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  Department of Rehabilitation Medicine 
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Spinal Cord Injury (SCI) & Maintaining Healthy Bowels

What is the Bowel and What Does it Do?

The bowel is the last portion of your digestive tract and is sometimes called the large intestine or colon. The digestive tract as a whole is a hollow tube that extends from the mouth to the anus (see illustration at right).

The function of the digestive system is to take food into the body and to get rid of waste. The bowel is where the waste products of eating are stored until they are emptied from the body in the form of a bowel movement (stool, feces).

A bowel movement happens when the rectum (last portion of the bowel) becomes full of stool and the muscle around the anus (anal sphincter) opens (see diagram below).

With a spinal cord injury, damage can occur to the nerves that allow a person to control bowel movements. If the spinal cord injury is above the T-12 level, the ability to feel when the rectum is full may be lost. The anal sphincter muscle remains tight, however, and bowel movements will occur on a reflex basis. This means that when the rectum is full, the defecation reflex will occur, emptying the bowel. This type of bowel problem is called an upper motor neuron or reflexic bowel. It can be managed by causing the defecation reflex to occur at a socially appropriate time and place.

A spinal cord injury below the T-12 level may damage the defecation reflex and relax the anal sphincter muscle. This is known as a lower motor neuron, flaccid or areflexic bowel. Management of this type of bowel problem may require more frequent attempts to empty the bowel and bearing down or manual removal of stool.

Both types of neurogenic bowel can be managed successfully to prevent unplanned bowel movements and other bowel problems such as constipation, diarrhea and impaction.

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What Methods Can Be Used For Emptying the Bowel?

Each person's bowel program should be individualized to fit his/her own needs, type of nerve damage (upper or lower motor neuron) and other factors (see "What Factors can Affect the Success of the Bowel Program," below). Components of a bowel program can include any combination of the following:

  • Manual Removal: Physical removal of the stool from the rectum. This can be combined with a bearing down technique called a valsalva maneuver (avoid this technique if you have a heart condition).
  • Digital Stimulation: Circular motion with the index finger in the rectum, which causes the anal sphincter to relax.
  • Suppository: Bysocodyl rectal suppository (Dulcolax® or Magic Bullet®) stimulates the nerve endings in the rectum, causing a contraction of the bowel. Glycerine draws water into the stool to stimulate evacuation.
  • Mini-enema (Enemeez): Softens, lubricates, and draws water into the stool to stimulate evacuation.

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What is a Bowel Program?

Most people perform their bowel program at a time of day that fits in with their prior bowel habits and current lifestyle. The program usually begins with insertion of either a suppository or an Enemeez®, followed by a waiting period of approximately 5-10 minutes to allow the stimulant to work. This part of the program should, preferably, be done on the commode or toilet seat.

After the waiting period, digital stimulation is performed every 10-15 minutes until the rectum is empty. Persons with a flaccid (areflexic) bowel frequently omit the suppository or mini-enema and start their bowel program with digital stimulation or manual removal. Most bowel programs require 30-60 minutes to complete.

Bowel programs vary from person to person according to their individual preferences and needs. Some people use only half of a suppository, some require two suppositories, and some use no suppository or mini-enema at all. Some choose to do the entire program in bed, while others sit on the toilet from the beginning. Some find that the program works better if they can eat or drink a warm beverage while it is in progress, others find that this is not helpful. What is most important is that you discover what works best for you.

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What Factors Can Affect the Success of the Bowel Program?

Any one of the factors listed below, or a combination of factors, can affect the success of a bowel program. Changing one factor may produce results almost immediately, or it may take several days to see the results. Changing more than one factor at a time makes it difficult to determine the effects of individual factors, and may increase the time it takes to develop a stable bowel program.

  • Previous bowel history: What have your bowel habits been in the past?
  • Timing: Do you do your bowel program in the morning or evening? At the same time every day? After a meal or warm beverage? What is the interval between programs -- half a day, one day or two days? (You should do a bowel program at least every 2-3 days to reduce your risk of constipation, impaction and colon cancer.)
  • Privacy and Comfort: Does someone else share your bathroom? Do you have enough time to complete your program?
  • Emotional stress: Has your appetite been affected? Are you able to relax?
  • Positioning: Where do you do your program -- on a commode chair, raised toilet seat, on the toilet, or in bed? It will probably work better when you are sitting up because of gravity.
  • Fluids: How much and what type of fluid do you drink? (Prune juice or orange juice can stimulate the bowels, or another type of fruit juice may work best for you.)
  • Food: How much fiber or bulk (such as fruits and vegetables, bran, whole grain breads and cereals) do you eat? Some foods (such as dairy products, white potatoes, white bread and bananas) can contribute to constipation, while others (such as excess amounts of fruit, caffeine, or spicy foods) may soften the stool or cause diarrhea.
  • Medication: Some medicines (such as codeine, Ditropan, probanthine, and aluminum-based antacids like Aludrox) can cause constipation, while others (including some antibiotics, such as ampicillin, and magnesium-based antacids such as Mylanta and Maalox) can cause diarrhea. Consult your health care provider for information about the medications you are taking.
  • Illness: A case of the flu, a cold or an intestinal infection may affect your bowel program while you are ill. (Even if your digestive system is not directly affected, your eating habits, fluid intake or mobility may change, which can alter your bowel program.)
  • Activity level/Mobility: How much exercise do you get? How much time do you spend out of bed?
  • Weather: Hot weather increases the evaporation of body fluids, which can lead to dehydration and constipation.
  • External massage: Massaging the lower abdomen in a circular, clockwise motion from right to left increases bowel activity.
  • Valsalva: (bearing down) This technique is not recommended for patients with cardiac problems.
  • Assistive/Adaptive Devices: Devices such as a suppository inserter, finger extension or digital stimulator may be required to assist you in establishing a successful bowel program.

