Developing a bowel management program

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To achieve the optimum bowel management program, consider all key components, individually and holistically.

A period of trial and error is often required to determine the right mix of components for an individual.

Changing one component at a time, although time-consuming, is the best way to determine the effectiveness of any change. Wait three to four bowel cycles before making another change.

Components of a bowel management plan

All people with spinal cord injury (SCI) should see a dietician.

Fibre

There is currently limited evidence for the correct amount of dietary fibre recommended for people with SCI:

  • An initial fibre intake of 15g per day is recommended, with gradual increases up to 30g per day of fibre, as tolerated from a variety of sources.1
  • Fibre intake of 15g per day may be associated with significant improvements in bowel function.1, 2, 3
  • Fibre intake greater than 20g per day may be associated with a delay in intestinal transit times in people with SCI.4

Dietary fibre can be found in fruits, vegetables, legumes, nuts and seeds, as well as wholegrain breads and cereals. A diet that contains adequate serves of grain (cereal) foods, fruits and vegetables will help an individual to meet the minimum 15g fibre recommendation.

Fluid

Adequate fluid intake is important for bowel management as it keeps the stool soft.

Assess fluid recommendations on an individual basis. Some individuals may require fluid restriction or additional fluid depending on their medical background, level of physical activity, metabolism and exposure to hot environments.5

The Consortium on Spinal Cord Medicine recommend that fluid intake should be approximately 500mL/day greater than the standard guidelines used to estimate the needs of the general public (for example: 1mL of fluid/kcal of energy needs + 500mL).6

This is because individuals with neurogenic bowel may have longer colonic transit times, leading to excessive fluid reabsorption and the formation of hardened stools.6, 7

The National Health and Medical Research Council recommend an adequate intake of 2.6L of fluid a day for men and 2.1L of fluid a day for women (from plain water, milk and other drinks).8 The adequate intake of total water from food and fluids is set at 3.4L for men and 2.8L for women.6 In clinical practice, 35mL/ kg or 1mL/kcal may also be used.5, 9

Patients should be encouraged to drink plain water as their main fluid.

Stool softeners (e.g. Coloxyl), stimulant laxatives (e.g. Bisacodyl), and bulking agents (e.g. Metamucil, Fybogel, or Normafibre) are often used.

The time taken for each product to take effect should be considered to promote suitable timing of bowel emptying, e.g. stimulant laxatives should be taken 8-12 hours before bowel emptying is planned to help increase colorectal contractions.9

The gastrocolic reflex can be stimulated by eating or drinking 20-30 minutes before bowel emptying is planned. This can promote mass movement of the stool through the bowel.9 Consider scheduling bowel care after breakfast to promote the gastrocolic reflex after a period of fasting overnight.

The person should assume a position as close as possible to the optimum position for defecation (over the toilet with knees flexed and the upper body bending forward supported by elbows or hands on knees). This will help defecation to take place.

Abdominal massage can increase the frequency of bowel movements10 by stimulating movement of stool through the colon.11

Massage is applied to the abdomen following the length of the colon in a clockwise direction. Pressure is applied and released firmly but gently, using the back or heel of the hand or using a tennis ball.12

A manual perianal or rectal stimulation technique can help the person to empty their rectum by:

  • increasing reflex muscular activity in the rectum, increasing rectal pressure
  • relaxing the external anal sphincter muscle.13

Digital rectal stimulation relies on preserved reflex bowel activity, and is only effective for the upper motor neuron bowel type (see Types of bowel dysfunction).3

Digital rectal stimulation can be performed by:

  • Gently inserting a gloved lubricated finger to the middle joint of the finger through the anus into the rectum and slowly rotating the finger in a circular motion, maintaining contact with the rectal mucosa.
  • Continue rotation until flatus or stool passes or the internal sphincter relaxes. Continue rotation for approximately 15-20 seconds (longer than one minute is not usually required).
  • Repeat steps approximately every 5-10 minutes until evacuation of stool is complete and there is no more stool in the rectum, or it is evident that the reflex has tired, and is not prompting evacuation of stool. Three to six repeats per episode of bowel management is common, but this varies for individuals.

Digital removal of faeces may be required following digital rectal stimulation, to ensure the rectum is empty and avoid incontinence.13

Small volume enemas that soften the stool are commonly used. Some individuals may choose suppositories as an alternative.13, 14, 15

The choice of product is dependent upon the bowel type and function.

They can be administered by

  • trained carers
  • self-administered sitting upright in a suitable commode chair
  • in bed whilst lying in the left lateral position.

Position and gravity will better assist bowel emptying.

Conduct a digital rectal examination (DRE) prior to inserting a suppository or enema, to avoid insertion directly into faeces and ensure lubrication of the mucosa is sufficient.

Transanal irrigation is an option that may be considered when conservative bowel management programs are no longer effective.16

Tepid water is installed into the lower bowel, via a rectal catheter or cone, to assist the evacuation of faeces. It can be self-administered or performed by a carer.

Transanal irrigation can improve constipation and reduce faecal incontinence, as well as reduce time spent on bowel care.11, 17

Aperients may still need to be used to support the formation and propulsion of stool through the large bowel.

Prior to commencing transanal irrigation, conduct a thorough assessment, particularly considering:

  • if there is an increased risk of perforation (transanal irrigation is contraindicated in this case)
  • which type of transanal irrigation system is required, such as a low versus high volume delivery and cone or rectal catheter.

Following assessment, if the decision is made to proceed with transanal irrigation, training and follow-up will be needed for the person with SCI and their carer, to incorporate this as part of bowel management.18

Digital removal of faeces is a technique using a lubricated gloved finger inserted through the anus to break up and remove faeces from the rectum.

Most commonly used for the lower motor neuron bowel type, digital removal of faeces needs to be done gently and sensitively.

