Reflexic Bowel Program

Spinal cord injury (SCI) affects the way the digestive system performs by interrupting signals between the brain and the gastrointestinal tract. This disruption often creates the need for a bowel management program.

The appropriate bowel program post-SCI depends upon the level of damage and the completeness of the injury.

Neurogenic bowel refers to the condition of bowel function post-SCI. There are two types of neurogenic bowel:

  1. Reflexic (spastic) bowel applies to an Upper Motor Neuron (UMN) injury above T12. This condition is also known as neurogenic bowel.
  2. Areflexic (flaccid) bowel results from a Lower Motor Neuron (LMN) injury below T12.

If damage to the spinal cord occurs at T12 or higher, the ability to feel when the rectum is full may be lost. Because of this, when the rectum is full defecation will occur on a reflex basis.

A bowel management program allows for a higher quality of life, more independence, fewer bowel accidents, and promotes overall digestive health and wellness.

What is a Reflexic Bowel Management Program?

A neurogenic bowel management program is a structured routine for passing stool on a predictable basis.

It’s important that a bowel management program fits into a person’s habits, lifestyle, and need to empty the bowel. This can occur daily or every other day, depending on what is needed for the individual.

Bowel programs can typically take 30-60 minutes to complete. It is preferable to perform a bowel program on a commode, but it’s important to take safety into account. If a person is at risk for skin breakdown, falls, or other health risks, bowel management can also occur in a side-lying position in bed.

The ultimate goal of any bowel management program is to allow for an optimum level of health, wellness, quality of life, and independence. Avoiding bowel accidents is paramount, so bowel programs should occur at the same time each day to train the bowel to empty stool on a predictable schedule.

Typically, first thing in the morning, before bed, and 30-60 minutes after a meal are good times to empty stool.

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Benefits of a Bowel Management Program

In addition to the ability to maintain control and predictability for bowel movements, there are other advantages to an effective bowel management program, including:

  • Avoiding bowel accidents by emptying stool at predictable times, increasing autonomy and quality of life
  • Fully emptying the bowel for every bowel movement
  • Promoting healthy stool consistency
  • Avoiding stool leakage between bowel movements
  • Performing bowel movements within a reasonable time frame (30-60 minutes), which also promotes independence and quality of life
  • Feeling confident in participating in daily activities
  • Maintaining a healthy digestive system
  • Training’ the bowel to empty at regularly scheduled times

Methods for Emptying Stool for Reflexic Bowel

There are several ways to empty stool for reflexic bowel and the best method will vary for each person depending on mobility, level of injury, and health considerations.

It’s important that all caregivers are knowledgeable about methods for emptying the bowel and have the physical ability to do so.

Caregivers should be prepared with the following:

  • Water-based and/or anesthetic lubricant
  • Powder and latex-free gloves
  • Toilet paper
  • Stool stimulant and/or stool softener, such as an Enemeez® mini-enema

It’s very important to wash hands, wear gloves, and use lubricant to avoid injury to the rectum. Often a bowel program begins by inserting a rectal stimulant, like a mini-enema or suppository,. A waiting period of up to 20 minutes to allow time for the medication to work is helpful.

3 Methods for Emptying Stool

Digital Stimulation: This involves inserting a lubricated, gloved index finger in the rectum and using a circular motion to cause the anal sphincter to relax. Rotate finger in a circular motion for approximately 10-30 seconds while maintaining contact with the rectal wall to prompt the bowel reflex and create muscle contractions.

Manual Removal of Stool: This is performed by inserting a gloved, lubricated finger into the rectum and gently hooking it around any reachable stool and removing it from the rectum.

Abdominal Massage: To help get stool moving, gently massage the lower abdomen in a circular motion from right to left.

Continue these steps until the bowel is completely empty of stool. The skin in and around the rectum is delicate and it’s important to be slow and gentle for digital rectal stimulation and manual removal techniques.

