Bowel management

Many people with spinal injuries, brain injury, stroke and neurological problems like multiple sclerosis tell me that the one thing they really would like to have control over is their bowel. They can cope with the wheel chair – but not the incontinence. So this time round I thought I would look at bowel management.

A complete discussion of this topic would fill up too much space – and has already been done very well by many others. You could go and look at any one of the three websites in the box for lots more detail, but in the meantime, here is a step-by-step recipe to guide to help you take control of your bowel management:

Assess your impairment with your doctor:

Do this now and then review your situation annually for life.

Discuss your bowel history – including a history of gastro-intestinal (GIT) problems you had before your injury/illness, your current bowel program, your current GIT symptoms, current bowel movement patterns and current medication.

Make sure that as part of the complete examination your doctor does a full abdominal examination and A RECTAL EXAM. Between you, you will be able to assess anal sphincter tone, assess the anal reflexes to distinguish between so-called reflexic and areflexic lesions and screen for other problems like piles.

Assess your level of function:

  • Do you know and understand what is happening with your bowel?
  • Can you direct your carers to do your bowel care or can you do it yourself?
  • Can you sit up on a toilet or commode?
  • If so how good is your balance and how long can you sit for?
  • How bad is your spasm?
  • Will this interfere with your ability to carry out his bowel programme?
  • How good is your upper limb function?
  • Can you use your arms for toileting?
  • How much help do you need with transfer and with dressing?
  • How big are you?
  • What do your home toilet facilities and equipment look like?

If you have, any problems with these questions you may want to discuss these with you doctor, with a nurse who understands disability issues and with an occupational therapist.

Design your bowel program:

The aim is to achieve prompt (less than 30 minutes) and complete emptying of the rectum at a predictable time and in an appropriate place and on a regular, convenient basis – all in your own home environment and without producing unwanted GIT symptoms or soiling between times and while preventing future complications.

DO NOT rush off and use a high fibre diet. Start off with 15g of fibre daily. Go for soluble fibres, rather than insoluble ones. Asking a neurogenic bowel to handle masses of fibre is like asking patient with SCI to walk harder! If you have questions here, go and see a dietician and ask for help.

Push your fluid intake usually around 40 ml/kg/day is sufficient (3000 ml for a 75 kg person).

Choose a rectal trigger – usually a finger or a rectal irritant (suppository.) Define individualised, regular and disciplined scheduling (ideally every 2 days and at the same time of day) and positioning for your bowel plan (preferably sitting on a commode or toilet).

Identify appropriate assistive equipment and techniques (Valsalva, abdominal massage, manual removal, ingestion of warm fluids, leaning forward).

Where possible exclude medications that affect bowel function.

Try to stick to a strict routine – same time of day, same interval, same medication and same routine.

Take your pre-injury GIT problems and your life plans and demands into account.

Stick to your programme for 3-5 cycles before changing anything.

Discuss you plan with you health care team (doctors, nurses, OT & PT).

For most people it will be possible to settle on a simple plan – and to finish off I have given 2 “recipes” which you could look at using as a basis for a plan but will have to adapt to your own needs.

A “Typical” initial reflexic bowel programme:

  • Try to keep the stool soft, but not sloppy.
  • Possibly use an aperient (senna product) 10-12 hours prior to bowel care. Place a chemical stimulant (e.g. glycerine or bisacodyl suppository) onto the rectal mucosa, preferably as high as possible. If the rectum is full of stool, remove some manually to ensure that the irritant is able to make contact with the mucosa and doesn’t disappear into the stool. and/or mechanically stimulate the rectum with a finger.
  • Establish how long your optimal waiting period (for the stimulation to work) is.
  • Assume an upright position on a toilet or commode (alternatively a side-lying position).
  • Perform any appropriate assistive techniques.
  • Repeat stimulation until complete.

A “Typical” initial areflexic Bowel

  • Try to keep stool firm and dry, but not hard.
  • Assume upright position.
  • Empty bladder to prevent vesico-ureteric reflux.
  • Perform gentle Valsalva manoeuvres.
  • Perform Manual evacuation of stool.

Make sure you find out about all aspects of bowel management:

  • Anatomy and physiology of defaecation.
  • Effect of SCI on bowel function.
  • Purpose, goals and nature of bowel programmes.
  • Key success factors or a bowel programme.
  • The importance of regularity, timing and positioning.
  • Safe, effective, equipment and techniques.
  • Medications used in bowel management.
  • Prevention and management of bowel problems and emergencies.
  • Long-term problems.

Yes, I know that there is so much more – but go look at the websites – they have covered it all very well. Oh – and talk to your doctor!

The point is that bowel management needs to be as much a science as any other aspect of SCI care – and until you give it the attention it deserves you will continue to get a **** deal.

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