Bowel Considerations with Spinal Cord Injury

Original Editor - Wendy Oelofse

Top Contributors - Ewa Jaraczewska, Jess Bell and Kim Jackson  

Introduction

The pattern of bowel dysfunction varies depending on the level of injury. The complications of neurogenic bowel dysfunction include constipation, obstructive defecation, and faecal incontinence.  Bowel dysfunction can cause significant restrictions in a person's social activities and quality of life.  There is no single program that can work for every patient, but the bladder and bowel dysfunction management program is a fundamental step following the initial spinal cord injury.

This article supplies additional information for the Bladder and Bowel Consideration with Spinal Cord Injury course.

Bowel Dysfunction in Spinal Cord Injury

Patient's symptoms in neurogenic bowel dysfunction vary depending on the injury level. One author defines three neuropathological patterns in patient with a complete spinal cord injury:

• Patter A: Patients with spinal cord injury above T7
  • Loss of voluntary control of abdominal muscles
  • Preserved spinal sacral reflexes
• Pattern B: Patients with spinal cord injury below T7
  • Voluntary control of abdominal muscles
  • Preserved sacral reflexes
• Pattern C: Patients with spinal cord injury below T7
  • Voluntary control of abdominal muscles
  • Absent sacral reflexes.

Another classification defines two types of neurogenic bowel:

• Spastic bowel
• Flaccid bowel

Spastic Bowel

• Observed in people with an SCI above T12 (Upper motor neuron SCI)
• Loss of feeling the need to have a bowel movement
• Loss or impairment of voluntary control of the external anal sphincter
• The reflex that makes the stool move out of the body is intact and can be stimulated
• Complications include constipation, usually with faecal retention, but uncontrolled evacuation of the rectum can occur.

Flaccid Bowel

• Observed in people with a SCI below T12 (Lower motor neurone SCI)
• Loss of feeling the need to have a bowel movement
• Loss or impairment of voluntary control of the external anal sphincter
• Loss of the bowel reflex. The rectum cannot easily empty itself, and the sphincter muscles may relax and stay open.
• Complications include constipation and incontinence

Bristol stool chart

Bristol Scale

The Bristol scale or Bristol Stool Chart is an assessment tool used by healthcare professionals and designed to classify stools. It helps to diagnose constipation, diarrhoea and irritable bowel syndrome.

Type 1 through 7 indicates the following:

• Type 1-2 indicate constipation
• Type 3-4 indicate ideal stools
• Type 5-7 may indicate diarrhoea and urgency

Management of Bowel Dysfunction

"The overall goal of bowel management is to achieve secondary continence with regular and sufficient bowel emptying within an individually acceptable time frame and at the right time according to the patient’s agenda."

The literature does not support one bowel management program for patients with spinal cord injury. A multidisciplinary team should assess each patient and choose the strategy that allow patient self-management as far as possible.

Spastic Bowel Management

The following strategies are recommended to manage spastic bowel:

• Bowel routine
  • Empty every other day or 3x/week
  • It should take no longer than 1 hour.
• Suppository
  • Bisacodyl and glycerin are the most common active ingredients in suppositories
  • Oral laxatives can become a component of bowel management programs
• Digital rectal stimulation
  • Gloved finger is inserted into the anorectal canal
  • The goal is to enhance contractions of the descending colon and rectum, which helps with bowel evacuation
• Abdominal massage
  • It takes about 15 minutes
  • The goal is to decrease colonic transit time, reduce abdominal distension and increase the frequency of bowel movements per week

Watch the video demonstrating abdominal massage to manage constipation:

Flaccid Bowel Mangement

The following strategies are recommended to manage flaccid bowel:

• Bowel routine
• Digital removal
• Suppositories
• Balanced diet and the use of medication to maintain stool consistency
• Transanal irrigation
  • Transanal irrigation system includes a coated rectal balloon catheter, manual pump, and a water container.
  • It involves inserting a balloon catheter into the rectum and slowly administering warm tap water in volumes, usually between 500 and 1,000 mL.
  • The system makes it possible to handle the irrigation procedure without assistance from another person.
  • Immobilized patients and patients with poor hand function can use the system.
  • The result includes fewer patients' complaints of constipation, less faecal incontinence, improved symptom-related quality of life, and reduced time consumption on bowel management procedures.
• Colostomy:
  • A viable option for some patients.
  • It improves quality of life, reduces time spent on bowel care, and increases independence.
  • It is considered a good option for individuals who spend long hours on bowel management, and non-invasive procedures were not effective.
  • The most common complications include rectal discharge, stoma prolapse, further surgery to remove the remaining colon, wound healing issues and skin irritation.

Possible Causes of Frequent Bowel Accidents

• Medication interfering with a bowel routine. Certain medications can cause constipation, and others can cause diarrhoea.
• Patinet's illness due to diet change or change in mobility.
• Patient's activity level. Mobility helps to manage the bowel as it helps to move stool through the colon.
• Weather. Increased temperature can lead to dehydration, which results in constipation

Bowel complications

• Consistency: Diarrhea
• Consistency: Constipation
• Hemorrhoids/rectal bleeding
• Autonomic dysreflexia
• Skin breakdown

Assessment for Independent Use of the Toilet for Bowel Care

Hand function

• Does the patient have a sufficient hand function to perform digital interventions?
• Individuals with complete SCI above C8 will not be able to perform independent bowel care due to a lack of sufficient motor power and sensation in the fingers.
• Some individuals may achieve reliable emptying after rectal stimulant insertion without the need for digital checking or further digital stimulation.
• Patients may require additional interventions with digital checking/stimulating because no equipment is available to aid with this task.

Toilet access

• An individual may sit directly on the toilet or sit on a shower chair over the toilet.
• A shower chair can reduce the need for transfers between the wheelchair/shower chair/toilet.
• Shower chairs can be difficult to balance for self-care. Portable shower chairs are available, but it can be difficult for the patient to take a shower chair with them.
• The individual should be instructed on independent toilet transfer. Falls from the toilet are common and can cause significant injury.
• Adaptation of toilet facilities should include wheelchair accessibility, handrails and a padded/contoured toilet seat. A home visit by an occupational therapist may be required.

Skin Integrity

• All individuals with diminished or absent sensation and prolonged toileting should use a pressure-relieving seat using the toilet or a shower chair.
• Individuals with a history of skin damage and resultant scarring may not safely tolerate even a short sitting time.
• Minimising the duration of bowel care through an effective and timely bowel management programme is essential.

General Factors for Successful Bowel Program

General factors to consider when planning caregiver training:

• Patient and caregiver motivation
• Skin condition
• General health/frailty (i.e.postural hypotension, extreme old age)
• Degree of spasticity
• Sitting balance
• Home circumstances: privacy and dignity, accessibility, availability of suitable equipment

Resources

• Kurze I, Geng V, Böthig R. Guideline for the management of neurogenic bowel dysfunction in spinal cord injury/disease. Spinal Cord. 2022 May;60(5):435-443.
• Guidelines for Management of Neurogenic Bowel Dysfunction in Individuals with Central Neurological Conditions