Spinal cord disorders and the associated neurological damage result in impaired voluntary and reflex activity with altered bowel transit and impaired storage/evacuation mechanisms. Spinal cord disorders are classified by neurological level (anatomic level) and by the degree of intactness of ascending and descending spinal cord pathways ("complete" or " incomplete"). Bowel function varies depending upon the level and, to some degree, the completeness of the spinal cord injury.
If you are experiencing any of the following symptoms or diagnoses or are caring for a person who needs care for the below, here are facts to consider before meeting with your physician.
Populations/Diagnostic Groups at Risk:
Spinal Cord Injury (SCI), Multiple Sclerosis (MS), Spina Bifida, Long-term Care (LTC), and Traumatic Brain Injury (TBl). All persons with complete SCI have a neurogenic bowel.
- Most persons with incomplete SCI have some manifestation of bowel dysfunction1
- Excluding bladder dysfunction, gastrointestinal disorders are the most common complications for patients with spinal cord injuries. 95% of SCI patients require at least one therapeutic intervention to initiate defecation. 54% of SCI patients report bowel and bladder dysfunction as a major life-limiting problem.2
Constipation is the most common gastrointestinal complaint in primary, acute, and long-term care settings in the United States. An estimated 42 million individuals in the United States have bowel issues or constipation, and an estimated 1 million have incontinence. As the United States grows older, the costs and quality of life issues related to constipation and incontinence of individuals will only increase. Further information and recommendations are needed in this area. Very few healthcare institutions have current bowel protocols in place, and the growing need is evident.
Studies show that patients placed on a regimented bowel care program, receiving both oral and rectal therapies to achieve complete rectal emptying, had 35% fewer episodes of fecal incontinence and 42% fewer incidents of soiled laundry.3
The highest reported incidences of constipation in specific populations were 45% of all patients with cancer,4 45% of all frail elders,5 and 46% of all hospitalized elders.6.
Chronic idiopathic constipation has both physical and psychological effects7. Patients with persistent stretching of the pudendal nerves may ultimately suffer from complications such as hemorrhoids, rectal prolapse, or incontinence. The psychological impact of constipation is often the result of changes in activity levels that often leads to increased isolation8.
Situations that place people at risk for acute constipation include imposed immobility, a change in toileting habits, dietary changes (whether self-imposed by dieting or for medical reasons), medications, and stress. The most common predisposing factors for chronic constipation include advanced age, being female, poor fluid and dietary intake, cognitive or functional impairment, ongoing privacy issues, and polypharmacy. Opioids are among the major medications that predispose patients to constipation9.
Constipation is a common cause of morbidity in palliative care persons. It affects up to 95% of the people who are taking opioids10. Even in the absence of oral intake, the body continues to produce 1–2 ounces of stool per day. The bowel lining is continually renewing itself, and sloughed cells, along with bacteria and digestive juices, comprise much of the stool11. Hence, individuals can easily become constipated even when they are not eating.
Complications of Constipation
Abdominal pain and increased cancer pain in people with abdominal or retroperitoneal malignancy
- Abdominal distention/discomfort
- Nausea, vomiting, and anorexia
- Overflow diarrhea
- Hemorrhoids/anal fissures
- Bowel obstruction
- Urinary retention
- Anxiety and restlessness
- Autonomic dysreflexia
Secondary Complications of an Ineffective Bowel Care Protocol
Incontinent patients have a 22–30% higher risk of developing pressure ulcers12
Odds of having a pressure ulcer were 22 times greater for adult patients with fecal incontinence13.
Data highlighted that fecal incontinence can damage the skin's integrity, leading to skin breakdown and possible wound contamination, giving rise to major healthcare costs14.
Nursing home residents at higher risk for developing ulcers are those who have limited ability to reposition themselves, cannot sense the need to reposition, have fecal incontinence, or cannot feed themselves15.
Both fecal and urinary incontinence increase moisture, but fecal incontinence is hypothesized to act as a more potential risk factor for skin breakdown than urinary incontinence16.
Fecal incontinence represents a major risk to perianal skin integrity and healing of perianal wounds14.
Pressure ulcers were more prevalent (12%) among residents who had any recent bowel or bladder incontinence than among continent residents (7%)17.
Disclaimer: The material contained is for reference purposes only. Alliance Labs, LLC and Summit Pharmaceuticals do not assume responsibility for patient care. Consult a physician prior to use. Copyright 2019 Summit Pharmaceuticals and Alliance Labs LLC.
1. Stiens, Bierner-Bergman, & Goetz, 1997
2. Higgins, Johanson, 2004
3. Age & Ageing 2000; 29: 159-164
4. McMillan & Williams, 1989
5. Wolfsen, et al., 1993
6. Wright, 1984
7. Dykes et al., 2001
8. Koch & Hudson, 2000
9. Levy, 1991; McMillan & Williams, 1989; Sykes, 1996
10. Driver LC, Bruera E., 2000
11. Chase, D. G. & Erlandsen, S. L. 1976
12. S. Foxley & R. Baadjies; Incontinence associated with dermatitis in patients with spinal cord injury; British Journal of Nursing Vol 18, No. 12
13. Advanced Wound Care/Maklebust&Magnan/1994 Nov;7(6):25, 27-28, 31-4 passim/
14. Risk factors associated with having a pressure ulcer: a secondary data analysis. Ousey, Karen and Gillibrand, Warren P. (2010) Using faecal collectors to reduce wound contamination. Wounds UK, 6 (1). Pp. 86-91.
15. Pressure Ulcers in the Nursing Home; Ann Intern Med. 1995;123 (6): 433-438.
16. Shannon ML, Skorga P. Pressure ulcer prevalence in two general hospitals, Decubitus. 1989;2: 38-43.
17. NCHS Data Brief, No. 14 February 2009. Pressure Ulcers Among Nursing Home Residents: United States, 2004 Eurice Park-Lee, PHD., and Christine Caffrey, PhD., Division of Health Care Statistics.