Bowel Regimen Protocol

Adjusting to life after a spinal cord injury (“SCI”) presents many challenges and changes, including the need to have a consistent bowel management regimen to maintain overall health and wellness, and achieve the highest quality of life possible.

Bowel Management after Spinal Cord Injury

Spinal cord injury disrupts the way the bowel sends signals to the brain about when stool needs to be emptied from the rectum. Post-SCI this signal no longer works like it did pre-injury, and without a quality bowel care program it can lead to further medical complications and falls.

Spinal cord disorders are classified in two ways:

  • neurological level (anatomic level); and
  • how intact the ascending and descending spinal cord pathways are (“complete” or “incomplete”).

All people with complete SCI have neurogenic bowel. Most people with incomplete SCI have some degree of bowel dysfunction.

The degree of bowel function post-injury depends upon the level of disorder, damage, and the completeness of the spinal cord injury.

Reflexive or upper motor neuron (“UMN”) bowel results from paralysis that damages the nerves that control the bowel.

Areflexic or lower motor neuron (“LMN”) results from a spinal cord injury below T-12, thus damaging the defecation reflex and relaxing the anal sphincter muscle.

If injury is above T-12, there is a loss of the ability to sense when the rectum is full, causing the anal sphincter to remain closed. In this instance, bowel movements occur on a reflex basis: when the rectum is full defecation reflex will occur. Loss of sphincter control may result in the inability to have a bowel movement and can lead to impaction, which can be serious.

A reflex bowel program typically involves digital stimulation, which is the manual removal of stool with a gloved finger or dil stick. Manual stool removal can be followed by the use of a laxative product, such as an ENEMEEZ® mini enema, along with circular movement of the finger inside the rectum once the laxative product begins to take effect.

A flaccid bowel program typically consists of manual-only/digital stimulation. After the removal of any reachable stool, it can also be effective to rotate a gloved finger around inside the rectum, massage the stomach, and physical movement to get stool moving.

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How to Create a Bowel Regimen

A bowel management program takes into account the nature of SCI, availability of attendant care, personal goals, life schedules, employment, and quality of life.

Neurogenic bowel programs are typically initiated during acute care and continued throughout life unless full recovery of bowel function returns. Careful measures must be taken to avoid pressure ulcers and falls.

In addition to risk of physical complications, social and emotional support should be available to help manage the emotional and mental impact associated with SCI and bowel management.

All aspects of a bowel care should be designed to be easily replicated in the home and community environment. Constipation care to minimize risk of further health complications and bowel accidents is especially important.

Establish a bowel management routine at time(s) of day that fit with your lifestyle. Ideally, bowel care can be done on the commode, however people at risk for skin breakdown need to take into consideration the value of bowel care in a seated position vs. a side-lying position in bed. People with an LMN or flaccid bowel may start their program with digital stimulation or manual removal.

Elements of a Bowel Management Program

After consulting with a qualified medical professional, a bowel management regimen may include some, or all, or the following:

Timing: Bowel movements can occur 1 to 3 times a day, usually after a meal. The need to ‘go’ is typically greatest in the first hour after breakfast, so an established morning bowel care program is recommended. Depending on the nature of your injury, leaning forward while seated on the toilet when having a bowel movement may help focus your attention on your lower abdomen, instead of your rectum, when passing stool.

Approach: Finding the least invasive approach to bowel care reduces discomfort and improves quality of life. Bear in mind that the most natural form of elimination is the best long-term approach.

Keeping a Bowel Chart: A daily bowel care chart is helpful to track the effectiveness of any bowel management program. It’s important to have the ability to take note of what works well and what doesn’t and to make changes accordingly.

Example Chart
Date Time of Evacuation Total Time for Bowel Care Fluid in ml Fiber in Grams Stool Consistency Bristol Stool chart Type 1-7 # of Incontinence Episodes Time Spent on Digital Stimulation Bowel Medication(s) Used

A review of medications. Certain medications can affect the bowel and cause obstruction or constipation. Anticholinergics, antidepressants, narcotic pain medications, and spasticity drugs are some examples.

Nutritional habits. Consuming fiber-rich foods is one of the most important things you can do to manage your bowel care.

Sugar, caffeine, unhealthy fats, and sodium take a toll on overall health and do not promote healthy bowel movements. Be mindful of your overall diet and keep unhealthy foods and beverages to a minimum, or even better eliminate them altogether!

