Neurogenic Bowel Dysfunction
Neurogenic bowel dysfunction is common. This condition encompasses both medical consequences and quality of life issues. Neurogenic bowel dysfunction is common in patients with spinal cord injury (SCI), stroke, amyotrophic lateral sclerosis, spina bifida, multiple sclerosis, diabetes mellitus, traumatic brain injury and brain tumors.
The primary symptom of neurogenic bowel disease is a loss of bowel control, causing incontinence or constipation. In addition, the disease can cause hemorrhoids, pain, diarrhea, impaction, or appetite loss. Finally, the disease requires extensive bowel management.
- Physical Therapy - In general, an improvement in mobility and activity levels in affected individuals improves the potential of lessening constipation and fecal impaction.
- Occupational Therapy - Occupational therapists work hand in hand with nurses to help improve toileting and transfer techniques, with the goal of improving independence and thereby potentially lessening fecal incontinence.
- Nursing - Nursing should start by setting up a daily bowel emptying program. This should be done daily at the same time. Preferably 30 minutes after a meal, this will let the natural peristalsis that occurs after eating help the bowel empty. Treatment may also involve taking stool softeners to help soften the stool. In addition oral laxatives and suppositories may be used. Nursing will be checking to ensure that a bowel movement has occurred in no more than 2 day. If no bowel movement in 2 days, measures must be taken to ensure bowel emptying.
- Manual Removal - Physical removal of the stool from the rectum. This can be combined with a bearing down technique called a valsalva maneuver (avoid this technique if you have a heart condition).
- Digital Stimulation - Circular motion with the index finger in the rectum, which causes the anal sphincter to relax.
- Suppository - Dulcolax (stimulates the nerve endings in the rectum, causing a contraction of the bowel) or glycerine (draws water into the stool to stimulate evacuation).
Factors that can affect success:
- Timing - Do you do your bowel program in the morning or evening? At the same time every day? After a meal or warm beverage? What is the interval between programs -- half a day, one day or two days? (You should do a bowel program at least every 2-3 days to reduce your risk of constipation, impaction and colon cancer.)
- Emotional Stress - Has your appetite been affected? Are you able to relax?
- Positioning - Where do you do your program -- on a commode chair, raised toilet seat, on the toilet, or in bed? It will probably work better when you are sitting up because of gravity.
- Fluids - How much and what type of fluid do you drink? (Prune juice or orange juice can stimulate the bowels, or another type of fruit juice may work best for you.)
- Food - How much fiber or bulk (such as fruits and vegetables, bran, whole grain breads and cereals) do you eat? Some foods (such as dairy products, white potatoes, white bread and bananas) can contribute to constipation, while others (such as excess amounts of fruit, caffeine, or spicy foods) may soften the stool or cause diarrhea.
- Medication - Some medicines can cause constipation (like narcotics), while others (including some antibiotics, such as ampicillin, and magnesium-based antacids such as Mylanta and Maalox) can cause diarrhea. Consult your healthcare provider for information about the medications you are taking.
- Illness - A case of the flu, a cold or an intestinal infection may affect your bowel program while you are ill. (Even if your digestive system is not directly affected, your eating habits, fluid intake or mobility may change, which can alter your bowel program.)
- Activity Level/Mobility - How much exercise do you get? How much time do you spend out of bed?
- Weather - Hot weather increases the evaporation of body fluids, which can lead to dehydration and constipation.
- External Massage - Massaging the lower abdomen in a circular, clockwise motion from right to left increases bowel activity.
- Valsalva (bearing down) - This technique is not recommended for patients with cardiac problems.
- Assistive/Adaptive Devices - Devices such as a suppository inserter, finger extension or digital stimulator may be required to assist you in establishing a successful bowel program.
What to avoid:
- Skipping or Changing the Time of your Program - Your bowels will move more predictably if your bowel care program is carried out on a regular, predictable schedule. Skipping your program can also result in constipation or accidents.
- More than Four Digital Stimulations at a Time - This can cause trauma to the rectum, resulting in hemorrhoids or fissures (cracks or breaks in the skin).
What to do if...
- Stool is Too Hard (Constipation) - Do your bowel program on a daily basis until constipation resolves. Add or increase the dose of a stool softener. Increase your activity level and your intake of dietary fiber. Avoid foods that can harden your stool, such as bananas and cheese.
- Stool is Liquid or Runny (Diarrhea) - Temporarily discontinue the use of any stool softeners. Continue your bowel program at the regular time and frequency. (If you are having accidents, increase the frequency of your program.) Try adding or increasing the dose of psyllium hydro-mucilloid (Metamucil, Citrucel), which adds bulk to liquid stool. If the diarrhea seems to be related to an acute viral or bacterial illness, change to a liquids only or very bland diet for 24 hours (avoid milk, however). If diarrhea persists for more than 24 hours or if you have a fever or blood in your stool, consult your health care provider.
A frequent cause of diarrhea is a blockage or impaction of stool (liquid stool leaks out around the blockage). Evaluate whether you may have this problem. Have you had small hard stools recently? Or have you had no results from the past several programs? If you suspect impaction, consult your health care provider.
- Frequent Bowel Accidents - Be sure your rectum is completely empty at the end of your program. Increase the frequency of your program (some people with a flaccid bowel may need to empty their bowels twice daily). Try using only half of a suppository. Evaluate stool consistency -- if it's too hard or too soft, see above. Monitor your diet for any foods that may over stimulate your bowel, such as spicy foods.
- Rectal Bleeding - Keep your stool soft. Be very careful to do digital stimulation gently and with sufficient lubrication, and keep your fingernails short. If you have known hemorrhoids, you may treat them with an over-the-counter hemorrhoidal preparation. If bleeding persists or is more than a few drops, consult your health care provider.
- Excessive Gas - Avoid constipation. Increase the frequency of your bowel programs. Avoid gas-forming foods, such as beans, corn, onions, peppers, radishes, cauliflower, sauerkraut, turnips, cucumbers, apples, melons and others that you may have noticed seem to increase your own gas.