Treating Neurogenic Bowel Dysfunction

After a spinal cord injury (“SCI”) or illness a person is faced with many challenges and changes, including the need to have a bowel care program to maintain overall health and wellness, and achieve the highest quality of life possible.

Neurogenic bowel refers to the loss or absence of normal intestinal function due to SCI or illness. Neurogenic bowel disease occurs after damage to the bowel's extrinsic neurological control, and the diagnostic groups at risk for neurogenic bowel include:

  • Spinal cord injury
  • Multiple sclerosis
  • Spina bifida
  • Long-term care
  • Traumatic Brain Injury

Quality care is vital for maintaining a healthy lifestyle after an injury or life-changing illness, however very little attention has been paid to the consequences of an ineffective bowel care program.

Neurogenic Bowel Dysfunction and Spinal Cord Injury

SCI disrupts the way the bowel system sends signals to the brain about when stool needs to be emptied. 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 by neurological level (anatomic level) and by the degree of intactness of ascending and descending spinal cord pathways (“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 varies depending 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 a full rectum and the anal sphincter remains tight, causing bowel movements to occur on a reflex basis. When the rectum is full, the defecation reflex will occur. Loss of sphincter control can result in an inability to have a bowel movement and can lead to impaction, which can be serious.

The best way to manage this is to have an effective bowel management program and ‘train’ your bowels to ‘go’ on a more predictable and manageable basis.

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Neurogenic Bowel Dysfunction and Multiple Sclerosis

One-third of people with Multiple Sclerosis suffer from constipation, and one-fourth of people with Multiple Sclerosis have incidents of incontinence at least once per week. Lesions in Multiple Sclerosis occur at multiple levels and tend to vary with time; The extent of lesions is the most important factor in determining potential bowel symptoms.

Multiple sclerosis-related bowel dysfunction may occur if lesions develop in areas of the brain or spinal cord involved in defecation. People with Multiple Sclerosis may experience constipation due to slowed bowel motility, resulting in hardened stools.

Other factors relating to constipation in patients with MS include:

  • Inadequate fluid intake
  • Inadequate bulk in the diet
  • Decreased physical activity or immobility
  • Medications such as anticholinergics used for bladder control
  • Diarrhea may occur secondary to fecal impaction or as the result of an infection, malabsorption, and food allergies
  • Disruption of motor nerves to the sphincters
  • Abnormal rectoanal reflexes
  • Disruption of anorectal sensation

Essential Bowel Program Elements for Neurogenic Bowel

A bowel program for neurogenic bowel should be designed to take into account the type of neurogenic bowel, attendant care, personal goals, life schedules, employment, and quality of life.

Bowel programs should be 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 individuals manage the mental health impact associated with neurogenic bowel.

All aspects of a bowel management program should be designed to be easily replicated in the home and community environment. Effective treatment of common neurogenic bowel complications, including fecal impaction, constipation, and hemorrhoids are necessary to minimize potential long-term complications.

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Establishing a Bowel Program for Neurogenic Bowel

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

Timing of Bowel Care: Bowel movements can occur 1 to 3 times a day, usually after a meal. Gastrocolic and duodenocolic reflexes are strongest for about 15 minutes in the first hour after breakfast, so an established morning bowel protocol is recommended.

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

Bowel Chart: A daily bowel care chart is helpful to track the effectiveness of any program for neurogenic bowel.

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 Time Spent on Digital Stimulation Bowel Medication(s) Used
                 
                 
                 

Daily: Encourage Exercise/Fluid/Fiber/Toileting Regimen: Bowel care should be performed at the same time each day (again, morning is recommended). It’s important to consume 64-96 ounces of non-diuretic fluid daily, as tolerated. Fiber is an essential element of a healthy bowel management program, with a recommended daily allowance of 20-35 grams of fiber. Drinking a hot beverage prior to the scheduled toileting regimen can be helpful.

Day 1-2 of no Bowel Movement: Depending on a person’s normal bowel movement patterns (you can refer to the bowel care chart for reference), if there is an absence of stool, hard stool, or an inadequate amount of stool, 100-400mg/day of docusate sodium can be taken orally or rectally. Stool softeners are most effective with consumption of at least 1 to 2 liters of fluid per day.  If no bowel movement occurs, use Enemeez® mini-enema X1, X2, X3 QD.

Day 2-3 of no Bowel Movement: Titrate 0.5 to 2 grams sennoside stimulant tablets; 2-4 tabs BDD up to four times/day, and docusate three or four times a day to achieve a regular bowel movement.

NOTE: Administer oral stimulant laxatives, Enemeez® (docusate sodium mini-enema) on Day 3, if ineffective, take a suppository or enema whenever a person does not have a bowel movement for 3 days.

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 1 5-10mg bisacodyl suppository as needed.

Wellness for People with Neurogenic Bowel

Hydration:

Staying hydrated 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.

Eat Fiber-Rich Foods

Consuming fiber-rich foods is one of the most important things you can do to manage your bowel care. Some nutritional bars that are high in fiber 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.

Follow a Regular Schedule

Following a regular bowel management program “teaches” the bowel when to have a movement. Bowel programs typically require 30-60 minutes to complete. Gravity can assist with bowel movements, so if a seated position on padded or inflatable seats is possible, this can be helpful.

Evaluate Medications

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

Range of Motion Exercises

Physical movement also helps stimulate the bowel. Stretching and range of motion exercises are helpful in keeping a regular bowel routine.

Foods and Beverages to Avoid or Moderate: 

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!

Join the Thrive Community!

We’ve gathered a number of inspiring individuals with disabilities in our very own Thrive Community! The Thrive Community Facebook Group is a private space for any person with a disability, as well as caregivers and healthcare providers that touch their lives. Our purpose is to provide a safe, educational space for group members to ask every question, connect with their peers, and empower each other through communication and connection. Our conversations are led by incredible individuals who themselves are living and thriving.

For more enlightening resources, information, and discussion, join the Enemeez® Thrive Community today!

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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 2020 Summit Pharmaceuticals and Alliance Labs, LLC.

 

Sources:

  1. Namey MA. Management of elimination dysfunction. In: Halper J, Holland NJ, eds. Comprehensive Nursing Care in Multiple Sclerosis. 2nd ed. New York, NY: Demos Medical Publishing; 2002:53-76.
  2. https://www.christopherreeve.org/living-with-paralysis/health/secondary-conditions/bowel-management
  3. https://alliancelabsprovider.com/wp-content/uploads/sites/3/2020/06/ENZ034-PilotStudy-04.08.19-2-1.pdf
  4. https://enemeez.com/wp-content/uploads/2020/07/ENZ010-Quality-Care-Bowel-Protocol-11.25.19-1.pdf