Neurogenic Bowel

Although all patients 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), physical (gastrocolic reflex, abdominal massage) and either a rectal stimulation (hyperreflexic bowel) or a manual evacuation (areflexic bowel) technique

Most patients will be on chronic laxatives (stool softners, stimulant or osmotic 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 10-14 days

Neurogenic bowel is a common reason patients with spinal cord injury have to go to A&E and a common cause of Autonomic Dysreflexia (AD)

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 such as autonomic dysreflexia (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).

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).

Pathophysiology

Reproduced from Neurogenic Bowel. Caring for Persons with Spinal Cord Injury - e-learning resource for family physicians. Ontario Neurotrauma Foundation.

Hyperreflexic Bowel
The upper motor neuron (UMN) bowel syndrome 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
The lower motor neuron (LMN) bowel syndrome is characterised by the loss of centrally-mediated (spinal cord) peristalsis and slow stool propulsion. 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. Stool evacuation usually involves manual evacuation.

Completeness of 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 SCIRE)

Signs and symptoms

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 bowel management

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

Guiding principles

• A systematic and comprehensive evaluation of bowel function and impairments is completed at the 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 carer.
• 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.
• 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.
• Effective treatment of common neurogenic bowel complications, including faecal impaction, constipation, and haemorrhoids, is necessary to minimise potential long-term morbidities.

Reproduced 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.

Designing a management programme

Assessment and initiation of bowel management program (download PDF)

Adapted from Multidisciplinary Association of spinal cord injured professionals (MASCIP) guidelines (2012). Guidelines for the management of neurological bowel dysfunction in individuals with central neurological conditions. www.mascip.co.uk and 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.

Evaluating bowel management

Evaluation of bowel care program (download PDF)

Adapted from Neurogenic Bowel. Caring for Persons with Spinal Cord Injury - e-learning resource for family physicians. Ontario Neurotrauma Foundation.

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 the cause and do not change more frequently than every 10-14 days. A change in bowel management takes about 10-14 days to be reflected. Make sure to ask patient about changes in activity as this may impact bowel function (less active = harder stool).

Troubleshooting (download PDF)

Adapted from Neurogenic Bowel. Caring for Persons with Spinal Cord Injury - e-learning resource for family physicians. Ontario Neurotrauma Foundation.

Reproduced from Neurogenic Bowel. Caring for Persons with Spinal Cord Injury - e-learning resource for family physicians. Ontario Neurotrauma Foundation.

Laxatives

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

We do not recommend bulk-forming laxatives or phosphate enemas due to the risk of bowel perforation.

Adapted from Neurogenic Bowel. Caring for Persons with Spinal Cord Injury - e-learning resource for family physicians. Ontario Neurotrauma Foundation.

Follow-up

• Yearly review of bowel management program
• If examination indicated 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 (FOB test may be very unreliable in this population)
• Provide patient with education/resources (e.g. LSCIC Education pack)