in grocery stores) daily to the diet. Bulk laxatives, such as Metamucil, also contain fiber. 9. Laxatives: TO BE AVOIDED, EXCEPT AS A LAST RESORT! because it will result in bowel accidents. Mild stimulants, such as prunes or prune juice, may be helpful. Problem Solving Suggestions It must be understood that there is no magical answer to any bowel problem. Trial and error, plus following a consistent routine, is the only way to be successful! 1. Bowel accidents occurring before the scheduled time: If this is happening often, it may be necessary to schedule more frequent BM's. It could be due to inadequate emptying during the bowel program. Be sure lower bowel empties completely. If happening consistently after certain foods, these foods should be avoided. Reduce intake of stimulants such as caffeine. 2. Diarrhea: (Abnormal frequency and liquidity of feces.) If stools are liquid, check for an impaction and remove it. Medications, especially antibiotics, may cause diarrhea. Following a course of antibiotics, it is advisable to eat 6-8 oz. of yogurt daily (with active culture) for several days. 3. Stool too soft: Add more fiber to the diet. Add "constipating" foods to the diet such as, cheese, meat and starches. 4. Constipation: (infrequent or difficult evacuation of feces.) Add more fiber to the diet. (See #8 above). Be sure fluid intake is adequate. Sometimes fluids are restricted as part of bladder management. It is important to find a fluid intake that is suitable for both bowel and bladder programs. Review medications. Constipation is a side effect of many medications, especially pain medications, anticholinergics (often used to treat bladder spasms), antacids and antidepressants. Check with your pharmacist about any medications you are taking - including nonprescription drugs. 5. Impaction: Impaction is a collection of hardened feces in the lower intestine. It should be suspected when there has been no BM for 3-5 days. This is probably the most common complication and can be difficult to manage if occurring frequently because it suggests poor or sluggish bowel tone. Although impactions are usually low enough to be reached with a finger from the rectum, they can also occur high in the transverse colon. The impaction must be removed, either manually or with enemas, followed by an effort to establish a regular bowel program for very two days with increased fiber intake. Lactulose syrup (available on prescription only) may be helpful in softening and mobilizing the impaction if other methods fail. 6. Hemorrhoids: A common complication, especially associated with chronic constipation. Although rectal bleeding is usually due to hemorrhoids, it should always be investigated to rule out more serious conditions. If they become severe, surgical removal may be indicated. 7. Autonomic Dysreflexia: For injuries above T6 who have dysreflexia frequently associated with BM, preventive medication can be used, such as 2.5 mg. Inversine 1 hour before a planned bowel program. References: Cosman, B. C., Stone, J. M., Perkash, I. (1991). "Gastrointestinal Complications of Chronic Spinal Cord Injury," Journal of American Paraplegia Society, Vol. 14, 175-181. Longo, W. E., Ballantyne, G. H., Modlin, I. M. (1989). "The Colon, Anorectum, and Spinal Cord Patient," Dis. Colon Rectum, Vol. 32, 261-267. Nino-Murcia, M., et al. (1990). "Colonic Transit in Spinal Cord Injured Patients," Investigative Radiology, Vol. 25, 109-112. Developed by: Shirley McCluer, MD, Medical Director, Arkansas Spinal Cord Commission. Date: July, 1992. Published by: Arkansas Spinal Cord Commission, 1501 North University, Suite 470, Little Rock, AR 72207. Phone: (501) 296-1788 (voice) / 296-1794 (tdd)