Digital removal of faeces can be performed by:

  • Positioning the person in the left lateral position or over the toilet and making sure the finger to be used for manual removal has a short fingernail (not extending beyond the tip of the finger) with no jagged edges.
  • Slowly and gently inserting a well lubricated, single gloved finger through the anus into the rectum.
  • Gently removing small sections of stool at a time until the rectum is empty. Avoid using a hooked finger as this can damage the rectal mucosa and overstretch the anal sphincter.
  • Using a local anaesthetic gel if the patient experiences symptoms of autonomic dysreflexia during this procedure.
  • Conduct a digital rectal examination 5 minutes after the emptying of the rectum to ensure the evacuation is complete.

Several surgical options can be used for bowel management following SCI:

  • Implantation of electrical stimulation systems.
  • Formation of an elective colostomy. Colostomy is effective to reduce the time spent on bowel care. 19
  • Formation of an appendicostomy to allow antegrade enema administration.11

Surgical options should only be considered after other options have been exhausted. Expert advice should be sought if these procedures are being considered.

It is ideal for the person with SCI to perform bowel self-management. However, not all people have sufficient residual function to do this independently. The individual should still be involved in decisions about their care, particularly during the training of personal carers.14

Where possible, carers should receive formal training in all elements of bowel management. This should include:

  • rationale and importance of a bowel management program for the person with a SCI
  • explanation of how the body functions, including training with anatomical models, where available.20

  1. Badiali D, Bracci F, Castellano V, et al. Sequential treatment of chronic constipation in paraplegic subjects. Spinal Cord. 1997;35(2):116-20. DOI: 10.1038/sj.sc.3100355
  2. Academy of Nutrition and Dietetics. Spinal cord injury evidence-based nutrition practice guideline. 2009. [cited April 2019].
  3. Academy of Nutrition and Dietetics: Evidence Analysis Library. What level of fibre is recommended to manage neurogenic bowel in spinal cord injury patients; and how should it be introduced? 2009 [cited April 2021].
  4. Cameron KJ, Nyulasi IB, Collier GR, et al. Assessment of the effect of increased dietary fibre intake on bowel function in patients with spinal cord injury. Spinal Cord. 1996;34(5):277-83. DOI: 10.1038/sc.1996.50
  5. Sawka MN, Cheuvront SN, Carter IR, et al. Human water needs. Nutr Rev. 2005;63(6 II):S30-S9. DOI: 10.1111/j.1753-4887.2005.tb00152.x
  6. Consortium for Spinal Cord Medicine. Clinical practice guidelines: management of neurogenic bowel dysfunction in adults after spinal cord injury. PVA. 2020.
  7. Krogh K, Mosdal C, Laurberg S. Gastrointestinal and segmental colonic transit times in patients with acute and chronic spinal cord lesions. Spinal Cord. 2000;38(10):615-21. DOI: 10.1038/sj.sc.3101066
  8. National Health and Medical Research Council. Nutrient reference values for Australia and New Zealand including recommended dietary intakes. Canberra: NHMRC; 2006 [cited April 2021].
  9. Coggrave MJ, Norton C. The need for manual evacuation and oral laxatives in the management of neurogenic bowel dysfunction after spinal cord injury: a randomized controlled trial of a stepwise protocol. Spinal Cord. 2010;48(6):504-10. DOI: 10.1038/sc.2009.166
  10. Coggrave M, Mills P, Eng JJ. Bowel dysfunction and management following spinal cord injury. In: Eng JJ, Teasell RW, Miller WC, et al. Editors. Spinal cord injury rehabilitation evidence Version 5. Vancouver, Canada. 2012. p. 1-48
  11. Krassioukov A, Eng JJ, Claxton G, et al. Neurogenic bowel management after spinal cord injury: a systematic review of the evidence. Spinal Cord. 2010;48(10):718-33. DOI: 10.1038/sc.2010.14
  12. McClurg D, Lowe-Strong A. Does abdominal massage relieve constipation? Nurs Times. 2011;107(12):20-2.
  13. Singal AK, Rosman AS, Bauman WA, et al. Recent concepts in the management of bowel problems after spinal cord injury. Adv Med Sci. 2006;51:15-22.
  14. Middleton JW, Arora M, McCormick M, et al. (2020). Health Maintenance Tool: How to stay healthy and well with a spinal cord injury. A tool for consumers by consumers. 1st ed. NSW: 2020 [cited 27 Oct 2022].
  15. Johns JS, Krogh K, Ethans K, et al. Pharmacological Management of Neurogenic Bowel Dysfunction after Spinal Cord Injury and Multiple Sclerosis: A Systematic Review and Clinical Implications. J Clin Med. 2021;10(4):882.
  16. Hultling C. Neurogenic Bowel Management Using Transanal Irrigation by Persons with Spinal Cord Injury. Phys Med Rehabil Clin N Am. Aug 2020;31(3):305-318. DOI: 10.1016/j.pmr.2020.04.003.
  17. Emmanuel AV, Krogh K, Bazzocchi G, et al. Consensus review of best practice of transanal irrigation in adults. Spinal Cord. 2013;51(10):732-8. DOI: 10.1038/sc.2013.86
  18. Shaw L. Transanal irrigation for bowel dysfunction: the role of the nurse. Br J Nurs. 2018;27(21),1226-1230. DOI:10.12968/bjon.2018.27.21.1226
  19. Stoffel JT, Van der Aa F, Wittmann D. et al. Neurogenic bowel management for the adult spinal cord injury patient. World J Urol. 2018;36:1587–1592. DOI: 10.1007/s00345-018-2388-2
  20. Holroyd S. Digital rectal examination: why, who, how? J Community Nurs. 2020;34(4):63-65.

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