Back to Basics: Bowel Program

Many individuals who have a neurogenic bowel or other similar diagnosis perform a bowel program to evacuate solid waste from the body. 

This is a necessary procedure to maintain health as well as to avoid complications in the bowel. You probably have a bowel program that you routinely conduct. This blog is designed to help you think about things that might assist in your bowel program or to think about how you can improve your technique.

Getting in the routine of an effective and efficient bowel program takes time. You might not be completely adjusted to your bowel routine by the time you are discharged from the rehabilitation hospital. Overtime, bowel programs may need to be adjusted due to changes in routine, diet, slowing of the bowel due to SCI and aging. Bowel function can change temporarily due to illness, dehydration, medication and just about anything else.

When thinking about an effective bowel program, review what you put into your body. Fiber is needed to give the bowel something to ‘grab on to’ to push waste through your system. If your diet is mostly refined or pasty foods, you are not going to have the bulk to move stool along. Add roughage to your meals. This can be done by adding foods with fiber such as beans, vegetables, nuts and whole grains. Even with a diet full of roughage, you still might not be taking in enough fiber. Supplements that contain fiber can be added. Fiber supplements come in powders added to fluid, pills, crackers and bars. There are many options as people who have not had a spinal cord injury also have issues with low fiber diets so the request for these supplements is great in all populations.

A second element to assisting your bowel program through intake is by adding water to your body. This helps to moisten your stool and to bulk up the added fiber. The bowel works by taking nutrients out of your food continuously along the long route of the bowel. In doing so, fluid is also removed from the bowel. By the time stool is formed at the end of the bowel, it can become very dry. Keeping the bowel well hydrated throughout this route can help the waste move along as well as making a softer, easier to pass stool.

Adding fluid can be difficult for individuals who catheterize their bladders as well as for those with heart conditions that can be overloaded with fluid. Adding fluid does not mean downing a huge amount of water at one time, rather add just a few sips every hour. This maintains fluid in your body and bowel over time instead of a huge, not advised once only drink. Check with your healthcare provider to ensure this is a process you can use for your individual situation.

Next, review your process for your bowel program. For everyone with or without a spinal cord injury, gravity plays a big part in removal of stool from the bowel. Sitting up to expel stool is very important to the process. Many people are taught to do their bowel program in bed. A few will need to continue this process if you cannot sit for a medical reason. If so, laying on your left side can help facilitate the process. In bed, the stool will be evacuated on the same level, in other words, not using gravity.

Sitting up uses gravity to help the bowel move waste in the body and out into a receptacle such as the toilet. This can result in much more efficient emptying of the bowel. Many individuals to not have a commode chair that accommodates sitting for their bowel needs. There are many styles of commodes that can be used by individuals with a variety of levels of injury. A person with a lower level of spinal cord injury might be able to transfer directly onto the toilet. Those with higher levels of injury will necessitate more support from the commode chairs. Your payor will generally assist with the finances to obtain the commode your physician and physical therapist recommend. The commode chair can be used at the bedside or if your bathroom is large enough, the chair can be placed right over the toilet. Many will use the commode chair in the shower as well, if you have a roll in shower. Be sure to get one with ‘crutch’ type breaks to secure the commode chair for transfers.There is also a ceiling lift transfer option where you are placed in a sling lift and moved via a track on the ceiling. These are generally not covered by a payor, but you should always ask if you are interested in this type of apparatus.

When performing the bowel program, think about the type of suppository you use, if you use one. Some people like Bisacodyl or the gentile glycerin (best for pediatric or geriatric), others prefer the magic bullet. The Bisacodyl has a vegetable coating, the magic bullet does not. It is a matter of personal preference as to which you prefer. People are drawn to either for the effects on their individual bowel.

Individuals with upper motor neuron injury or those with injury in the cervical or thoracic area will typically use a suppository. Those with a lower motor injury in the sacral spine will not use a suppository as they will perform a manual evacuation. Those with a lumbar injury may or may not use a suppository.

The adage, what you see on the outside of the body is probably what is happening on the inside of your body, applies to the bowel. If you have an upper motor level injury or a higher-level injury, you could see spasticity in your body, but you might not know if it is present in your bowel and bowel sphincters. If you can see spasticity at any time in your body, it most likely is in your bowel and sphincters. It is important that you perform digital stimulation slowly and gently to not set off spasticity in your bowel, sphincters and even your body.People are so time driven, that they typically perform digital stimulation at such a rapid pace that they set off spasticity in the bowel and sphincters causing them to constrict and thereby lengthening the time and difficulty of the bowel program.

The purpose of digital stimulation is to relax the internal sphincter of the bowel. You can see the external sphincter as the body’s opening to the bowel. The internal sphincter is higher up in the end of the bowel, about a finger’s length. Some people will feel the internal sphincter when performing digital stimulation, but most others will not. If you can feel the internal sphincter, you will know when you have relaxed it. If you cannot feel it, you will have to learn to gage how long it needs to be stimulated before relaxing. It can take anywhere from 30 seconds to up to 2 minutes. If you have a slow bowel program, digitally stimulate for a longer time until you find what is right for you.

When inserting a suppository or performing digital stimulation, be sure to use a gloved, well lubricated finger. Use a lubricating jelly as other things such as petroleum does not dissolve in the rectum or water will wet your finger but will not lubricate it. Lubrication is needed to avoid hemorrhoids, fissures (tears in the bowel) or even a prolapsed bowel (part of the bowel that drops out of the rectum.)

If you would like to perform your own bowel program but lack hand dexterity, you can obtain a suppository inserter and digital stimulator. There are bidets that can be added to your toilet for cleanup. These work well however drying yourself thoroughly enough to avoid pressure injuries is still a challenge for most people.

Movement is another often overlooked advantage to the bowel program. Our bodies use the muscle movement produced by the legs to stimulate the abdomen muscles to add assistance to the movement of the bowel. You can stimulate these muscles through range of motion exercises provided by your movement of your legs or someone doing it for you. Every time you do your pressure releases, you are stimulating your abdominal muscles with movement. If you have a power chair, use the tilt button to provide movement to your abdomen. Even rolling in bed can move gas in your belly to push stool along. Not only will these activities help maintain your skin, but also the urine in your bladder will be shaken within it to decrease urinary tract infections in addition to improving your bowel program.

For most individuals, the bowel program works well without many adjustments. Sometimes, you might notice some dryness in the stool or diarrhea with an illness. This generally resolves with time. A new medication can affect your bowel program. A change in routine can affect your bowel program such as starting a new job, getting married or divorced, or any anxiety producing event. A temporary upset in bowel routine happens to everyone. If the situation does not resolve, it is time to rethink your routine.

There are some individuals for which the bowel program is a difficult situation. Sometimes the bowel will not conform to a reasonable bowel routine. This is an especially good time to review what you are doing and how you are doing it.

Pediatric Considerations
Parents of younger children will perform bowel programs for their child. Typically, a glycerin suppository or a part of the glycerin suppository is used for the younger child due to its gentile action. Treating the bowel program as a usual activity helps the child realize that this is what is standard for them. The adjustment to doing a bowel program becomes natural as they age. How you react to the bowel program will be how they mimic their thoughts about bowel activities in the future.

Transitioning to independence with the bowel program is a developmental step for the child. Divide the activities of the bowel program in to steps appropriate for your child. Getting the supplies out might be a first step while you do something else. Inserting the suppository might be another step. Doing digital stimulation, a third step. Cleaning up another. You do not have to go in order of the bowel program. Starting with cleaning up might be the natural first step for your child. Offer praises for a job well done or a good try.

Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.