Bowel Course Script

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Section 1 – Confidence and comfort

1.1 – Confidence and comfort

A spinal cord injury can cause many changes in how your body works and how you go about your everyday life.  For many people, one of the biggest changes affects how they go to the bathroom.

It can be stressful and embarrassing to lose control of your bowel function, but the skills you will learn in this course can help you master your bowel program, giving you more confidence and comfort.

The first step is to pay careful attention to your body & what it is telling you.  This can be tricky because some of your sensations may be changed.

It may take time and trial & error.   You will need to develop your problem-solving skills, and work in partnership with your health care team.  With patience, you can retrain your bowel, and develop a bowel program that works for you.  The perfect program for you will allows you to stay healthy & get on with your life!

1.2 – How digestion works

The digestive system breaks down the food we eat and absorbs nutrients into the bloodstream.  After entering the mouth and traveling down the esophagus to the stomach, food enters the bowel. First, the small intestine takes most of the nutrients from our food.  Next, the digested food travels through the large intestine, which absorbs excess water. The rectum, which is the last part of the large intestine, temporarily stores anything that remains.

The opening through which digested food or stool passes is called the anus.  The circular muscle that controls the anus and opens to allow stool to pass out is called the sphincter.

The nervous system controls food passage through the digestive system.

Normally, when the rectum fills with stool, a sensory message tells your brain that you need to defecate.  When you go the bathroom, you relax the sphincter so the stool can exit.

1.3 – Digestion after SCI

After a spinal cord injury, your digestive system works differently.

A spinal cord injury can damage the nerves that help control the rectum.  It’s difficult to respond to your body’s signals in the same way.  For example, you may not be able to get to a toilet in time to empty your bowel if you wait until your rectum is full. Therefore, bowel movements require more time and planning.

Fortunately, it’s possible to retrain your bowel to empty according to a regular schedule.

When your digestive system functions differently because of a spinal cord injury, this condition is known as neurogenic bowel.

Two types of neurogenic bowel can occur after a spinal cord injury. The type of neurogenic bowel you have depends on which area of the spinal cord was injured, whether it’s above, or below, the T12 level.

Everyone’s situation is different and requires individual evaluation and management, but there are two basic kinds of problems people tend to experience: reflex bowel when the injury is above T12, and flaccid bowel.

The type of neurogenic bowel that you have will determine what type of bowel program you have.

Both types of neurogenic bowel can be managed successfully to prevent unplanned bowel movements and other bowel problems such as constipation, diarrhea and impaction.

1.3a – Reflex bowel

A higher-level injury, to the spinal cord in the neck or chest area above T12, typically results in a type of neurogenic bowel called reflex bowel.

If you have this type of neurogenic bowel, you may not feel the need to have a bowel movement. The reflex that makes you defecate, however, is still there, and the bowel will empty with the assistance of a suppository that triggers the reflex.  If you have a reflex bowel, you can use this to have a consistent routine where you empty your bowel on a regular schedule.  You can use a suppository to start the bowel movement, and digital stimulation to make sure you finish it.

People with higher-level injuries often use assistance of various kinds with their bowel program.  It’s important to have a good understanding of the different aspects of your bowel program so that you can explain them clearly to somebody else and direct your own care.

People with an injury above the T6 level also need to be aware of autonomic dysreflexia.  This is a sudden increase in blood pressure, and it can result from irritation during rectal stimulation, or from a blockage of stool in the bowel.  Symptoms include headache, sweating and chills. If you have problems with autonomic dysreflexia, you should contact your health care provider.

1.3b – Flaccid bowel

A lower-level injury at T12 or below may relax the anal sphincter and damage the reflex that makes you defecate. This is called flaccid bowel.

To manage this condition you may need to empty your bowel more frequently, maybe several times a day.  You may also need to use technique like bearing down or manual removal of stool.

With attention to your diet you can make sure your stool is the right consistency so you avoid leakage and accidents.

1.4 – Your bowel program

After a spinal cord injury, going to the bathroom takes planning and some special techniques.

