Spinal cord injury (SCI) affects most aspects of a person’s life, and that of their loved ones. It impacts their physical, social, mental and emotional health.
It’s common to have loss of control over gastrointestinal function, along with motor function, which has a significant impact on bowel function.
Maintaining healthy bowel function is essential following SCI, not only for a person’s comfort and quality of life, but also because bowel function is connected to other essential bodily functions including the immune system.
Spinal cord injury affects an individual’s ability to move stool through the bowel, control emptying the bowel, and the ability to sense when the bowel is full. Due to these changes, people with spinal cord injury are susceptible to constipation, bowel leaking and/or stool accidents (incontinence), and fecal impaction.
How the Bowel Changes after Spinal Cord Injury
There are two main types of changes to bowel function following a spinal cord injury:
Upper motor neuron (“UMN”) bowel function results from the paralysis that damages the nerves that control the bowel. This is known as neurogenic bowel, and occurs with injuries at T12 and above. UMN bowel produces intact bowel reflexes and tightened anal sphincters.
Lower motor neuron (“LMN”) bowel function results from a spinal cord injury below T-12, thus damaging the defecation reflex and relaxing the anal sphincter muscle. This is known as a ‘flaccid bowel’.
With a neurogenic bowel, stool is emptied by reflex when the rectum is full, making defecation occur on a reflex basis. Bowel care can be managed by causing the bowel movement to occur at socially appropriate times and places.
With a flaccid bowel, when the bowel is full it attempts to signal the brain through the sacral nerve, instructing it to empty stool. The signal to evacuate doesn’t reach the spinal cord because the nerves are disrupted due to the spinal cord injury. Because the signal remains undetected, when enough stool has collected in the bowel, it empties on its own.
Spinal Cord Injury and Bowel Care Management
It’s essential to have a regular bowel care management program following a spinal cord injury, and it should address the following, at a minimum:
- Provide a regular, predictable time for bowel evacuation that fits in with a person’s life and routine
- Minimize or eliminate accidental bowel movements
- Reduce risk of gastrointestinal complications
Evaluation
When designing a bowel program, the first step is to complete a thorough evaluation of existing bowel function, degree of impairment, and a full medical history - including a full review of medications - to identify any potential gastrointestinal complications or disorders that need to be addressed. From this evaluation, a determination should be made on what degree of assistance an individual will need to maintain their bowel program.
Schedule
It’s important to create a consistent schedule for bowel care. This effectively ‘trains’ the bowel to anticipate emptying on a regular basis. Any bowel care program should work with a person’s care needs, lifestyle, and daily routine. Time to complete a bowel management program is another consideration.
The average time required to complete bowel care for people with spinal cord injury is approximately 10-11 hours each week. If it is taking longer it has a negative impact on a person’s quality of life and the program needs to be re-evaluated to improve quality of care and comfort. Other considerations to take into account are a person’s food, fluid intake, and physical activity.
Nutrition and Hydration
Every bowel management program should include lifestyle habits that support optimum health and wellness. A high-fiber diet with adequate daily fluid intake is essential to the success of bowel management. Physical activity is also important for keeping stool moving; range of motion exercises are recommended for people with limited mobility.
Consuming food approximately 30 minutes before performing bowel care helps to activate the gastrocolic reflex and promote stool motility.
Bowel Stimulation
Reflex neurogenic bowel (UMN) leaves the reflex pathways intact, and these can be used to stimulate bowel evacuation. In this instance, a bowel care program typically uses direct mechanical or chemical (laxative) stimulation, or a combination of both. Typically, the use of chemical stimulants like bisacodyl, should be avoided unless absolutely necessary due to the risk of adverse side effects and skin breakdown.
Flaccid bowel (LMN) typically results in hard, round stool due to decreased movement of stool through the bowel. Because of this, digital stimulation or manual removal of stool may be required. This can be done in conjunction with chemical intervention, such as a stool softener, as well.
What to Avoid with a Bowel Management Program
While every individual’s bowel program should be customized to fit their particular needs, there are some common pitfalls to avoid.
Change in Routine
It’s important to maintain a regular schedule for bowel movements whenever possible. Skipping or changing the program can result in constipation or bowel accidents.
Overuse of Stimulant Laxatives
It’s important to avoid overuse of stimulant laxatives for several reasons. There are adverse physical side effects, such as gas, bloating, cramping, and skin irritation/breakdown that are uncomfortable and often painful. The bowel can also become dependent on stimulant laxatives and lose its ability to empty stool without it.
Rushing
Bowel care should be performed efficiently, but not quickly. It’s important not to rush the process, which can result in injury, incomplete evacuation, or additional health complications.
Frequently Asked Questions
What type of bowel complications can occur after spinal cord injury?
Constipation, fecal impaction, leaking, and accidents are three of the most common bowel complications following SCI. Constipation produces dry, hard stools that are difficult to pass. Leaking and accidents (fecal incontinence) is the inability to control the timing of bowel movements, resulting in involuntary emptying of the bowel.
Fecal impaction is when a bulk of solid stool builds up within the bowel and gets stuck, making regular bowel emptying methods ineffective. This typically occurs when an individual has been constipated for a long period of time.
Why is maintaining bowel function so important?
Establishing a bowel care routine should be a top priority when recovering from a spinal cord injury. Without proper care, a number of health and lifestyle problems can result. Complications may include constipation, fecal impaction, skin breakdown, autonomic dysreflexia, and pressure wounds.
What if I am unable to do a bowel program or it doesn't work?
If you are unable to do a bowel program or if bowel function remains impaired, it’s important to access a qualified healthcare professional to assist you. A professional would be able to do a comprehensive evaluation of your existing bowel care program and make recommendations that will help.
How Can I Diagnose Bowel Changes?
Keeping a daily stool diary can help you diagnose any changes. Write down the timing, quantity, and consistency of stool, along with the food and fluid intake for each day. The Bristol Stool Chart (see below) is frequently used to track consistency of stool.
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Disclaimer: The material contained is for reference purposes only. Quest Products, LLC and Summit Pharmaceuticals do not assume responsibility for patient care. Consult a physician prior to use. Copyright 2020 Summit Pharmaceuticals and Quest Products, LLC