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Spinal Cord Injury Paralysis Resource Center

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Bowel Management

Bowel Care

- Download a FREE PDF fact sheet about Bowel Management

The digestive tract in its entirety is a hollow tube beginning at the mouth and ending at the anus. The bowel, the final portion of the tract, is where the waste products of digested food are stored until they are emptied from the body in the form of stool, or feces.

After food is swallowed, it moves through the esophagus to the stomach, which is basically a storage bag, and then on to the intestines or bowels. The absorption of nutrients occurs in the small intestines, the duodenum, the jejunum and the ileum. Next is the colon, which encircles the abdomen, starting on the right with the ascending colon, passing across the top with the transverse colon, and down the “s”-shaped sigmoid colon to the rectum, which opens at the anus.

Feces move through the bowel by coordinated muscular contractions of the colon walls called peristalsis. This motion is managed by a network of nerve cells at several different levels. The myenteric plexus nerves direct local intestinal movement, seemingly without input from the brain or spinal cord. More than 100 years ago it was discovered that the intestines, even when removed from the body, have an inherent tendency to produce peristalsis. If the intestine wall is stretched, the myenteric plexus triggers the muscles above the stretch to constrict and those below to relax, propelling material down the tube.

The next level of organization comes from autonomic nerves from the brain and spinal cord to the colon, which receives messages through the vagus nerve. The highest level of control comes from the brain. Conscious perception of a full rectum permits discrimination between solid material and gas, and the decision to eliminate fecal matter when appropriate. Messages relayed via the spinal cord produce voluntary relaxation of the pelvic floor and anal sphincter muscles, allowing the defecation process to occur.

Paralysis disrupts the system.
There are two main types of neurogenic bowel, depending on level of injury: an injury above the conus medullaris (at L1) results in upper motor neuron (UMN) bowel syndrome; a lower motor neuron (LMN) bowel syndrome occurs in injuries below L1.

In a UMN or hyperreflexic bowel, voluntary control of the external anal sphincter is disrupted; the sphincter remains tight, which promotes constipation and retention of stool, which cannot be ignored; it is associated with episodes of autonomic dysreflexia. UMN connections between the spinal cord and the colon remain intact, thus reflex coordination and stool propulsion remain intact. Stool evacuation in people with UMN bowel occurs by means of reflex activity caused by a stimulus introduced into the rectum, such as a suppository or digital stimulation—best triggered at socially appropriate times and places.

LMN or flaccid bowel is marked by loss of stool movement (peristalsis) and slow stool propulsion. The result is constipation and a higher risk of incontinence due to lack of a functional anal sphincter. To minimize formation of hemorrhoids, use stool softeners, minimal straining during bowel efforts, and minimal physical trauma during stimulation.

Bowel accidents happen.
The best way to prevent them is to follow a schedule, to teach the bowel when to have a movement. Most people perform their bowel program at a time of day that fits with their lifestyle. The program usually begins with insertion of either a suppository or a mini-enema, followed by a waiting period of approximately 15–20 minutes to allow the stimulant to work. After the waiting period, digital stimulation is performed every 10–15 minutes until the rectum is empty. Those with a flaccid bowel frequently start their programs with digital stimulation or manual removal. Bowel programs typically require 30–60 minutes to complete. Preferably, a bowel program can be done on the commode. Two hours of sitting tolerance is usually sufficient. But those at high risk for skin breakdown need to weigh the value of bowel care in a seated position, versus a side-lying position in bed.

Constipation is a problem for many people with neuromuscular-related paralysis. Anything that changes the speed with which foods move through the large intestine interferes with the absorption of water and causes problems. There are several types of laxatives that help with constipation. Laxatives such as Metamucil supply the fiber necessary to add bulk, which holds water and makes it easier to move stool through the bowels. Stool softeners, such as Colace, also keep the water content of the stool higher, which keeps it softer and thus easier to move. Stimulants such as bisacodyl increase the muscle contractions (peristalsis) of the bowel, which moves the stool along. Frequent use of stimulants can actually aggravate constipation – the bowels become dependent on them for even normal peristalsis.

