• Areas of Concern heading
  • Areas of concern Autonomic Dystrifexlia Link
  • Areas of concern Neurogenic Bladder link
  • Areas of concern Neurogenic Bowel link
  • Areas of concern Pressure Ulser link
  • Areas of concern Respiratory complications link
  • Health promotion and maintenance link
  • resources link

Neurogenic Bowel

  • Neurogenic bowel is a common reason patients with spinal cord injury have to go to the emergency department and a common cause of Autonomic Dysreflexia (AD).
  • Although all individuals with a spinal cord injury will have a neurogenic bowel, the type and symptoms will depend on the level and completeness of the lesion. Individuals with lesions above T10 vertebral or T12 spinal will have a hyperreflexic bowel, while those with lesions below T10 vertebral or T12 spinal will have an areflexic bowel
  • Stool incontinence has a significant social and emotional impact
  • Each patient requires an individualised bowel management program that considers timing of bowel movements, diet (e.g., fibre and fluid intake), and either a rectal stimulation (hyperreflexic bowel) or a manual evacuation (areflexic bowel) technique
  • Most patients will be on chronic laxatives
  • If bowel management routine is ineffective, change 1 element of the management plan at a time to help identify cause and do not change more frequently than every 3-5 planned stools

Definitions

Neurogenic Bowel: “A life-altering impairment of gastrointestinal and anorectal function resulting from a lesion of the nervous system that can lead to life-threatening complications” (Consortium for Spinal Cord Medicine Clinical Practice Guidelines, p. 8).

Areflexic Bowel: “A lower motor neuron [LMN] bowel produced by an injury at the sacral segments in which no spinal cord-mediated reflex occurs” (Consortium for Spinal Cord Medicine Clinical Practice Guidelines, p. 37).

Hyperreflexic Bowel: See reflexic bowel.

Reflexic Bowel: “An upper motor neuron [UMN] bowel produced by a spinal cord injury above the sacral segments in which defecation cannot be initiated by voluntary relaxation of the external anal sphincter” (Consortium for Spinal Cord Medicine Clinical Practice Guidelines, p. 37).

Prevalence

  • Bowel dysfunction affects life activities or lifestyle in 41-61% of patients with spinal cord injury
  • Almost 1 in 4 patients with spinal cord injury require hospitalisation for a bowel complaint
  • 95% of outpatients with spinal cord injury require at least one therapeutic procedure to initiate defecation
  • 25% of patients age 50+ and 3% <50 years experience incontinence of stool (Consortium for Spinal Cord Medicine Clinical Practice Guidelines)

Pathophysiology

Neurogenic bowel pathophysiology

Hyperreflexic Bowel

The UMN [upper motor neuron] bowel syndrome, or hyperreflexic bowel, is characterised by increased colonic wall and anal tones. Voluntary (cortical) control of the external anal sphincter is disrupted and the sphincter remains tight, thereby promoting retention of stool. The nerve connections between the spinal cord and the colon, however, remain intact; therefore, there is preserved reflex coordination and stool propulsion. The UMN bowel syndrome is typically associated with constipation and faecal retention at least in part due to external anal sphincter activity (Stiens et al., 1997).  Stool evacuation in these individuals occurs by means of reflex activity caused by a stimulus introduced into the rectum, such as an irritant suppository or digital stimulation.

Areflexic Bowel

LMN [lower motor neuron] bowel syndrome, or areflexic bowel, is characterised by the loss of centrally-mediated (spinal cord) peristalsis and slow stool propulsion.  A segmental colonic peristalsis occurs only due to the activity of the intrinsic myenteric plexus, resulting in the production of drier and round-shaped stool. LMN bowel syndrome is commonly associated with constipation and a significant risk of incontinence due to the atonic external anal sphincter and lack of control over the levator ani muscle that causes the lumen of the rectum to open.

Completeness of injury

Completeness of injury also has a significant impact on bowel function in individuals with spinal cord injury.  Those with an incomplete injury may retain the sensation of rectal fullness and ability to evacuate bowels so no specific bowel program may be required.

(used with permission from www.scireproject.com)

Stiens, S.A., Bergman, S.B., & Goetz, L.L. (1997). Neurogenic bowel dysfunction after spinal cord injury: Clinical evaluation and rehabilitative management. Archives of Physical Medicine and Rehabilitation, 78, S86-S102.