Your bowel program is what gives you control of your bowel function by allowing you to:

•            empty your bowel completely at a predictable time, and

•            prevent bowel accidents and health complications.

You will work with your health care team to develop your bowel program and adjust it over time.  It’s customized based on your needs and your lifestyle, and  includes:

•            your diet;

•            medications like laxatives & suppositories, and

•            techniques like digital stimulation.

You’ll learn more about these in the next section of the course.

Bowel care is when you empty your bowel.  This can take anywhere from 15 minutes to an hour to complete and can happen daily, or every other day.  You shouldn’t go more than three days at most without having a bowel movement.

It’s important to keep a regular schedule and technique for your bowel care.

It begins with starting a bowel movement. That’s usually done with a suppository.  After the bowel movement starts, you can use digital rectal stimulation to help make sure you’re done.

1.4b – Digital stimulation: step-by-step

Digital rectal stimulation is a technique used to trigger a bowel movement.  By gently touching the wall of the rectum, you can relax and open the passage and trigger muscle contractions, which push stool out of the body.

Digital stimulation is also known by other names like dig stim. or rectal touches.

If you have an injury above T12, you may start your bowel movement by inserting a suppository.

You’ll find it helpful to sit up.  If you do your bowel care lying down, lie on your left side.

Begin by washing your hands, putting on gloves and lubricating your finger.  Make sure you use enough lubricant.

Insert your finger gently into the rectum, with your finger pointing toward your belly button.  Insert only the first part of your finger, about as far as the first knuckle.  Keep your finger next to the wall of your rectum and gently move it in a circular motion.  The stimulation should last for no longer than 10 to 20 seconds at a time.

From the time you start digital stimulation, it should take no more than a few minutes for the stool to come down the rectum and get pushed out.  When you use digital stimulation to complete your bowel movement, repeat every 5 to 10 minutes until you’re done.

At every stage of digital stimulation, it’s important to use plenty of lubricant and be gentle. If you push or rotate your finger too roughly, you can irritate or tear the lining of your rectum or the anus.

If your injury is T6 or higher, you need to be aware of the risk of autonomic dysreflexia.  This is a sudden increase in blood pressure, and it can result from irritation during rectal stimulation.  Symptoms include headache, sweating and chills.

If you have problems with discomfort or autonomic dysreflexia, you should contact your health care provider.

1.5 – Making the transition

After a spinal cord injury, one of the first things people worry about is how they’ll go to the bathroom.  This is one of the most important things you will need to learn in rehabilitation.

Your starting point is to figure out what your pre-injury routine was.  For example, did you empty your bowels once of day?  Several times a day?  Or every other day?

Early in rehabilitation, people typically start on a program to empty their bowels 3 times per week.  Then, they modify this schedule based on their pre-injury routine and their success at avoiding bowel accidents

Retraining your bowel does take time, so you will need to watch for changes and pay careful attention to what works for you.  This means monitoring how long your routine takes, what the result is, and how hard or soft your stool is.  It’s also important to monitor what and when you eat and drink, and your medications and the potential side effects.

You won’t be alone in learning this.  Different members of your rehab team will help you with various aspects of your bowel program.  For example, nurses will teach you many of the techniques you will need to know to perform your bowel program, techniques like inserting a suppository or doing digital stimulation.  And your occupational therapist will help you choose the right equipment and devices to suit your needs.

 

Section 2 – The perfect program

2.1 – The perfect program

A successful bowel program means being able to empty your bowels predictably, regularly and completely, without accidents.  It also means preventing complications and long-term damage.

Some people think your bowel program starts when you sit on the toilet, but it actually begins with the food you put on your plate. In addition to the techniques you use to empty your bowel, your diet is an extremely important element of your program.

Your activity level, the medications you take, the fluids you drink and your position during your bowel movement can also have important effects on your program, and you may need to make adjustments over time.

You will probably use special pieces of equipment when you do your bowel care, like a shower commode chair or a raised toilet seat.  You may also use assistive devices to help with inserting suppositories and doing rectal stimulation.  Many people also work with an attendant to help them with certain parts of their bowel care, such as transfers and positioning, suppository insertion and digital stimulation.

