Neurogenic Bowel Program Details

Posted by Nurse Linda in Daily Dose on August 05, 2022 # Health

BowelThe details of a neurogenic bowel program are extensive. Many individuals learn the basics but not the nuances or reasons why a step is taken. Overlooking some of the steps can lead to a neurogenic bowel disaster. This list of steps can be overwhelming because, quite frankly, it is. But you can quickly master them. Review your practice habits to see if there are steps that you are overlooking.

Food and Fluid

Review your diet. Look for triggers for bowel overstimulation such as spicey food, poorly cooked food, or too much roughage. Under stimulation of the bowel can develop from too little roughage, a diet of processed foods, constipating foods, or lack of movement.

Be sure you are hydrated within the limits of your bladder program restrictions. If you need to add some fluid, include foods with high water content while monitoring your fluid intake and bladder output. Be sure to add the water content to your fluid intake to stay within your limits.

Make your food visually pleasing and smells tasty, as sight and smell stimulate the digestive process. Vary your food choices to make dining more interesting.

If you have issues with your teeth, visit a dentist to get your teeth in order. A sore tooth or gum, tooth decay, abscess, or loss can impair chewing, which is the first step to breaking food down for digestion.

Swallowing issues can impact your digestion. If you are unable to swallow or have difficulty swallowing, check with your healthcare professional for methods to protect your airway, such as tucking your chin when swallowing or special dietary needs. If tube feeding is required, you may need to thicken or thin the solution for optimal digestion. Tube feedings that are started slowly over longer periods of time tend to have fewer diarrheal episodes. You can increase your tube feeding amounts over time as recommended by your healthcare professional.

Request a nutritional consultation to expand your dietary options, assess calorie appropriateness, as well as include foods that help the bowel function.

Taking in food stimulates the gastrocolic reflex. In other words, eating makes the bowel more active. Plan your bowel program after eating to take advantage of this boost in bowel function. The gastrocolic reflex is most stimulated about 20 minutes after breakfast because of a quiet bowel at night, but a bowel program after any meal or snack will have the gastrocolic advantage.

Neurogenic Bowel Programs

Establish a time that is best for your bowel program by your normal bowel pattern or your daily living needs. The neurogenic bowel program time should be set in stone. If your needs change, it is possible to change your bowel program time, but this is disrupting and does not allow the bowel to regulate. Changing the timing should only be done on the rarest of occasions.

Use a gloved, well-lubricated finger for the neurogenic bowel program.

Follow the bowel program for the type of neurogenic bowel for your diagnosis, reflexive, flaccid, or mixed.

Reflexive bowel programs are used in upper motor neuron injuries that typically have too much tone keeping the rectal sphincter tight. A stimulant is inserted into the bowel. This can be a suppository or mini enema. The stimulant must be placed next to the bowel wall to work. Putting it in stool does not allow dissolving or stimulate the bowel to work. If stool is present, it may need to be removed prior to inserting the stimulant. Options for cathartics include bisacodyl suppositories which have a vegetable coating, that may take a few minutes to dissolve. This can be important if you need a bit more time to transfer to the toilet. The magic bullet suppository has no coating which takes a bit less time to dissolve. Mini enemas include Enemeez and Theravac which can stimulate the bowel into action. These are small amounts of fluid that work quickly for stool expulsion.

If there is mucous evacuated on a regular basis after the completion of your bowel program, you will need less stimulant which means trying other brands mentioned above, a glycerin suppository, or cutting your suppository in half -lengthwise- to get the maximum use of the suppository against the wall of the bowel.

After about ten to twenty minutes, digital stimulation is done by inserting a gloved, well-lubricated index finger into the rectum, attempting to feel the inner rectal sphincter. This sphincter is 2-3 inches inside the rectum. You may feel it or may just get close to it. GENTLY swirl your finger until you feel the internal sphincter relax. This may take 10 to 20 seconds. Aggressive digital stimulation will tighten the sphincter making the bowel program slower. Wait five to 10 minutes and repeat the sphincter relaxation if no results. This can be repeated up to four times. Stool will drop from the rectum into the receptacle of your choice. Your bowel program should be complete.

Flaccid neurogenic bowel occurs when there is an injury to the lower motor neurons as a result of brain injury or lower-level spinal cord injury. This bowel has flaccid rectal sphincters which do not keep stool in the bowel but can be expelled at any time. Daily emptying of the lower rectum using a gloved, well-lubricated finger in a ‘hooking’ motion will manually remove the stool. Many will do this program daily, a few every other day, but many at urine toileting times to ensure accidents are avoided. You will get to know your bowel pattern to recognize the frequency that is right for you.