Signs and symptoms

Upper Motor Neuron
(UMN) Lesion

Lower Motor Neuron
(LMN) Lesion
Level of lesion >T10 vertebral or T12 spinal segment <T10 vertebral or T12 spinal segment
Colonic transit time Increased Increased
External anal sphincter (EAS) Spastic paralysis Flaccid paralysis
Sympathetic output Absent with lesions > T6 spinal segment Retained
Symptoms

Constipation

Difficulty with evacuation

Incontinence

Constipation

Difficulty with evacuation

Incontinence

Faecal impaction Proximal colon Rectal
Autonomic dysreflexia Common with injuries above T6 level Rare
Reflex defecation Present Not known

Adapted from Singal, A.K., Rosman, A.S., Bauman, W.A., & Korsten, M.A. (2006). Recent concepts in the management of bowel problems after spinal cord injury. Advances in Medical Sciences, 51, 15-22.

Additional symptoms of neurogenic bowel include:

  • Abdominal distension
  • Respiratory compromise
  • Early satiety
  • Nausea
  • Evacuation difficulty
  • Unplanned evacuations
  • Rectal bleeding
  • Diarrhoea
  • Constipation
  • Pain

Management and recommendations

Goals of bladder management

  1. Regular and thorough bowel emptying (every 2 days)
  2. Maintain continence
  3. Prevent and treat complications (e.g., constipation, haemorrhoids, faecal impaction, perforation, abscess, Autonomic Dysreflexia (AD))

Designing a management program

Hover over or touch the info icon icon for more information. Hover over touch the evidence icon icon for information on evidence level.

Neurogenic bowel management program flowchart

Assessment should include: ability to learn and to direct others, sitting tolerance and position, sitting balance, upper extremity strength and proprioception, hand and arm function, spasticity, transfer skills, actual and potential risks to skin, anthropometric characteristics, and home accessibility and equipment needs. Assessment of ability to adhere to a consistent bowel care program and identification of major factors such as community setting also is recommended.

In each type of bowel care program:

  1. Bowel care should be scheduled at the same time of day
  2. Food should be ingested approximately 30 minutes prior to bowel care so gastrocolic response may occur, and
  3. Bowel care should be routinely scheduled at least once every 2 days over the long term to avoid chronic colorectal overdistention.

A spinal cord injury above the sacral segments of the spinal cord produces a REFLEXIC or upper motor neuron (UMN) bowel in which defecation cannot be triggered by conscious effort. Spinal cord and colon connections remain intact, allowing for reflex coordination of stool propulsion.

A complete spinal cord injury below the sacral segments (damaged nerves connecting the spinal cord to the colon) produces an AREFLEXIC or lower motor neuron (LMN) bowel in which no spinal cord mediated reflex defecation can occur.

The least noxious stimulant meeting effectiveness, type of bowel dysfunction, tolerance, and availability of product criteria should be chosen. There are two methods of rectal stimulation, chemical and mechanical, which can be used individually or in combination. Chemical agents include suppositories and enemas. Mechanical methods include digital stimulation and manual evacuation.

Regardless of method, rectal stimulation has the potential to cause autonomic dysreflexia, which is a potentially life-threatening condition, in individuals with T-6 thoracic spinal cord lesions or above.

The least noxious stimulant meeting effectiveness, type of bowel dysfunction, tolerance, and availability of product criteria should be chosen. There are two methods of rectal stimulation, chemical and mechanical, which can be used individually or in combination. Chemical agents include suppositories and enemas. Mechanical methods include digital stimulation and manual evacuation.

Regardless of method, rectal stimulation has the potential to cause autonomic dysreflexia, which is a potentially life-threatening condition, in individuals with T-6 thoracic spinal cord lesions or above.

Diet, fluids, and activity are used to modulate stool consistency. Increased fluid intake helps prevent hard stool that can result from decreased colonic transit time. Individuals with SCI should not be placed uniformly on high fibre diets. A diet history should be taken to determine usual fibre intake to evaluate how it affects stool consistency and evacuation frequency. A diet containing no less than 15 grams of fibre daily is needed initially. Increases in fibre intake should be done gradually, from a wide variety of sources. Symptoms of intolerance should be monitored, and reduction in fibre is recommended if they occur.