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What to Avoid

Regular Use of Stimulant Laxatives: Stimulant laxatives such as bisa­codyl (Dulcolax) tablets, phenolphthalein (Ex-Lax), cascara, senna and magnesium citrate are not recommended for use as a regular part of a bowel program. An occasional small dose of a mild laxative, such as Milk of Magnesia or Miralax (polyethylene glycol), can be used to treat constipation if other measures have not worked. Some people may require a small daily dose of one of these mild laxatives. If you need to use laxatives frequently, discuss the problem with your health care provider.

Enemas: Any full-size enema (such as Fleet’s, soap suds or tap water) is too irritating to the bowel and can cause autonomic dysreflexia. A “mini-enema”, which has only a few drops of liquid stool softener, does not fall into this category and can be used regularly. Occasionally, your health care provider may prescribe a full-size enema as preparation for a medical procedure or for treatment of severe constipation.

Skipping or Changing the Time of Your Program: Your bowels will move more predictably if your bowel care program is carried out on a regular, predictable schedule. Skipping your program can also result in constipation or accidents.

Rushing: The more tense you are, the more difficult it will be for you to empty your bowels. A hurried program will increase the likelihood of an unplanned bowel movement later in the day. People with upper motor neuron (reflexic) bowels should avoid straining (Valsalva) to push out stool because this can cause a contraction of your sphincter that will block passage of stool.

More Than Four Digital Stimulations at a Time: This can cause trauma to the rectum, resulting in hemorrhoids or fissures (cracks or breaks in the skin).

Long Fingernails: They can damage the rectal tissue and cause bleeding, even through a glove.

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What To Do If...

Stool is Too Hard (Constipation): Do your bowel program on a daily basis until constipation resolves. Add or increase the dose of a stool softener (such as ducosate or colace). Add or increase the dose of psyllium hydro-mucilloid (such as Metamucil or Citrucel). Increase your fluid intake (this is essential if you are increasing psyllium). Increase your activity level and your intake of dietary fiber. Avoid foods that can harden your stool, such as bananas and cheese.

Stool is Liquid or Runny (Diarrhea): Temporarily discontinue the use of any stool softeners. Continue your bowel program at the regular time and frequency. (If you are having accidents, increase the frequency of your program.) Try adding or increasing the dose of psyllium hydro-mucilloid (Metamucil, Citrucel), which adds bulk to liquid stool. If the diarrhea seems to be related to an acute viral or bacterial illness, change to a liquids only or very bland diet for 24 hours (avoid milk, however). If diarrhea persists for more than 24 hours or if you have a fever or blood in your stool, consult your health care provider.

A frequent cause of diarrhea is a blockage or impaction of stool (liquid stool leaks out around the blockage). Evaluate whether you may have this problem. Have you had small hard stools recently? Or have you had no ­results from the past several programs? If you suspect impaction, consult your health care provider.

Frequent Bowel Accidents: Be sure your rectum is completely empty at the end of your program. Increase the frequency of your program (some people with a flaccid bowel may need to empty their bowels twice daily). Try using only half of a suppository or switch to a mini-enema. Evaluate stool consistency — if it’s too hard or too soft, see above. Monitor your diet for any foods that may over stimulate your bowel, such as spicy foods.

Mucous Accidents: If you notice a clear, sticky, sometimes odorous drainage from the rectum, try switching from a suppository to a mini-enema or using only half of a suppository. Avoid hard stools.

No Results in 3-4 Days: Treat constipation as recommended above. If there are no results in three days, take 30 cc. of Milk of Magnesia or a single scoop of Miralax at bedtime. Do your bowel program in the morning. If there are still no results, repeat the laxative the next evening. If there are no results in the morning, consult your health care provider.

Rectal Bleeding: Keep your stool soft. Be very careful to do digital stimulation gently and with sufficient lubrication, and keep your fingernails short. If you have hemorrhoids, you may treat them with an over-the counter hemorrhoidal preparation such as Anusol or Anusol HC. If bleeding persists or is more than a few drops, consult your health care provider.

Excessive Gas: Avoid constipation. Increase the frequency of your bowel programs. Avoid gas-forming foods, such as beans, corn, onions, peppers, radishes, cauliflower, sauerkraut, turnips, cucumbers, apples, melons and others that you may have noticed seem to increase your own gas. Try simethicone tablets to help relieve discomfort from gas in your stomach.

Bowel Program Takes a Long Time to Complete: Try switching from a suppository to mini-enemas. Increase your intake of dietary fiber. Try switching your program to a different time, and be sure you schedule it after a meal to help increase intestinal peristalsis. Do your bowel program in the sitting position if you have been doing it in bed. Try exercising before your program.

Autnonomic Dysreflexia During Bowel Program: Use xylocaine jelly (available by prescription from your health care provider) for digital stimulation. You may also need to insert some of the jelly into your rectum before beginning the program. Keep your stool as soft as possible. If dysreflexia persists, consult your health care provider. You may need medication to treat or prevent this condition.

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