Chapter 7
Bowel Management

WHAT IS THE BOWEL?

The bowel, also called the colon, is the large intestine, the last part of your digestive system. The waste products of digested food are stored in it until you need to have a bowel movement.

 
HOW THE DIGESTIVE SYSTEM AFFECTS BOWEL MOVEMENT

 
BOWEL PROGRAM

A bowel program is the total combination of diet, exercise, fluids, medication, and scheduled bowel care. The goals of your bowel program are to prevent bowel accidents (unplanned bowel movements), to produce bowel movements at regular and predictable times, and to minimize bowel-related complications.

 
Bowel Care

Bowel care is the scheduled process of starting and assisting your body to have a bowel movement. Bowel care is part of the bowel program. Bowel care is the procedure for assisting bowel movements that can be learned and followed in a series of steps.

Good control of your bowels after a spiral cord injury is possible with planned bowel care as part of a bowel program. Keeping your bowel emptied on a regularly scheduled basis to prevent chronic over-distention is the goal. Using an abdominal binder to support the abdomen may be helpful.

To stimulate peristalsis (wave-like movement of the intestines), you may use a rectal suppository, mini-enema, and/or digital stimulation of the rectal muscles. Scheduled bowel care can be done on a commode, on a toilet, or in bed with pads, whichever works best for you.

The types of things you will need included in your bowel care as part of your overall bowel management program will be best determined by the type of bowel you have following your SCI, whether it is reflexic or areflexic. The rehabilitation nurse and your health-care provider will work with you to establish the most effective bowel care routine. The following is a description of things and techniques that are commonly used in bowel care regimes. Table 7.A lists some medications that may be prescribed as part of your bowel program.

 
Do:

1. Establish a regular time for bowel care that will fit into your daily schedule. Your actual bowel care can be every day, every other day, or every three days. In the first weeks after your spinal cord injury, your bowel care will be every day.
2. Eat a well-balanced diet with high-fiber foods.
3. Have privacy.
4. Be comfortable.
5. Exercise regularly (range-of-motion exercises).
6. Drink as much liquid as your bladder management will allow.

 
Don’t:

1. Use large enemas, because they decrease normal bowel muscle tone. Mini-enemas may be prescribed.
2. Take strong oral laxatives routinely.

 
Supplies Needed:

• Suppository inserter (if you need one)
• Suppository or mini-enema
• Lubricating jelly
• Waterproof pads
• Gloves
• Antibacterial soap and warm water
• Toilet paper or moist wipes for cleansing
• Scissors if using mini-enema

TABLE 7.A. Bowel Medications

 
HOW TO PERFORM BOWEL CARE

If you have sufficient upper extremity function, you will learn to do your own bowel care. If you are not able to do your own bowel care, you will learn to instruct others in the process.

Do your bowel care about 30 to 45 minutes after a meal or hot drink, because this stimulates peristalsis to promote stool movement in your colon. If you use intermittent catheterization procedure (ICP) to empty your bladder, you should do it before bowel care.

• Washing Hands: Wash your hands and put on a clean pair of exam gloves. Hand washing is important to maintain a clean environment and decrease the risk of infection that can be caused by stool contamination.

• Set Up and Positioning: Arrange all the supplies you will need so they are easily within reach when you are ready for them. Many people sit up on a commode chair for bowel care, as gravity may help with emptying the bowel. Some transfer to the commode chair after medication insertion (step 4) while others position themselves on the commode chair first. Others do their care in bed for a variety of reasons. If you are side lying in bed, the left-side-down position is usually recommended.

 
Autonomic Dysreflexia

If you experience symptoms of autonomic dysreflexia (AD) during bowel care, you may need to use an anesthetic cream (contact your health-care provider for prescription) for medication insertion and digital stimulation. Please refer to the chapter on autonomic dysreflexia for further information.