Although there is no research supporting assistive techniques to aid in evacuation, evaluation of these techniques should occur when designing a bowel care program as some manoeuvres may be helpful. Caution should be used as positioning devices may be necessary to reduce risks to safety in some of the following techniques: push-ups, abdominal massage, Valsalva manoeuvre, deep breaths, ingestion of warm fluids, seated position, and leaning forward.

Prior to embarking on oral medications, individuals with chronic constipation should be initially maintained on a well-balanced diet, with adequate hydration and appropriate daily physical activity.

A number of oral agents currently are employed to promote bowel function in individuals with chronic constipation. If evacuation of stool has not occurred within 24 hours of scheduled evacuation or if stool is hard-formed and difficult to pass, a trial is warranted of a bulk-forming agent or of one or more of the following categories of laxative agents: lubricants, osmotics, and stimulant cathartics.

When developing or revising a bowel management program, it is important to monitor and document the following factors after every bowel care procedure: date and time of day; time from rectal stimulation until defecation is completed; total time for completion of bowel care; mechanical stimulation techniques; pharmacological stimulation; position; colour, consistency, and amount of stool; adverse reactions; and unplanned evacuations.

In determining program effectiveness, the absence of constipation, GI symptoms or complaints, and delayed or unplanned evacuations are key elements.

An educational program should include components on: anatomy; process of defecation; effect of SCI on bowel function; description, goals, and rationale of a successful bowel program; factors promoting successful bowel management; role of regularity, timing, and positioning; safe, effective use of assistive devices and equipment; techniques for manual evacuation, digital stimulation, and suppository insertion; prescription medications; prevention and treatment of common bowel problems; when and how to make changes in medications and schedules; managing emergencies; and long-term implications of neurogenic bowel dysfunction.

Constipation is a frequent reason for ineffective bowel programs and the cause should be investigated. Obstruction or disease unrelated to SCI should be excluded. If other disease has been ruled out, and constipation is chronic and severe despite the use of laxatives and other program modifications, a trial of prokinetic medication may be considered. These medications must be used with caution because of potential side effects and weak evidence of efficacy in people with SCI.

The role of surgery to effect optimal bowel function is limited. The decision about a colostomy or ileostomy should by based upon the results of specialised screening procedures and individual's expectations.

When considering surgical changes in the anatomy of individuals with SCI, discussions of anaesthesia, surgical and postoperative risks, body image, independence in self-management after the procedure, and permanency of the procedure should take place between the individual and the entire interdisciplinary team, including enterostomal therapists. If surgery is decided upon, a permanent stoma is the best option.

No research reports were found on the clinical benefit of biofeedback as a treatment for neurogenic bowel in individuals with spinal cord injuries.

Electrical stimulation has potential as a treatment modality, but further study is needed to support its use in clinical practice.

Level 5 grade C

There is level 4 evidence (from six studies) (Frisbie et al., 1986; Stone et al., 1990; Kelly et al., 1999; Rosito et al., 2002; Branagan et al., 2003, Munck et al., 2008) that colostomy reduces the number of hours spent on bowel care.

There is level 4 evidence (from 1 retrospective pre-post study) (Frisbie et al., 1986) that colostomy greatly simplifies bowel care routines.

There is level 4 evidence (from 1 case study) (Rosito et al., 2002) that colostomy reduces the number of hospitalisations caused by gastrointestinal problems and improves physical health, psychosocial adjustment, and self-efficacy areas within quality of life.

Reproduced with permission from the Paralyzed Veterans of America (PVA) Consortium for Spinal Cord Medicine Clinical Practice Guidelines “Neurogenic Bowel Management in Adults with Spinal Cord Injury” Washington, DC: © 1998 Paralyzed Veterans of America.

Copies of the PVA’s Guidelines are available at www.pva.org or through the PVA Distribution Centre (toll free 888-860-7244).

