Management of the neurogenic bowel for adults with spinal cord injuries

Bowel management after spinal cord injury - flow chart

This flow chart has been developed to guide clinicians in performing bowel management for a person with a spinal cord injury. It is relevant for both upper and lower motor neuron bowel dysfunction.

Neurogenic bowel is a general term for a bowel dysfunction due to neurological damage resulting from trauma, disease or injury.

*Gastrocolic reflex occurs when the ingestion of food stimulates decation 20-30 minutes later.

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Introduction

This resource is for clinicians working with people with spinal cord injuries (SCI) in acute, non-acute and community settings. It provides an introduction to neurogenic bowel management for adults with SCI.

Clinicians can find more information and guidance about:

  • how neurogenic bowel dysfunction presents in people with SCI
  • how to implement individualised bowel management plans.

What is neurogenic bowel?

Neurogenic bowel is a general term for a bowel dysfunction due to neurological damage resulting from trauma, disease or injury.

The majority of people with SCI, even those who can walk or who have very incomplete injuries, experience problems with faecal defecation, such as constipation, difficulty with evacuation and faecal incontinence.

In people with SCI, there are two distinct patterns of neurogenic bowel dysfunction:

  • Upper motor neuron or ‘reflex bowel’ syndrome
  • Lower motor neuron or ‘flaccid’ bowel syndrome

This guide outlines bowel management approaches for each type of dysfunction.

Background

This is an update to the fact sheet, Management of the Neurogenic Bowel for Adults with Spinal Cord Injury, first published in 2002 and updated in 2005 and 2014. The original fact sheet was developed based on a systematic review of the literature and expert consensus.

Evidence

The State Spinal Cord Injury Service (SSCIS) consulted with senior clinicians in NSW Spinal Cord Injury Units, to update this document according to contemporary research evidence and advances in neurogenic bowel management practices.

Literature search

A rapid review of Medline, Embase, Emcare and Cochrane was conducted in July 2022, to inform this update. Key search terms included: “spinal cord injury” OR “paraplegia” OR “quadriplegia and neurogenic bowel management”, “digital rectal examination”, “digital rectal stimulation”, “digital removal of faeces and transanal irrigation”.

Snowball searches were conducted from the reference lists of key articles.

Guideline review

This work was informed by clinical guidelines for SCI care developed by Spinal Cord Injury Rehabilitation Evidence (SCIRE)1 and the Consortium for Spinal Cord Medicine (Paralyzed Veterans of America)2.

Produced by: State Spinal Cord Injury Service

SHPN: (ACI) 221025

ISBN: 978-1-76023-375-4

Version: 2 Trim: ACI/D22/50

  1. 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.
  2. Paralyzed Veterans of America. Publications: Clinical Practice Guidelines. Washington, DC: PVA [cited 22 Nov 2022].

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Understanding how the body defecates

What is defecation?

Defecation is the elimination of waste and undigested food in the form of faeces from the colon via the anus.

The enteric nervous system interacts with the central nervous system, via the sympathetic and parasympathetic system and neuropeptides, to allow ingested food and fluids to move from the stomach through the gut.1

The diagram below shows the nerve supply (or innervation) to the colon, anal sphincters and pelvic floor.

Figure 1 – Innervation of the colon, anal sphincters and pelvic floor

Source: Rural Spinal Cord Injury Project Management of the Neuropathic Bowel for Adults with Spinal Cord Injuries 2005 guidelines fact sheet

For people without damage or injury to the nervous system:

  • The bowel is typically emptied daily, usually in the morning and in response to a gastrocolic reflex (where ingestion of food stimulates defecation 20-30 minutes later).
  • When a person senses that their rectum is full, they are able to suppress the urge to defecate by contracting the external anal sphincter until it is convenient to access a toilet.
  • Voluntary contraction of the external anal sphincter completes evacuation.

Best position for defecation

  • The optimal position to defecate is with knees flexed and the upper body bending forward, supported by elbows or hands on knees.
  • The person can easily increase intra-abdominal pressure to push faeces in the rectum towards the anorectal verge. With stretching of this area, the anorectal reflex is stimulated causing relaxation of the proximal anal region to allow expulsion of faeces.

Stool consistency

Stool consistency is important and can take a variety of forms, which are best described using the Bristol Stool Chart.

Bristol Stool Chart
Figure 2 – Bristol Stool Chart

Source: Reproduced with permission of Dr KW Heaton, Reader in Medicine at the University of Bristol.