Establishing good bowel habits will help you avoid accidents and prevent digestive complications.  You’ll find that mastering the knowledge and skills you need to manage your digestive system will make it easier to participate fully in all the things you want to do and to have a rich and fulfilling life.

2.2 – Diet & eating habits

Your diet has a major impact on your digestion, and on how well your bowel routine goes.  Over time, if you pay attention, you’ll learn how different things affect you—what foods you eat, when you eat, how much you drink, and even how much you chew your food.

It’s important to notice how your diet and fluid intake affect your bowel program.   You may find it helpful to keep a journal of what you eat and drink, as well as details of your bowel program.  For a sample Diet Journal, click on the top link.

Fluid is an important part of your diet.  If you don’t drink enough water, it will make your stool hard and it could cause constipation.

There are specific foods that you may find helpful in maintaining a healthy bowel program.  And there are also certain foods you may want to avoid if you’re having problems like constipation or diarrhea.  For more information on making healthy food choices, click on the bottom link.

2.3 – Timing & activity

The timing of your bowel program should fit your lifestyle and preferences.  At the same time, you may also find that you have to make some lifestyle adjustments in order to meet your body’s needs.

The key is to do your bowel care on a consistent schedule, and at a convenient time.  Having a regular time for your bowel movements will help retrain the muscles

Some people with a reflex bowel may do their bowel care every day in the morning, and others do it every second day in the evening.  If you have a flaccid bowel, you may want to check morning, after every meal and before bed.

How often you do bowel care can depend on what you eat and how much you eat.

Eating a meal may stimulate a bowel movement because of the stomach’s reflexes. Beginning your bowel care about 30 to 60 minutes after you eat may help it go faster and give you better results.

Being active helps with your bowel program, too.  The more you move around and change your position, the more you help the muscles in your digestive system do their work.  So getting regular exercise is good for your bowel program.

2.4 – Position, Equipment, devices and skin health

Sitting up in a commode chair rather than lying in bed will allow gravity to help you empty your bowel. If you need to be in bed, turn so that you’re on your left side for your bowel care.

Your bowel program can affect your skin too.  The duration of your bowel care tasks and bowel accidents may put your skin at risk for breakdown.

In the same way that you spend time choosing your seating and positioning for your wheelchair, it’s also important to make sure your bathroom equipment is appropriate and that it allows you to perform your bowel tasks.  It’s also very important to make sure your equipment doesn’t damage your skin.

Some toilet seat surfaces are hard, solid plastic, while others are padded, and designed to provide pressure relief.  Work with your Occupational Therapist to figure out what positioning and seating you’ll need to perform ALL of your bowel care tasks.

For example, will you be performing your own suppository insertion and digital stimulation, or will your attendant?  This will influence the style of seat you choose and the orientation of the cut-out.

Toileting equipment options include:

– a stationary commode,

– a wheeled commode,

– a raised toilet seat,

– grab bars, and

– a toilet safety frame.

Make sure you inspect your equipment regularly, check for signs of wear and tear, and replace any broken parts.

There are also assistive devices that can help you perform your bowel care, such as a suppository inserter, digital stimulator, or long-handled toilet paper holders.

For a visual guide to equipment and devices, click on the Image gallery tab.

2.6 – Bowel care: Step-by-step

Different people use different methods to empty their bowel and keep their digestive system healthy after a spinal cord injury.  You’ll work with your health care team to develop a bowel program that meets your individual needs.

Bowel care can involve a combination of techniques, including digital stimulation, manual removal, and suppositories and laxatives.

Click on the appropriate link for a step-by-step guide to doing your bowl care.

2.6a – Reflex bowel

If you have a reflex bowel, the goal of your bowel program is to have soft, formed stool that you can pass easily with minimal rectal stimulation.

You’ll want to empty your bowel on a regular schedule, every day or every other day.  You can trigger your bowel movement using a suppository or digital stimulation.