Guiding principles

  • A systematic and comprehensive evaluation of bowel function and impairments is completed at onset of injury and continues on an annual basis.
  • Bowel management starts during acute care and is revised as needed.
  • Bowel management program provides predictable and effective elimination and reduces gastrointestinal and evacuation complaints.
  • Knowledge, cognition, motor performance, and function are important assessments in determining the ability of the individual to complete a bowel care program or instruct a caregiver.
  • Attendant care needs, personal goals, life schedules, role obligations, developmental needs, and self-rated quality of life are to be considered in the development of bowel care programs.
  • The design of effective interventions includes an awareness of the individual’s social and emotional support, as well as impairments, disabilities, and handicaps.
  • Establishing a consistent schedule for defecation, based on factors that influence elimination, preinjury patterns of elimination, and anticipated life demands, is essential when designing a bowel care program.
  • Prescriptions for appropriate adaptive equipment for bowel care should be based on the individual’s functional status and discharge environment.
  • All aspects of the bowel management program are designed to be easily replicated in the individual’s home and community environments.
  • Adherence to treatment recommendations is assessed when evaluating bowel complaints and problems.
  • Knowledge of the unique clinical presentation and a prompt diagnosis of common complaints is necessary for the effective treatment of neurogenic bowel conditions.
  • Effective treatment of common neurogenic bowel complications, including faecal impaction, constipation, and haemorrhoids, is necessary to minimise potential long-term morbidities.

Reproduced with permission from the Paralyzed Veterans of America (PVA) Consortium for Spinal Cord Medicine Clinical Practice Guidelines “Neurogenic Bowel Management in Adults with Spinal Cord Injury” Washington, DC: © 1998 Paralyzed Veterans of America.

Copies of the PVA’s Guidelines are available at www.pva.org or through the PVA Distribution Centre (toll free 888-860-7244).

Troubleshooting

If bowel management routine is ineffective and regular bowel emptying does not happen regularly (every 2 days), change one element at a time to help identify cause and do not change more frequently than every 3-5 planned stools. A change in bowel management takes about 3-5 cycles to be reflected. Make sure to ask patient about changes in activity as this may impact bowel function (less active = harder stool).

ProblemPossible Solutions
Stool too soft
  • Reduce or stop stool softener or laxative
  • Consider adding fibre supplement to bulk up stool
  • Increase dietary insoluble fibre (e.g., prunes)
  • Consider overflow from impaction (rectal exam and/or x-ray to rule out)
  • Check medications (e.g., antibiotics)
  • Check for bacterial infection in colon
  • Consider spacing out bowel routine
  • Inquire about dietary changes (e.g., fatty or spicy foods)
  • Ask about psychological stress
Stool too hard
  • Check fluid intake, if adequate consider fibre supplement
  • Add stool softener
  • Check medications (e.g., anticholinergic, narcotic)
  • Consider using lactulose
Alternating diarrhoea and constipation
  • May be indicative of higher faecal obstruction
Incontinence prior to planned evacuation time
  • If stool is too hard or too soft may be the result of ineffective emptying
  • Change stimulant laxative to later time
  • Ask about adherence to bowel care program
  • Ask about use of laxatives
Incontinence after evacuation
  • Consider incomplete emptying
  • Change stimulant laxative to earlier time
  • Consider increasing stimulant dose
  • If stool too hard, may have longer transit time
Excessive gas or abdominal bloating

Ask about:

  • Chewing gum (increases swallowing of air)
  • Swallowing air while drinking through a straw or eating
  • Snoring
  • Consumption of gas producing foods or  beverages (e.g., carbonated drinks)
  • Changes to tube feeding or intake of artificial sweeteners in food or liquid medications 
  • Lactose tolerance

Laxatives

Most patients will be on chronic laxatives, which is OK.

Class Mechanism of Action Onset of Action Available Products Adverse Effects
Bulk-forming

Increases stool weight and consistency

Decreases GI transit time

12h-3 days
  • Psyllium (Metamucil) 3.4g OD-TID
  • Polycarbophil calcium (Prodiem) 1250mg PO OD-QID
  • Sterculia gum (Normacol) 7g OD-BID
  • Bloating, flatulence, abdominal discomfort
  • Colonic obstruction (if water intake not sufficient)
  • May affect absorption of medications so take 2h apart
Hyperosmotic

Increases bowel water retention, which stimulates peristalsis

2-24h
  • Lactulose 15-30ml OD-BID
  • Bloating, flatulence, cramps, diarrhoea
Osmotic

Increases bowel water retention, which stimulates peristalsis

0.5-6h (mag hydroxide)