  1. Lynch AC, Antony A, Dobbs BR, Frizelle FA. Bowel dysfunction following spinal cord injury. Spinal Cord. 2001;39(4):193-203.

Defecation following spinal cord injury

Types of bowel dysfunction

There are two distinct patterns of bowel dysfunction after spinal cord injury (SCI), depending on whether the sacral reflexes have been affected.

Table 1: Patterns of clinical presentation of bowel dysfunction following SCI
Supraconal
(upper motor neuron [UMn] or reflex) lesion		 Conal or cauda equina
(lower motor neuron [LMn] or flaccid) lesion
Injury or damage usually at or above T12 vertebral level1 Injury or damage usually L1 vertebral level and below1
  • Positive anal and bulbo-anal reflex1
  • Inability to effectively increase intra-abdominal pressure2
  • Rectal hyperreactivity3
  • Loss of rectal sensation2
  • Loss of voluntary sphincter control3
  • Hypertonic external anal sphincter2
  • Anorectal dyssynergy2
  • Faecal impaction in the proximal colon4
  • Absent anal and bulbo-anal reflex1
  • No reflex response to increased intra-abdominal pressure2
  • Decreased rectal tone3
  • Reduced anorectal sensation3
  • Loss of voluntary sphincter control3
  • Absent external anal sphincter tone2
  • Rectal faecal impaction4

Testing bulbo-anal and sacral reflexes

Identify if the bulbocavernosus (bulbo-anal) reflex is present by:

  • applying pressure to the glans penis or clitoris, to see if a palpable and visible contraction of the anal sphincter occurs1
  • applying a gentle tug to the urethral catheter to see if a palpable anal response occurs.

Identify if there is sparing of the sacral reflexes by applying a pinprick to the person’s buttock, just lateral to the anus. If there is a visible contraction of the anal sphincter, this shows that the sacral reflexes have been spared.1

Common issues with defecation

  • Constipation
  • Difficulty with evacuation
  • Faecal incontinence

What causes issues with defecation?

Depending on the level and completeness of injury, SCI can have a number of impacts on defecation, including the following:

Time taken for movement of ingested food and liquids

  • Gastric emptying time
  • Colonic and whole gut transit time5

Changes in function

  • Altered anal sphincter tone
  • Altered pelvic floor functioning
  • Decreased ability to attain optimum position for defecation due to poor trunk control and balance or equipment available
  • Decreased ability to increase intra-abdominal pressure during defecation
  • Decreased sitting balance
  • Decreased upper limb function
  • Decreased ability to transfer

Absence or alteration of reflexes and sensation

  • The gastrolic reflex may be absent or reduced
  • The ability for a person to sense their rectum is full may be absent or altered
  • Anorectal dyssynergy1 (occurs when the muscles and nerves in the pelvic floor, including the anal sphincter fail to coordinate and relax to  allow bowel evacuation6)

  1. Coggrave M, Ash D, Adcock C, et al. Guidelines for management of neurogenic bowel dysfunction in individuals with central neurological conditions. Multidisciplinary Association of Spinal Cord Injured Professionals. 2012.
  2. Lynch AC, Antony A, Dobbs BR, Frizelle FA. Bowel dysfunction following spinal cord injury. Spinal Cord. 2001;39(4):193-203.
  3. Krogh K, Christensen P. Neurogenic colorectal and pelvic floor dysfunction. Best Pract Res Cl Ga. 2009;23(4):531-43. DOI: 10.1016/j.bpg.2009.04.012
  4. 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.
  5. Williams RE, Bauman WA, Spungen AM, et al. SmartPill technology provides safe and effective assessment of gastrointestinal function in persons with spinal cord injury. Spinal Cord. 2012;50(1):81-4. DOI: 10.1038/sc.2011.92
  6. Cleveland Clinic. Anismus. Cleveland, Ohio: Cleveland Clinic; 24 May 2022 [cited 8 Nov 2022].

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Bowel management

Goals of bowel management

The goals of bowel management following spinal cord injury are to:

  • achieve regular and predictable bowel emptying at a socially acceptable time and place
  • use a minimum of physical and pharmacological interventions to completely empty the bowel within an acceptable timeframe
  • avoid bowel accidents, constipation, autonomic dysreflexia1 (which can be life threatening) and other complications.

Initial bowel symptoms following spinal cord injury

The onset of paralytic ileus (a motility disorder of the intestine causing acute failure of peristalsis) may occur soon after acute injury to the spinal cord. There may be signs within minutes of cord injury or they may be delayed for up to 48 hours.