When you use digital stimulation, you should repeat until you’re done, but if you need a lot of stimulation, or if your routine lasts more than about an hour, you should talk to your health care provider.

Here’s a step-by-step guide to bowel care for someone with a reflex bowel:

Step 1: Set-up

Begin by getting in position, which may mean transferring to a commode chair or toilet.  Make sure you’re in a comfortable, upright position with your feet placed on the floor or on the footrest of your chair.

When you sit upright, gravity helps you empty your bowel.

If you need to do your bowel care in bed, you should lie on your left side.

Wash your hands thoroughly.  If your attendant performs your bowel care, make sure they wash their hands.  Be careful about fingernails.

You may need to empty your bladder or move your drainage equipment.

Step 2: Insert suppository

When you’re in position and ready, you can start your bowel movement by inserting a suppository.  But before insertion, check first to see if the rectum is full of stool.  If so, you may need to remove some by breaking it up with a finger and gently removing it by hooking.  This is so you can make sure the suppository is touching the wall of the rectum.

Before you insert the suppository, coat it with water-soluble lubricant.

Use a gloved and well-lubricated finger to push the suppository into the rectum, against the wall.  If the suppository isn’t in contact with the wall of the rectum, it won’t work.

Step 3: Digital stimulation

Wait for 5 to 15 minutes; if you pass gas or some stool, it’s a sign that the suppository is beginning to work. If stool starts to come out, just wait and let things take their course.  When that motion is finished, wipe carefully and check for more stool by doing digital stimulation.

Repeat the digital stimulation every 5 to 10 minutes, or after each motion, until you’re done.  If you need to repeat the digital stimulation many times, more than 3 or 4, you may damage the lining of the rectum.  If you have difficult bowel movements and need to repeat digital stimulation frequently, this may indicate a problem, and you should consider speaking with your health care team.

For more info on how to do digital stimulation, click on the link.

Step 4: How to know you’re done

To make sure your rectum is empty, do a final check with a well-lubricated and gloved finger.

There are three signs that your bowel movement is done:

•            First, if no stool has come out after two digital stimulations at least 10 minutes apart;

•            Second, if you find mucus without any stool;

•            And finally, if the muscles in the rectum become tight again and close around your finger.

After you’re done, wash and dry the area around your anus.

2.6b – Flaccid bowel

People with an injury below the T12 level usually empty their bowels more frequently, often several times per day, using digital stimulation and manual removal.

The goal of your bowel program is firm, formed stool that:

-can be passed manually with ease, and

-doesn’t pass accidentally between bowel care routines.

Not everyone with a flaccid bowel uses suppositories as these can cause a lot of mucous.

Some people will need to take stool softeners or gentle laxatives ever day, or every other day depending on your personal needs.

Every morning, after every meal and before you go to bed check to see if any stool has moved into the rectum and needs to be removed.

Here’s a step-by-step guide to bowel care for someone with a flaccid bowel:

Step 1: Set-up

Begin by getting in position, which may mean transferring to a commode chair or toilet.  Make sure you’re in a comfortable, upright position with your feet placed on the floor or on the footrest of your chair.

When you sit upright, gravity helps you empty your bowel.

If you need to do your bowel care in bed, you should lie on your left side.

Wash your hands thoroughly.  If your attendant performs your bowel care, make sure they wash their hands.  Be careful about fingernails.

You may need to empty your bladder or move your drainage equipment.

Step 2: Emptying

You may use a combination of techniques to empty your bowel, including digital stimulation, manual emptying, bearing down and changing your position.

Use digital stimulation, with a gloved, well-lubricated finger, to start the bowel movement.  To keep stool coming, repeat digital rectal stimulation every 5 to 10 minutes as needed, until all the stool has passed.

For more info on how to do digital stimulation, click on the link.

You can empty your bowel manually by using one or two gloved and well-lubricated fingers to break up stool, hook it, and gently pull it out.

You can help bring down stool by breathing in and bearing down.  This is sometimes called a valsalva technique or maneuver, and it can help you increase pressure in the colon to push stool out.