24-48h

(mag sulfate)
  • Magnesium citrate (Citromag) 3.75-7.5g (75-150ml) daily PO. Follow doses with 250ml water
  • Magnesium hydroxide (Milk of magnesia) 30-60ml PO OD
  • Magnesium sulfate (Epsom salts) 10-30g OD (dissolve in 240ml water)
  • Polyethylene glycol 3350 (Restoralax, Laxaday, Pegalax) 17g PO OD
  • Sodium phosphates (oral or rectal (Fleet)) 120ml PO OD (dilute in 120ml of water) or 120ml PR
  • Nausea, cramping, diarrhoea
  • Magnesium: risk of hypermagnesemia in renal failure
  • Phosphates: risk of hyperphosphatemia in renal failure; decrease absorption of quinolones and tetracyclines (administer at separate times)

Stimulant

Irritate bowel wall which stimulate colonic peristalsis

0.5h (bisacodyl)

6-12h (senna)
  • Bisacodyl (Dulcolax) 5-10mg PO OD or 10mg PR OD
  • Senna (Senokot) 2-4 tabs PO QHS
  • Abdominal cramping
  • Melanosis coli (Senna)
Softeners Surfactant, keeps stool soft 12-72h
  • Docusate sodium (Colace) or calcium 100mp PO OD-BID
  • Nausea, cramping
  • Should not be used in combination with lubricants as may increase absorption and toxicity
Lubricants Coat stool to prevent colon from reabsorbing water 6-8h
  • Glycerin 2.6g PR OD-BID
  • Mineral oil (Lansoyl) 15-45ml PO OD
  • Seepage from rectum can cause irritation and pruritus
  • Decreases absorption of fat soluble vitamins

Follow-up

  • Yearly review of bowel management program
  • Annual examination should include:
    • Abdominal palpation
    • Rectal exam to check for tone and anocutaneous and bulbocavernous reflexes
  • Consider colorectal cancer screening for patients >50 years of age (FOBT may be very unreliable in this population)
  • Provide patient with education/resources (e.g., Neurogenic Bowel: What you should know)

References

Branagan, G., Tromans, A., & Finnis, D.(2003). Effect of stoma formation on bowel care and quality of life in patients with spinal cord injury. Spinal Cord, 41(12), 680-3.

Consortium for Spinal Cord Medicine. (1998). Neurogenic Bowel management in adults with spinal cord injury. Washington, DC: Paralyzed Veterans of America.

The Canadian Continence Foundation

Frisbie, J.H., Tun, C.G., & Nguyen, C.H. (1986). Effect of enterostomy on quality of life in spinal cord injury patients. Journal of the American Paraplegia Society, 9(1-2), 3-5.

Heaton, K. W., & Lewis, S. J. (1997). Stool form scale as a useful guide to intestinal transit time. Scandinavian Journal of Gastroenterology, 32(9), 920-4.

House JG, Stiens SA. (1997). Pharmacologically initiated defecation for persons with spinal cord injury: effectiveness of three agents. Archives of Physical Medicine and Rehabilitation, 78(10), 1062-1065.

Kelly, S.R., Shashidharan, M., Borwell, B., Tromans, A.M., Finnis, D., & Grundy, D.J. (1999). The role of intestinal stoma in patients with spinal cord injury. Spinal Cord, 37(3), 211-4.

Munck, J., Simoens, Ch., Thill, V., Smets, D., Debergh, N., Fievet, F., & Mendes da Costa, P. (2008). Intestinal stoma in patients with spinal cord injury: a retrospective study of 23 patients. Hepatogastroenterology, 55(88), 2125-9.

Rosito, O,. Nino-Murcia, M., Wolfe, V.A., Kiratli, B.J., & Perkash, I. (2002). The effects of colostomy on the quality of life in patients with spinal cord injury: a retrospective analysis. Journal of Spinal Cord Medicine, 25(3), 174-83.

Stiens, S.A., Bergman, S.B., & Goetz, L.L. (1997). Neurogenic bowel dysfunction after spinal cord injury: Clinical evaluation and rehabilitative management. Archives of Physical Medicine and Rehabilitation, 78, S86-S102.

Stone, J.M., Wolfe, V.A., Nino-Murcia, M., & Perkash, I. (1990). Colostomy as treatment for complications of spinal cord injury. Archives of Physical Medicine and Rehabilitation, 71(7), 514-8.

Wathen, N., Watson, G., Caldwell, S., & Lewis, N. (2007). Research summary: Improving continence care in complex continuing care. Ontario Women’s Health Council.