 
Things That Can Affect Your Bowel Program

1. Exercise stimulates peristalsis. Range of motion can be done before bowel care or after inserting the suppository and before digital stimulation. Your routine use of your wheelchair, even an electric wheelchair, is also exercise.
2. Some medications can affect peristalsis. For example, many narcotics or anticholinergics may slow down peristalsis and cause constipation.
3. Emotional stress may cause either constipation or diarrhea.
4. Change in time of scheduled bowel care may lead to bowel accidents.
5. Your diet can harden or soften your stool. (See table 7.B.)

TABLE 7.B. Dietary Effects on Bowel Management

 
PROBLEM SOLVING

Diarrhea

Diarrhea is frequent loose or watery stools, which may cause unplanned bowel movements and accidents.

Causes

1. Spicy foods or foods containing caffeine: coffee, tea, cocoa, or many soft drinks
2. Medications such as antibiotics; or an increase or decrease in medications you are already taking
3. Over-use of laxatives or stool softeners
4. Severe constipation
5. Flu or intestinal infection
6. Psychological stress

Solutions

1. Eat the recommended foods for when you have diarrhea (see table 7.B).
2. Stop any laxatives until diarrhea clears up.
3. Stop stool softeners temporarily, then begin after diarrhea is over, adjusting dose to get the stool consistency you want.
4. Evaluate whether there is a chance that you have an impaction or blockage: no stools, hard stools, or small, hard bowel movements within the last week. One of the most common causes of diarrhea is an impaction where only liquid and soft stool can get past the impaction. Call your SCI clinic or physician.
5. After diarrhea clears up, re-evaluate your bowel program, use of stool softeners, diet, etc.
6. Try eating yogurt with active cultures when taking antibiotics to help restore the normal bacterial flora in your bowel.
7. Call your health-care provider if diarrhea lasts more than 24 hours.

 
Constipation

Constipation is a common condition in which stool does not pass as often, as fast, or as completely as we usually expect. The stool may be hard and dry. It is sometimes hard to determine if you are constipated until you have had incomplete results or no results after 2 or more episodes of bowel care. Be sure you know the amount of stool produced with each bowel movement.

Causes

1. Lack of a regularly scheduled bowel care
2. Incomplete emptying during bowel care
3. Diet low in fiber
4. Bed rest or low physical activity levels
5. Medications: Narcotics, iron, aluminum hydroxide, or an increase or decrease in medications you are already taking
6. Dehydration

Solutions

1. Do bowel care on a scheduled basis. You may need to increase the frequency of bowel care.
2. Eat foods high in fiber to help prevent constipation; see the chapter on Nutrition.
3. Increase activity, range of motion.
4. Take psyllium hydro-mucilloid (Metamucil).
5. Take docusate sodium (DOSS).
6. Drink plenty of fluids as tolerated by your bladder program.
7. Try milk of magnesia or senna the night before scheduled bowel care.
8. Talk to your health-care provider about trying a rectal stimulant medication, or a stronger one if you are already using one, for you bowel care.

 
Impaction

An impaction is a partial or complete blockage in the intestine by stool.

Causes

• Same as for constipation.

Solutions

1. Manually remove stool in rectum.
2. Call your health-care provider for advice.

 
Rectal Bleeding

Rectal bleeding is seen as bright red blood on your stool, toilet paper, or glove.

Causes

1. Hemorrhoids
2. Hard stools (constipation).
3. Rectal fissures (cracks or breaks in the skin).
4. Traumatic digital stimulation of anus (for example, long fingernails damaging the rectum during digital stimulation).
5. Bleeding from higher up in the gastrointestinal tract.

Solutions

1. Soften stools with DOSS, psyllium powder, or increased fluid intake.
2. Do gentle digital stimulation using much lubrication.
3. If bleeding continues for two to three bowel care episodes, consult your health-care provider.
4. If bleeding does not stop between scheduled bowel care episodes, consult your health-care provider immediately.

 
Autonomic Dysreflexia

See the chapter on Autonomic Dysreflexia.