Paralytic ileus generally lasts 48-72 hours.

Unrecognised paralytic ileus can have serious consequences:

  • In a person with tetraplegia, decreased cough may lead to aspiration of gastric contents.
  • Progressive abdominal distension may contribute to ventilatory insufficiency by pressing up on the diaphragm and limiting its excursion.

Management of paralytic ileus

During paralytic ileus:

  • keep the person nil-by-mouth with a nasogastric tube inserted to decompress the stomach
  • administer intravenous fluid therapy to maintain hydration
  • check the rectum for the presence of stool on a daily basis
  • gently remove any stool manually, using a water-based lubricant.

After resolution of the paralytic ileus, when bowel sounds have returned and flatus passed, fluids and food can be gradually reintroduced, and a bowel management program commenced.

Self-management and self-determination

Self-management of bowel care is ideal. However, not all people with spinal cord injury (SCI) will have the ability to perform their own bowel care procedures.

It is important to allow the person with SCI to be as involved as possible in decisions about their care. This is known as self-determination.

Provide education to the person with SCI and their carer to ensure they are able to make informed decisions, and support self-management and self-determination.

Education topics

As defecation can be a sensitive topic, it is important to take this into account with education about this topic.

  1. Cosgrave M, Ash D, Adcock C, et al. Guidelines for management of neurogenic bowel dysfunction in individuals with central neurological conditions. Multidisciplinary Association of Spinal Cord Injured Professionals. 2012.

Planning bowel management

Bowel management should be personalised for each individual.

To achieve optimal bowel function, the following factors should be taken into account for each person:

  • Type of bowel dysfunction
  • Co-morbid pathologies of the gastrointestinal tract
  • Medications (and their side-effects)
  • Functional ability, particularly mobility, transfers, sitting balance, arm reach and hand function
  • Cognitive ability
  • Personal factors such as diet, fluid intake, food preferences, activity and exercise patterns, lifestyle, motivation, problem solving skills
  • Personal history of bowel management
  • Availability of a carer with the required skillset

Developing a bowel management program

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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Troubleshooting

See below for a number of common problems associated with neurogenic bowel following spinal cord injury (SCI) and recommendations for how to manage them.1, 2, 3

Autonomic dysreflexia is an abnormal, widespread overactivity of the involuntary (autonomic) nervous system to stimulation, which is uncontrolled and if not promptly treated can be life threatening.4

Signs and symptoms

Sudden hypertension; pounding headache; bradycardia; flushing or blotching of skin above SCI level; profuse sweating above SCI level; skin pallor and piloerection below SCI level; chills without fever; nasal congestion; blurred vision; shortness of breath; sense of apprehension or anxiety.

Possible cause

  • Any irritating (nociceptive) stimulus below the level of SCI can trigger excessive reflex activity of sympathetic nervous system and secondary parasympathetic activity
  • Constipation
  • Rectal prolapse (when the rectum protrudes from the anus), caused by high volume enemas, digital stimulation and removal
  • Enlarged haemorrhoids
  • Irritation from enema

Recommendation

  • Autonomic dysreflexia during bowel care is usually temporary and resolves without lasting effects. If signs and symptoms occur, reduce digital stimulation
  • Review bowel care techniques
  • Prevent constipation, e.g. through dietary considerations and fluid intake
  • Consider using topical anaesthetic gel (2% lignocaine) inserted into the rectum 5 minutes prior to digital stimulation and manual evacuation

Bristol stool type: ≥6

Possible cause

  • Excess fluid intake
  • Alcohol intake can affect consistency of the stool
  • Medications (especially antibiotics)
  • Diet, e.g. poor soluble fibre intake, fatty or spicy foods, and caffeine may cause diarrhoea
  • Gastrointestinal illness

Recommendation

  • Review fluid and dietary fibre intake
  • Review medications and aperients. Stool softener dosage is individual and too much can often be a problem
  • Consider adding or increasing bulking agents
  • Use a food diary to record foods and the outcomes of stool consistency
  • Consider stool culture and clostridium difficile (a type of bacteria) if recently on antibiotics
  • If unresolved, seek medical review

Notes

Review stool softener dosage before increasing fibre or bulking agents. This should be done gradually to allow the bowel to adjust, which will in turn prevent bloating and intestinal wind and gas.

