Neurogenic Bowel Program Hierarchy of Treatments

Posted by Nurse Linda in Daily Dose on September 29, 2022 # Health

September is Spinal Cord Injury Awareness Month. In recognition of this event, let’s talk about neurogenic bowel function. It is one of the most common issues for individuals with spinal cord injury and for many individuals with brain injury from disease or trauma. Specifics of neurogenic bowel management can be found on the Christopher and Dana Reeve website. This blog has a bit of a different approach, as many individuals question what they can do when their neurogenic bowel program is not working as they would like. It will begin with the simplest strategies, working up to more complex treatments.

A simple summary of the neurogenic bowel is that it is an issue with nerve communication for digestive function. It is a miscommunication of the nerves that occurs anywhere along the entire digestive tract. A part of the brain or spinal cord is affected, which leads to this diagnosis. Motor neurons control movement, including the bowel. It is not constipation. Treatments for constipation alone will not assist with the treatment of the neurogenic bowel.

When upper motor neurons are affected, the bowel and bowel sphincters have high tone (spasticity). This is often called a reflexive bowel. The stool will remain in the bowel as there is not enough pressure from the bowel to push it out through the tight internal rectal sphincter. Occasionally, some individuals will have leakage of stool, but this is the result of pressure build-up in the bowel. It is not predictable or reliable, and rarely does the entire stool get ejected. Incontinence can occur at any time, or the stool can reverse up into the colon. A bowel program with stimulation is used to bring the stool down to the internal rectum, followed by digital stimulation for relaxation of the internal rectal sphincter.

If the lower motor neurons are affected, the bowel and internal sphincter are flaccid or without tone (areflexic). The stool will roll out of the body, which is also unpredictable and may not be completely empty. The treatment for this type of bowel is manual removal of stool to ensure emptying and continence.

Occasionally, an individual has a mixture of a reflexive and areflexia neurogenic bowel. For this situation, elements of the bowel program from each situation above are created. Often, one or the other bowel programs work, but this must be individualized for the person. You will need to discuss this situation with your healthcare provider for the uniqueness that is you and to find the elements that will create the best and healthiest results for you.

For all bowel care, use a gloved, well lubricated finger. Only one finger should be used. This can prevent complications such as fissures, hemorrhoids, bleeding, as well as other bowel issues.

Below is a simple look at levels of advancing strategies for neurogenic bowel treatment. When reviewing your neurogenic bowel program, you and your healthcare professional should determine how to proceed. Remember, it takes about six weeks for changes to be seen in your bowel function, so allow time before you start something new. Some people will see changes sooner and some later. Whenever you change something to your bowel program, it takes time for adjustments. The information below is designed for those who are already doing a neurogenic bowel program but have a desire to improve it. If your bowel program is working for you, keep doing it as is. Use these hints if issues arise later.

Review Lifestyle Changes:

  • Diet review (reducing processed foods, adding roughage)
  • Movement (especially of the lower limbs by moving your legs manually, having someone move them for you, or using functional electrical equipment)
  • Drinking warm fluid about 20 minutes prior to your bowel program may stimulate the gastrocolic reflex
  • Very slowly increasing water intake, if you are not on a fluid restriction for other issues, will assist with keeping the stool moist, thereby making it easier to pass into the gut
  • Biofeedback can assist with the education of the pelvic floor for some individuals

Reconsider Oral Fiber Supplements: Dietary supplements to add fiber to the diet have been recommended for years. However, it has been found that many individuals do not take the recommended amount of water to activate them. This creates a blockage in the bowel, as instead of dissolving, the fiber creates a ‘rock’ in the bowel. If your bowel program is difficult and your stool is hard, discuss reducing oral fiber supplements over time.

Use the Bristol Stool Scale: This provides definitions of the quality of stool, a way to communicate with healthcare providers, and a chart that will help recall the consistency of your stool over time rather than attempting to remember details. A free app is available.

Review the Timing of Your Bowel Program: An effective neurogenic bowel program works well only if you perform it at the same time consistently and routinely.

Review Your Medications with Your Healthcare Provider: Look for medications that you are taking that may have the side effect of constipation or diarrhea. Ask if adding an oral osmotic medication such as MiraLAX or Senna will assist with adding moisture to your stool for easier passage through the gut and with removal. If the injury is incomplete and you have a sensation in the rectum or if rectal stimulation triggers an episode of autonomic dysreflexia (AD), include rectal analgesic medication.

Suppository Issues: If using a suppository (mostly in reflexive neurogenic bowel programs), be sure it is inserted next to the bowel wall so the suppository can use your body heat to melt. It should be placed above the internal rectal sphincter. If there is stool in the rectum, it may need to be manually removed before inserting the suppository. More stool will be forthcoming. Bisacodyl suppositories have a vegetable coating for extra time before dissolving. Magic bullet suppositories do not have a coating, therefore, melting quickly.

Consider a Mini Enema: Some individuals have difficulty with the speed of suppository stimulation and will switch to a mini enema. One example includes Enemeez (a hyperosmotic) which stimulates the nerves of the bowel. These can be used in reflexive and in some flaccid neurogenic bowel programs.

Anal Irrigation: A trans anal irrigation system works in the lower bowel allowing the upper bowel to continue to function. Persistent is an example. This can be used in a reflexive or areflexive neurogenic bowel.

Digital Stimulation: Most individuals want to get in and get out with bowel care. In individuals with a reflexive bowel, too quickly performing digital stimulation will further increase tone in the internal rectal sphincter making the bowel program longer as the internal sphincter tightens. Be gentle in stimulation. The bowel program will work much faster with slow and steady stimulation.

Nerve Stimulation: Functional electrical stimulation either applied to the surface of the skin for individuals with an upper motor neuron (reflexive) neurogenic bowel or implanted on peripheral nerves in individuals with a lower motor neuron (a reflexive) neurogenic bowel has demonstrated results in individuals to be able to stimulate and perform bowel movements.

Colostomy: Elective colostomy reroutes the bowel from an internal to an external opening surgically created on the abdomen. This surgical procedure should be discussed with your healthcare professional to see if the risks vs. benefits are right for you.

These are just some of the actions you can take to improve your bowel program. Discuss your concerns openly with your healthcare professional as you want to be safe in maintaining your neurogenic bowel care. Checking will ensure you do not create issues such as exercising without checking to make sure it is safe for you.

Pediatric Consideration:

Care for adults in neurogenic bowel is basically the same for children. Many people forgo the neurogenic bowel program because babies wear diapers. However, neurogenic bowel care must be performed for all ages. Not doing so can lead to consequences of bowel dysfunction and complications which follow the child into adulthood.

Bowel program techniques can be different. Some may need to be more frequent, and suppositories should be cut in quarters or in half (the long way), as needed for the size of your child. Digital stimulation should be done with your smallest finger and as always, gently.

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.

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.