Bowel accidents that occur in between either a reflexive or flaccid bowel program can be incidental due to a temporary fast gut for reasons of diet or stress or incomplete emptying of the bowel during the bowel program. Check your bowel with your finger when your bowel program is complete to feel that your bowel is empty.

Always use a gloved, well-lubricated finger for the bowel program to avoid ripping or tearing your delicate internal bowel tissue, developing hemorrhoids, and fissures.

Clean yourself completely to keep your skin healthy. Stool can erode your skin leading to openings (sores), and even pressure injury.

Dispose of your equipment properly and wash your hands.

Medication

Some medications can affect the taste of food or create constipation or diarrhea. If this is occurring with your medication, ask for a medical consultation to see if alternatives are available.

Stool softeners are available to make your stool easier to pass through the bowel and out of the body.

If you have sensation and find the bowel program to be uncomfortable, rectal anesthetics are available.

Fiber was a traditional supplement for adding bulk to the diet. However, due to the amount of fluid needed to activate it, especially for those with fluid limitations due to bladder management programs, this is now no longer automatically recommended. If you do take fiber with success, do not stop. Just be sure you are taking the product’s recommended amount of fluid to flush it through your body. Taking too little fluid creates a cement block in the bowel which can lead to impaction, blockage, an inability to pass stool from the body, hemorrhoids, and other issues. Discuss starting or stopping any medication with your healthcare professional. Suddenly stopping fiber intake can lead to issues as well. Depending on your healthcare needs, tapering off the use of fiber is an effective way to discontinue it.

There are a variety of products to assist with constipation, diarrhea, and other bowel issues. Discuss these options with your health professional, both over the counter and prescription to ensure the medication or supplement is right for your uniqueness of you and that they will not counteract or potentiate your other medications.

Movement

Activity or self-movement of your body may be decreased from paralysis or just difficulty in getting around. Adding movement actively by moving your body under your own ability or using medical equipment, or passively by moving your body parts through physically picking them up or someone doing it for you, is essential to bowel function. Moving muscles, especially in the thighs, can stimulate movement in the abdomen helping the bowel to move stool through the body.

As with most processes in the body, there is a lot of detail in procedures. Knowing the how’s and why’s can assist in improving your neurogenic bowel program. It is important to remember that just as each individual is unique, the nuances of your bowel program will be unique to you. Regulating a neurogenic bowel program requires time, experimentation, and patients until you find the elements that are perfect for your system.

Pediatric Consideration:

Differences in infant and children’s bowel programs include the use of the gentler glycerin suppository, perhaps cut lengthwise in half or even quarters for the right dose. Mini enemas come in pediatric concentrations. Lubricant should be generously used on a gloved pinky finger. Digital stimulation is done with a gentle motion. The finger does not have to be inserted too far as the rectum is shorter. You will be able to feel the inner sphincter that you are attempting to relax in reflexive neurogenic bowel programs. Flaccid bowels can be emptied of stool with a shorter reach as well.

The neurogenic bowel program should be a matter of fact to help your child adjust. Help teach your child to perform their own bowel program by describing what you are doing even to the smallest child. As the child develops, they can help set up supplies, learn to insert the suppository, learn digital stimulation (if used), and clean up. Performing the bowel program independently with the adult ‘on call’ for assistance as needed by school age is a good goal but should be individualized by the child’s abilities, not the parents’ desire to do all for their child. Independence within the child’s normal is the goal for independence.

Even more detailed information about neurogenic bowel programs can be found here: https://www.christopherreeve.org/living-with-paralysis/health/secondary-conditions/bowel-management

https://pva.org/wp-content/uploads/2021/09/consumer-guide_neurogenic-bowel.pdf

Linda Schultz is a leader, teacher, and provider of rehabilitation nursing for over 30 years. In fact, Nurse Linda worked closely with Christopher Reeve on his recovery and has been advocating for the Reeve Foundation ever since.

In our community, Nurse Linda is a blogger where she focuses on contributing functional advice, providing the "how-to" on integrating various healthcare improvements into daily life, and answering your specific questions. Read her blogs here.

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The National Paralysis Resource Center website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $8,700,000 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.