Bristol stool type: 1

Possible cause

  • Poor fluid intake (<1.5L)
  • Caffeine and alcohol may have a diuretic action
  • Excess insensible fluid loss (perspiration and vomiting)
  • Low insoluble fibre diet
  • Insufficient stool softeners
  • Over-use of bulking agents
  • Medication side-effects

Recommendation

  • Increase fluid intake (>2L per day)
  • Increasing insoluble fibre in diet will improve the consistency of stools
  • Increase softeners and stimulants or decrease bulking agents
  • Review and rationalise medications, e.g. narcotic analgesics, iron, and anticholinergics
  • Review the frequency of bowel care if less than daily

Notes

  • If fibre is increased in the diet then fluid intake should also be increased
  • Stool softeners and stimulants should be taken at the same time each day in order to ensure maximum effect at the desired time. Stimulants should be taken 8-12 hours before bowel care

Possible cause

  • Irregular bowel regimen
  • High impaction with spurious (overflow) diarrhoea
  • Bowel pattern may be changing

Recommendation

  • Abdominal X-ray may help to confirm diagnosis
  • In addition to the recommendations for constipation (above), ensure aperients are taken on a regular basis, i.e. twice per day
  • Start a bowel chart and review if bowel routine is inadequate

Possible cause

  • Insufficient time for bowel care or insufficient evacuation
  • Stool too soft
  • Certain irritant enemas or suppositories can cause incontinence or residue later in the day
  • Change in diet
  • Excessive digital stimulation can overstimulate the large bowel causing it to secrete mucous and contract causing incontinence
  • Over-use of aperients
  • Food poisoning or gastroenteritis

Recommendation

  • Allow sufficient time for bowel care
  • Review carer’s bowel management practices
  • Review aperients and enema or suppository use
  • Consider the use of an anal plug (for flaccid bowels)*
  • Seek medical review if gastroenteritis is suspected

Notes

* The use of anal plug may cause autonomic dysreflexia, so should be used with caution.

Possible cause

Exacerbated by manual procedures (digital stimulation and digital removal of faeces), enemas and constipation.

Recommendation

Review rectal stimulant.

  1. Consortium for Spinal Cord Medicine. Clinical practice guidelines: management of neurogenic bowel dysfunction in adults after spinal cord injury. PVA. 2020.
  2. Middleton JW, Leong G, Mann L. Management of spinal cord injury in general practice - part 1. Aust Fam Physician. 2008;37(4):229-33.
  3. 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]
  4. MedlinePlus. Autonomic dysreflexia. Maryland, USA: National Library of Medicine [cited 14 Nov 2022].

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Useful contacts

Funding sources to obtain supplies

People may be eligible for financial support for continence supplies through various schemes or programmes in NSW. Details are below with contact details for further information including eligibility information.

iCare NSW
1300 738 586		 For participants of Lifetime Care and Support Scheme or Work Cover. All continence supplies deemed reasonable and necessary will be provided under this scheme for eligible participants.
National Disability Insurance Scheme (NDIS)
1800 800 110 		For those who are under 65 years, or who have accessed the scheme before they turned 65, are Australian citizens and have a permanent disability. Participants of this scheme will have money allocated towards continence consumables, and have the choice and flexibility for purchasing these.
My Aged Care (MAC)
1800 200 422 		For those over 65 years, and on a Home Care Package. Costs of continence products may be provided by the service provider, within the limits of the level of home care package.
Continence Aids Payment Scheme (CAPS)
1800 330 066 		For people of any age, that are NOT covered by any of the above schemes, but have permanent and severe incontinence. This payment is administered by Medicare, and is a direct payment, providing consumers with flexibility and choice for purchasing continence products. Contact the National Continence Helpline for details
Enable NSW
1800 362 253 		Provides assistance for consumers not covered by icare, NDIS or MAC, have used all of their CAPS assistance payment, but require additional continence supplies. Eligibility criteria applies, including means test to determine co-contribution.
Pharmaceutical Benefits Scheme (PBS) Some oral and rectal medications are available on restricted access via the PBS for people with paraplegia or tetraplegia. Limited oral and rectal medications to assist with the management of a bowel program are also available free of charge under the Forward Ability Support Program, provided the individual is a member of this association and has neurological loss resulting in paraplegia or quadriplegia. The individual must also be eligible for Medicare.

Contacts for advice

© State of New South Wales (Agency for Clinical Innovation).

Creative Commons Attribution-ShareAlike 4.0 International License. For current information go to: aci.health.nsw.gov.au The ACI logo and third party tables are excluded from the Creative Commons licence and may only be used with express permission.

Publication date 2022-12-06.

Accessed from https://aci.health.nsw.gov.au/publications/neurogenic-bowel

Accessed on 2023-03-26.

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