Breathe in, then block the air with your throat and increase the pressure in your belly.  If possible, try to contract your abdominal muscles as well.  Repeat for 30 seconds at a time to help with manual emptying.

If you have good torso stability, you can try lifting yourself or doing forward and sideways bending while you bear down. This can help change the position of the colon, making it easier to empty stool.

Step 3: Finish

Make sure the rectum is empty by doing a final check with a gloved and well-lubricated finger.  If you find stool, continue with your manual emptying and repeat, if necessary, the techniques in step 2.  When you are confident that all stool has passed, wash and dry the area around your anus.

 

Section 3 – Problem-solving

3.1 – Problem-solving

Over time, you will adapt your bowel program to changes in your body and your lifestyle, and as you learn more, you will become more skilled in your self-care.

From time to time, you may encounter problems with your bowel program.  Constipation, bowel accidents, hemorrhoids and other problems can have a major impact on your daily life.

When you’re having a problem and you’re not sure what to do, the best option is to use this problem-solving approach to tackle it:

Step 1: Identify the problem.  Start by getting a clear picture of what’s wrong.  If you’re having problems with constipation or bowel accidents, pay attention to when they happen and what seems to cause them.  If you have problems with hemorrhoids, make sure you know where they are, and how severe they are.

Step 2: Gather information.  Try to get a better understanding of what may be causing your problem, and some different ways you might try to solve it.  This may involve doing research or consulting health care providers.  You may also find it helpful to speak with peers, people who have had similar experiences.  Make sure you evaluate the reliability of the information you find, and try not to rely on information from only one source.

Step 3: List possible solutions. Based on the information you find, list some things you might try. To deal with constipation, you might want to adjust your diet and drink more water.  For hemorrhoids, you may want to keep your stool soft and take special care when doing digital stimulation.

Step 4: Try one & evaluate the results.  Using your list of solutions, choose the one that seems best and give it a try.  It’s important to make only one change one at a time so you can tell whether it works or not.  Make sure you keep track of what you do and what the results are.   If you solve the problem, that’s great!  If not, you may want to go back to step 3 and choose another option.  Problem-solving can involve lots of trial and error.

Step 5: Know when to ask for help. Don’t try to take everything on by yourself.   You can ask your health care team for information and help with your problem-solving, as your needs change over time.

3.2 – Bowel accidents

Accidents happen, and bowel accidents can be frustrating and embarrassing.  It helps if you can take charge of the situation.  If you need assistance, you can make it easier for others to help by explaining the situation clearly and calmly.  You may feel embarrassed, but don’t let those feelings keep you from doing what’s necessary to care for yourself.

Over time, you’ll find it easier to handle these embarrassing feelings.  Remember that there’s nothing wrong with you—this is just how your body works.  Most people with spinal cord injury deal with the same problem.  Mastery of your bowel program will give you confidence.

If you do have a bowel accident, it’s important to get cleaned up quickly.  If you delay, you risk skin damage.  If your injury is above T6, you might also experience autonomic dysreflexia if you block the flow of stool.

It also helps to be prepared: if you think you might experience a bowel accident, take a change of clothes and some cleaning materials with you.

If you have repeated problems with bowel accidents, you may want to revisit your bowel program, using the problem-solving technique we just learned.

Here are some tips to consider:

•            Be sure your rectum is completely empty at the end of your program.

•            Try increasing the frequency of your program–some people with a flaccid bowel may need to empty their bowels more than once a day.

•            Try using only half of a suppository.

•            And monitor your diet for any foods that may overstimulate your bowel, such as spicy foods or greasy foods.

For more help understanding how to prevent bowel accidents, click on the Troubleshooting tab.

3.3 – Constipation

When your digestive system has been affected by spinal cord injury, you may have problems with constipation.  This can mean infrequent bowel movements or it can also mean passing small, hard, dry stools.

Pay attention to the appearance of your stools; if they look like type 1 or 2 on the stool chart, you may be constipated.

Constipation can happen if you don’t get enough fibre or drink enough water.  Some medications, like certain pain-killers, can cause constipation.