Fitness: Don’t forget about exercise! Moving your body is one of the most effective ways to get your stools moving. Create a fitness routine that is sustainable and manageable with your schedule. Stretching, light yoga, and range of motion exercises are helpful in keeping a regular bowel routine.

Hydration: Proper fluid intake is essential to both a bowel and bladder management program. Adequate non-diuretic fluid intake helps keep stool moving through the gastrointestinal tract and reduces the risk of constipation. Drinking two or more quarts of water a day is ideal.

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When You Have Bowel Problems

If you develop problems of any kind with your bowel management before you make any changes to your bowel routine the first step is always to consult with your physician or other qualified medical professionals.

Your physician may recommend a protocol that resembles the following:

Day 1-2 of no Bowel Movement: Depending on your normal bowel movement patterns (if you aren’t sure, refer to your bowel chart), if there is an absence of stool, hard stool, or an inadequate amount of stool, 100-400mg/day of docusate sodium may be taken orally or rectally. Stool softeners are most effective with consumption of at least 1 to 2 liters of fluid per day.

Day 2-3 of no Bowel Movement: Sennoside stimulant tablets and docusate sodium combined may help to achieve a regular bowel movement.

Day 4-5 of no Bowel Movement: If there is no bowel movement for over three days take 1 rectal glycerin suppository as needed or a bisacodyl suppository as needed may also help.

Bowel Preparation and Spinal Cord Injury

Colorectal cancer (CRC) is the third most common fatal cancer in America. The good news is that it can be prevented with early screening via colonoscopy. In the general population, it is recommended that a colonoscopy be performed every 10 years, starting at age 50.

For people with SCI, there are unique difficulties associated with colonoscopies, because bowel effluent caused by bowel preparation can cause skin hygiene problems causing increased risk for skin irritation and pressure ulcers. For people with neurogenic bowel (loss of bowel control that can result in diarrhea, constipation, and/or difficulty with full evacuation) bowel preparation can be suboptimal, causing the need to have modified bowel preparation for colonoscopies in this population.

Studies indicate that the quality of bowel preparation was not associated with level or completeness of SCI. It remains unclear, however, if people with SCI are at increased risk of post-colonoscopy complications and if the benefits of colonoscopy outweigh the risks.

One finding of note in the study was the higher rate of inadequate bowel preparation when compared to non-SCI patients. It is recommended that people with SCI should include a longer bowel prep regimen before a colonoscopy. Many people with SCI are admitted to a hospital or other medical facility the night before the procedure to help ensure adequate bowel preparation before colonoscopy.

Frequently Asked Questions

What is the bowel and what does it do?

The ‘bowel’ is the tube that transports solid waste from the stomach, through the intestines, and out of the body through the anus. For a normally functioning bowel, digested food leaves the stomach and goes into the intestines, where muscle contractions squeeze food along. As food passes through the bowel, the body absorbs needed fluids and nutrients. What isn’t absorbed by the body is expelled from the bowel in the form of waste through stool and urine.

How do I start a bowel routine?

Any bowel routine should be established and monitored by a physician or other qualified medical professional.

What foods are good if constipated?

Foods that are high in fiber are good for relieving constipation. Some nutritional bars can provide as much as 20% of your recommended daily fiber intake. Other foods that are high in fiber include chickpeas, legumes, raspberries, broccoli, kidney beans, split peas, pears, avocado, and even dark chocolate!

Note: not everyone will benefit from a high-fiber diet. You need to recall how much fiber you had in your diet before your injury or disease versus how much you eat now. Speak with your healthcare professional.

ENEMEEZ® is Fast-Acting & Gentle

ENEMEEZ® is a unique stool softener laxative. While oral products take12 to 72 hours for relief, our mini-enema works within 15 minutes!

Your comfort is important to us, which is why we developed ENEMEEZ® and ENEMEEZ® Plus to act quickly and be as gentle as possible. Our formula produces fast, predictable results, typically in 2–15 minutes, with no after-burn.

ENEMEEZ® has been a preferred and trusted formula assisting people to improve their bowel care needs for more than 15 years. The convenient twist-off tip makes ENEMEEZ® easy to administer for safe and effective bowel care needs.

You can request a free sample, or purchase ENEMEEZ® and ENEMEEZ® Plus easily on our website. You can also find answers to frequently asked questions, and watch this quick video on how to use our products.

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