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Important Considerations for a Bowel Management Program

In addition to the specific techniques used to physically empty the bowel, there are several other elements to consider as part of overall bowel management.

Other essential elements should also include:

Nutrition
Maintaining a healthy diet has a big impact on healthy bowel movements. It’s essential to eat a balanced diet that incorporates fruits, vegetables, whole grains, and other fiber-rich foods into a daily nutrition plan. Fiber helps to promote health for the entire digestive system and boosts the immune system.

Typically adults need about 25 to 35 grams of daily fiber, but it’s important to consult a physician to determine the optimum amount. Increasing fiber intake too quickly can cause diarrhea and decreasing fiber can lead to constipation, so make any adjustments to fiber intake in increments.

Other foods are more likely to cause bowel problems, so it’s important to moderate saturated fats, dairy, protein, and processed foods/snacks that are high in sugar, sodium, and/or fat. Alcohol and caffeine should be moderated or eliminated as well.

Hydration
Non-diuretic fluids, preferably water, are essential for a healthy bowel management program. Water regulates the digestive system, keeps stool soft and easier to pass, and helps prevent constipation and fecal impaction. Avoiding or moderating diuretic fluids, like caffeine and soda, is also important.

Fitness
Moving the body helps keep food moving through the digestive system and helps promote the passage of stool. Range of motion and/or stretching exercises can help people with limited mobility.

Routine
Maintaining regularity is important for any bowel management program. If there is an increase in unplanned bowel movements, make adjustments to the bowel routine accordingly. Plan ahead for how to manage predictable disruptions in routine for things like travel, visiting with family/friends, etc.

Medications
Certain medications can affect bowel movements, so it’s important to consult with a physician to determine if any medications could be impacting your bowel routine. Blood pressure medication, opiate pain medication, antidepressants, and anticholinergic medications are a few examples of medications that may impact the bowel.

How to Address Common Complications to a Bowel Management Program

Even a well-managed bowel program can develop complications, so it’s helpful to be informed of some of the more common problems and take measures to avoid or prevent them. If you’re experiencing any of these complications, it’s always important to consider consulting your physician for additional advice and recommendations.

Frequent Bowel Accidents
The occasional bowel accident will happen, but if they are occurring more frequently it could be because the rectum isn’t fully emptied at the time of evacuation. Evaluate diet to determine if food may be causing runny and/or loose stools (like spicy foods, inadequate fiber, and/or caffeine). Using half a suppository or reducing the use of stool softeners may also help. Take time to be sure the rectum is fully emptied as well.

Mucosal Discharge
If there is sticky, clear leakage in or around the rectum, switching from a suppository to a mini-enema may help. Eliminating the use of suppositories or mini-enemas before employing digital stimulation or manual removal may also reduce mucosal discharge.

Rectal Bleeding
This can be a sign that stool removal techniques are damaging the skin in and around the rectum. Ensure that adequate lubrication is used during digital stimulation and/or manual removal, fingernails are kept short, and gloves are used to prevent skin damage.

Bowel Program Takes Too Long
An effective bowel program should not take more than 60 minutes to complete. If it is taking longer than that on a regular basis, vary the timing of bowel movement routine and/or increase dietary fiber.

Frequently Asked Questions

People with neurogenic bowel need to have a routine bowel management program which includes scheduled times to remove the stool from the rectum on a regular basis. This helps prevent accidents, constipation, and bowel blockage. A bowel program typically also includes a balanced diet, a fitness routine, and proper hydration. It’s important to always consult with your healthcare provider before beginning any bowel management program.

Enemeez® mini-enema products have shown to be effective for bowel care needs associated with spinal cord injury, or disease and general constipation. Enemeez® products are designed for ease of use for users and caregivers, with a gentle, non-irritating formula that provides fast, predictable results typically within 15 minutes.

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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. http://www.braininjurysupport.org/living-with-a-spinal-cord-injury/bowel-management/
  2. https://www.sci-info-pages.com/bowel-management/
  3. https://livingwithsci.ca/bowel-management/