The first line of defense against constipation is to increase your intake of fluids, probiotics and foods that contain fiber.  You can also talk to your health care team about your medications and their effects on your bowel program.

You may want to increase your dose of stool softener, or of a laxative like psyllium.  Your activity level also has a big impact on your bowel program, so try getting more exercise.

For more help understanding how to prevent constipation, click on the Troubleshooting tab.

3.4 – Diarrhea

Diarrhea is the opposite of constipation.  It involves having frequent bowel movements and loose, watery stools.

When you have diarrhea, your stool looks like type 6 or 7 on the stool chart.

Diarrhea can be caused by spicy or greasy foods, by caffeine and even by stress.  It can also happen if you use too much laxative or stool softener.  Some medications, like certain antibiotics, can cause diarrhea.  And finally, it can also be the result of a viral infection or the flu.

If you have diarrhea, you’re at risk of dehydration, so make sure you get plenty of fluid.  It might help to eat foods like whole grain bread, cereal, rice and yogourt.

You may want to stop using stool softeners and laxatives until the diarrhea stops.  If you’re having bowel accidents, you may want to do your bowel care more often.

If the diarrhea seems to be related to a viral or bacterial illness, change to a bland diet for 24 hours with lots of liquids (except milk). If the diarrhea persists for more than 24 hours, or if you have a fever or blood in your stool, you should consult your health care provider.

Diarrhea can also result from a blockage of stool, called impaction.  In this case, liquid stool leaks out around the blockage. If you’ve had small, hard stools in the past week, or if you’ve done bowel care with no results, you should be aware of the possibility of impaction.  This is a serious medical problem, so contact your health care provider for advice.

For more help understanding how to prevent diarrhea, click on the Troubleshooting tab.

3.5 – Other problems

If you make repeated or excessive use of digital stimulation, suppositories and other stimulants, you might damage the area around the rectum and anus.  This can result in hemorrhoids, rectal bleeding and other problems.

The best way to prevent these problems is to be very careful when emptying your bowel, use plenty of lubrication and keep your stool soft.  Avoid straining or pushing too hard.

If your routine takes too long, more than an hour or so, you may want to increase your intake of dietary fibre and fluid.  You could also increase your use of laxative and use a stronger suppository.  You might also try switching your program to a different time, from morning to evening for example.  And try doing your bowel care an hour after you eat.

If you have problems with autonomic dysreflexia, make sure you’re not doing anything to irritate your bowel.  Keep your stool soft and contact your health care provider if the problem doesn’t go away.

3.6 – Signs to monitor

You have the ultimate responsibility for your bowel health, and you know yourself best, so it’s up to you to take the lead in keeping yourself healthy.  Start by sticking to your program—a good bowel program is like a habit or a routine, something reliable and regular.

If you’re having problems, work with your health care provider.  Be aware of warning signs, like blood in your stool, a sudden change in the colour of your stool, or autonomic dysreflexia.

And at all times, listen to your body and what it’s telling you.

Each time you have a bowel movement, pay careful attention to the following:

•            First, check the consistency of your stool: s it hard or soft?

•            Second, note the quantity.  Is your bowel completely empty?

•            Third, do you see any blood?

•            Fourth, how long did your routine take?

•            Fifth, do you experience sweating or spasticity?

If you notice a change in any of these areas, you should be aware that this may signal a problem with your bowel program.  Telling your health care provider about these changes is important. By working in partnership with your health care providers you can maintain your bowel health and independence.

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Course contents
Section 1 – Confidence and comfort
1.1 - Confidence and comfort
1.2 - How digestion works
1.3 - Neurogenic Bowel
1.4 - Your bowel program
1.5 - Making the transition

Section 2 – The perfect program
2.1 - The perfect program
2.2 - Diet and eating habits
2.3 - Timing & activity
2.4 - Position, equipment and skin health
2.5 - Bowel care: step by step

Section 3 – Problem-solving
3.1 - Problem-solving
3.2 - Bowel accidents
3.3 - Constipation
3.4 - Diarrhea
3.5 - Other problems
3.6 - Signs to monitor