Managing a neuropathic bowel
Following a spinal cord injury both bladder and bowel control changes. Usually a satisfactory routine is established during the rehabilitation phase. However, there are often ongoing problems with bowel management and this leads to frustration and embarrassment as continence (or rather incontinence) becomes an issue. This simple step wise approach to the problem will hopefully assist those readers that are struggling with a suitable bowel management programme.
After suffering a spinal cord injury, the two biggest changes related to bowel function that impact on continence are a decrease in colonic transit times and the in coordinate functioning of the sphincters. With regards transit times, studies have indicated that there is an increase in the time it takes for food to enter the mouth and to reach the point of evacuation as faeces – this is normally increased by up to 30%. The main area of holdup appears to be in the large intestine, although transit times are reduced throughout the small and large bowel. This is related directly to the paralysis and reduced activity of the musculature surrounding the bowel, which normally propels food and faeces through the system. It is therefore essential that this is properly managed in order to prevent complications. The other major factor impacting on continence is the in coordinate functioning of the anal sphincter.
Establishing a bowel routine that works for you is very important and once established, maintaining this routine is vital. Normally during rehabilitation a simple alternate day regime is started. This comprises taking an oral stimulant laxative (usually senokot) by mouth followed by the use of a rectal suppository some 10 to 12 hours later. Those who prescribe these medications should always start at the lowest dose possible – normally taking 2 to 4 senokot orally on alternate days and a single suppository 10 to 12 hours later. It is important to remember that the normal reflex to empty the bowel is retained in spinal cord injury (this is called the gastro colic reflex) and is triggered by a meal or/and hot drink. Therefore it is important to insert the suppository after your meal and taken with a hot drink to facilitate bowel evacuation. It is vital to maintain a good fluid intake and high fibre diet to assist in preventing constipation. Avoid “junk foods” and highly refined foods such as white bread etc as this will lead to constipation and bowel problems. Also remember to manage your bowels on a toilet or commode as gravity does ensure a better result. If the stool is too loose, the advice is then to reduce the senokot by 1 or 2 tablets and if too constipated then increase by 1 or 2 tablets. It should not be necessary to take more than 4 to 6 senokot in the early post injury phase. As one ages normally the need for more senokot increases but this should be delayed as long as possible. This simple regime will work for most patients.
For those patients that have good upper limb function, the suppository may be replaced by a process called digital stimulation. This entails gently inserting a gloved and lubricated finger in the anal passage and gently in a circular fashion “massaging” the anal sphincter. This normally triggers a rapid emptying of the rectum and colon and is a far quicker and more effective way of managing the bowel.
If this “routine” fails, then some patients prefer to use a low volume colonic lavage. The routine entails the instillation of a set volume of warm water via a tube into the rectum. This then flushes out the stool. This is not ideal, as these lavages can result in complications. However, under guidance some patients do manage their bowels using this regime very successfully. Manual evacuation of faeces should be avoided as this leads to injury of the sphincter.
If all else fails, then one can consider a permanent colostomy. Colostomy and the actual procedure have been discussed in an earlier edition and so will not be further mentioned here.
In a nutshell.
Establish a simple regime early on.
Once the regime is established, stick to it – changes or alterations lead to problems.
Avoid complications – chronic constipation due to lack of a proper regime or poor diet can lead to “spurious diarrhoea”, haemorrhoids, bloating and pain, increase in spasm and autonomic dysreflexia.
Use the lowest dose of medication to maintain a regular pattern.
Remember that a change in your bowel habit or blood in the stool needs to be investigated.