Aside from the loss of mobility, the loss of bowel control following a spinal cord injury is often the biggest concern, but with the correct bowel management programme there is no need to worry
Many people with an SCI say that after loss of mobility, the loss of bowel control is the most distressing aspect of SCI. It impacts self-confidence, social interaction, recreational activities, sexual function and most other activities of daily living. It creates an enormous psychological burden and substantially lowers quality of life.
Establishing an effective bowel management programme is essential for day-to-day wellbeing. The aim of a successful bowel management programme is to not only ensure adequate bowel emptying, but also to establish control over bowel function. In order to manage a neurogenic bowel successfully, caregivers need to understand the basics of the problem and how it specifically affects the person they are caring for.
Bowel function before and after SCI
As with the bladder, there are muscles that aim to empty the bowel and those that prevent the emptying of the bowel until it is convenient to have a bowel movement. The muscles that control the emptying of the bowel are controlled by nerves that react to the bulk of stool in the bowel.
These nerves cause the bowel muscles behind the stool to contract and the muscles in front of it to relax, pushing the stool towards the anus. The muscles of the anal sphincter keep the anus closed in order to prevent leakage. When someone needs the bathroom but no toilet is in sight, the sphincter works extra hard to prevent an accident.
An SCI disrupts this process in a number of ways, depending on the level and the completeness of the injury. Most injuries present the following challenges to a greater or lesser degree:
• A loss of sensation that there is a need to pass a stool;
• Incoordination of the muscles of the bowel causing a slow-down in the movement of stools to the anus; and
• A loss of nerve control over the function of the anal sphincter.
The major difference between higher- and lower-level injuries lies in the impact on the anal sphincter. In the case of a higher-level injury, the anal sphincter remains in spasm, causing a build-up of faeces in the rectum. With a lower-level injury, the anal sphincter is flacid and stool can easily leak out.
Caregivers need to have specific information about the bowel function of the person they are caring for, including the level of the SCI and its impact on the anal sphincter.
Aims of bowel management
Caregivers should aim to achieve the following with their patient’s bowel management programme:
• Regular and predictable bowel emptying at a socially acceptable place and time;
• Avoiding constipation, faecal incontinence and autonomic dysreflexia;
• Completing the bowel routine in a reasonable time – preferably in less than an hour; and
• Trying to use the minimum physical interventions and medicines.
The overall aim is for the person with SCI, assisted by the caregiver, to be in control of their bowel function in order to achieve confident integration into society.
Here are a few measures that help stool move through the bowel:
• Activity and exercise, as far as the person with SCI is able, which includes passive movements where the caregiver moves the limbs and joints through their ranges of movement;
• A well-balanced diet that is low on sugar and fat, includes vegetables, fruit and cereals together with fish, meat or dairy products, and plenty fluids. Avoid excessive fibre. Eating and drinking promotes peristalsis – the synchronised contraction and relaxation of the bowel muscles that move the stool along the bowel;
• Abdominal massage using a half-closed fist or the heel of the hand, starting just above the pelvis on the right side, moving up to the ribs then across to the left just below the ribs and finally down to the left side of the pelvis;
• Laxatives are used by many SCI individuals as part of their bowel routine, although they are not essential to bowel management. There are many different types of laxatives, and they can be taken orally or as a suppository;
• Digital stimulation of the rectum with a gloved finger generally causes the anal sphincter to relax. If contact is made with stool, manual removal may be attempted, especially if impacted stool (when immobile faeces becomes dry and hard) is a concern.
Developing a routine
A bowel management programme is very personal and each individual will have their own preferences. It is important to keep these in mind and to stay motivated throughout the trial-and-error phase. Here are a few tips to help you find the right routine:
• Keep a bowel movement diary, recording what measures were tried and how well they worked;
• Consider the pre-SCI bowel routine. Do not try to force a daily routine if the person had a three-day routine before the injury;
• Using a commode with a bucket is the most versatile option, but consider the abilities and preferences of the person with SCI when deciding how to go about the process;
• A good digital stimulation protocol is doing ten circles with the finger, waiting five minutes before repeating, and allowing for only three stimulations at any one time;
• The use of laxatives, suppositories and enemas should ideally be guided by a doctor who is knowledgeable in SCI care; and
• Straining should be limited to a minimum and avoided completely if there is a history of high blood pressure, heart disease or diabetes.
In conclusion, remember that the best kind of rectum is an empty one. Whether the person you are caring for has a tight anal sphincter causing constipation and build-up of faeces, or a flaccid anal sphincter with a tendency to leak stool, an empty rectum will prevent either complication.
However, there is no need to obsess over daily bowel movements. If a good movement can be achieved every second or third day, that is also acceptable. So, here’s to bidding constipation farewell and welcoming consistently clean underwear with lots of happy crappies.
Ida’s Corner is a regular column by George Louw, who qualified as a medical doctor, but, due to a progressing spastic paralysis, he chose a career in health administration. The column is named after Ida Hlongwa, who worked as caregiver for Ari Seirlis for 20 years. Her charm, smile, commitment, quality care and sacrifice set the bar incredibly high for the caregiving fraternity.