Faster than a speeding ...
There are two main types of suppositories, both based on the active ingredient bisacodyl: those with a vegetable base (e.g. Dulcolax) and those with a polyethylene glycol base (e.g. Magic Bullet). Bullets are said to be about twice as fast as the alternative.

Antegrade continence enema is an option for some people with difficult bowel problems. This technique involves surgery to create a stoma, or opening, in the abdomen; this allows introduction of liquid above the rectum, thus causing an effective flushing of fecal material from the bowel. This method may significantly decrease bowel care time and allow for the discontinuation of some bowel medications.

Bowel facts for better digestive management:

- It is generally not necessary to have a bowel movement every day. Every other day is okay.
- Bowels move more readily after a meal.
- Fluid intake of two quarts daily aids in maintaining a soft stool; warm liquid will also aid bowel movement.
- A healthy diet including fiber in the form of bran cereals, vegetables and fruits helps keep the digestive process working.
- Activity and exercise promote good bowel health.

Some medications commonly used by people with paralysis can affect the bowel. For example, anticholinergic medications (for bladder care) may slow bowel motility, resulting in constipation or even bowel obstruction. Some antidepressant drugs, such as amitryptyline; narcotic pain medications; and some drugs used for the treatment of spasticity, such as dantrolene sodium, contribute to constipation.

Many people report significant improvements in quality of life after colostomy. This surgical option creates a permanent opening between the colon and the surface of the abdomen to which a stool collection bag is attached. Colostomies sometimes become necessary because of fecal soiling or pressure sores, continual stool incontinence, or excessively long bowel programs. Colostomy enables many people to manage their bowels independently, plus, colostomy takes less time than bowel programs. Studies have shown that people who get colostomies are pleased and would not reverse the procedure; while many may not have embraced the idea of a colostomy at the outset, the procedure can make a huge difference in quality of life, cutting bowel time from as much as eight hours a day to no more than 15 minutes.

Sources
Spinal Cord Injury Information Center/University of Alabama at Birmingham, University of Washington School of Medicine, ALS Association, National Multiple Sclerosis Society

Resources
Paralyzed Veterans of America, in support of The Consortium for Spinal Cord Medicine, offers authoritative clinical practice guidelines for bladder management. Consumer guides are available to download.

The Spinal Cord Injury Rehabilitation Evidence (SCIRE) project is a Canadian research collaboration of scientists, clinicians and consumers that reviews, evaluates, and translates research knowledge to establish best practices following SCI.

A Reeve Foundation Fact Sheet on Bowel Management (PDF)

CareCure CommunityCareCure Community features a SpinalNurse bulletin board with informed comments on matters of the bowel, and all issues of paralysis.

Clinical Practice GuidelinesRecommendations for assessment, education and management of the neurogenic bowel.

University of Washington School of Medicine: Bowel CareThe University of Washington School of Medicine/Department of Rehabilitation Medicine.

Paralysis Resource Center The Reeve Foundation Paralysis Resource Center Information Specialists are reachable business weekdays, Monday through Friday, toll-free at 800-539-7309 from 9:00 am to 5:00 pm ET. You may also schedule a call or send a message online.

Reeve Foundation Online Paralysis Community Connecting people living with paralysis, families, friends and caregivers so we can share support, experience, knowledge, and hope.

Quality of Life Grants DatabaseFind resources within the PRC Quality of Life Grants Database. Search by Zip Code, State or an Entire Category.

Library Books and VideosFind resources within the PRC library catalog.

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The Reeve Foundation Paralysis Resource Center Information Specialists are reachable business weekdays, Monday through Friday, toll-free at 800-539-7309 from 9:00 am to 5:00 pm Eastern U.S. Time. International callers use 973-467-8270. You may also schedule a call or send a message online.

This project was supported, in part by grant number 90PR3001, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.