Causes

1. Hemorrhoids or fissures
2. Full or overdistended bowel (constipation, skipped bowel care, impaction)
3. Rough digital stimulation

Solutions

1. Regularly scheduled bowel care with adequate emptying. You may have to increase the frequency of the scheduled bowel care you do.
2. Comfortable positioning during bowel care.
3. Anesthetic ointment applied to anal area 5-10 minutes before suppository insertion and digital stimulation.

 
No Bowel Movements for Two to Three Scheduled Bowel Care Episodes

Causes

1. Constipation
2. Impaction
3. Not eating

Solutions

1. Try to determine cause.
2. Call your health-care provider.

 
Excessive Gas

Causes

1. Gas forming foods (see table 7.C)
2. Constipation
3. Swallowing air while eating or drinking
4. More than normal bacterial breakdown of bowel contents

Solutions

1. Eat your food slowly, chewing with your mouth closed; avoid gulping food.
2. Certain foods may give you gas. Do trial periods of omitting these foods one at a time to enable you to determine which, if any, cause you to have excess gas.
3. Begin a scheduled bowel care regime.

TABLE 7.C. Foods that may Cause Gas

 
RESOURCES

Publications

Neurogenic Bowel: What You Should Know: A Guide for People with Spinal Cord Injury

Constipation and Spinal Cord Injury: A Guide to Symptoms and Treatment

Purchase

PVA Distribution Center
PO Box 753
Waldorf, MD 20604-0753
(888) 860-7244

Bowel Management Programs: A Manual of Ideas and Techniques

Purchase

Accent Press
Accent Special Publications
Cheever Publishing, Inc.
PO Box 700
Bloomington, IL 61702
(309) 378-2961

Taking Care of Your Bowels

Purchase

VA San Diego Healthcare System
Spinal Cord Injury Center (128)
3350 La Jolla Village Dr.
San Diego, CA 92161
(858) 552-8585

Taking Care of Your Bowels-The Basics

Taking care of Your Bowels-Ensuring Success

Purchase

Northwest Regional Spinal Cord Injury System
University of Washington
Rehab Medicine Clinic
1959 NE Pacific
Seattle, WA 98195
(800) 366-5643

Home Care Manual for Spinal Cord Injury

Purchase

Santa Clara Valley Medical Center
Education Dept.
751 S. Bascom
San Jose, CA 95670
(408) 885-2000

"Preventing Secondary Medical Complications: A guide for personal assistants to people with spinal cord injury"

Purchase

Research Services
UAB, Department of Physical Medicine and Rehabilitation
619 19th Street, South, Room 529
Birmingham, AL 35249
(205) 934-3283

Bowel Management in Spinal Cord Injury: Fact Sheet #10

Purchase

Arkansas Spinal Cord Commission
1501 North University,
Suite 470
Little Rock, AR 72207
(501) 296-1788

 
Videos

SCI Video Access, a lending program of information videos
Spinal Cord Injury Network
3911 Princeton Drive
Santa Rosa, CA 95405
(800) 548-2673 or (707) 577-8796

 

SCI Self-Care Guide Main Page Chapter 1     SCI Anatomy & Physiology Chapter 2     Skin Care Chapter 3     Circulatory System Chapter 4     Respiratory Care Chapter 5     Range of Motion Chapter 6     Bladder Management Chapter 7     Bowel Management Chapter 8     Nutrition Chapter 9     Medications Chapter 10   Nerves, Muscles, and Bones Chapter 11   Autonomic Dysreflexia Chapter 12   Pressure Sores Chapter 13   Psychosocial Adjustment Chapter 14   Sexual Health & Rehabilitation

Chapter 15   Community Resources Chapter 16   Vocational Rehabilitation Chapter 17   Recreation Chapter 18   Driver’s Training Chapter 19   Attendant Management Chapter 20   Home Modifications Chapter 21   Approaching Discharge Chapter 22   Pain after Spinal Cord Injury Chapter 23   Substance Abuse and SCI Chapter 24   Exercise Chapter 25   Alternative Medicine Chapter 26   Equipment Chapter 27   Staying Healthy Glossary