Changes to bowel function are common after spinal cord injury (SCI). This page provides an overview of bowel changes and basic bowel care after SCI.
- Most people experience changes to bowel function after SCI, which can affect their ability to sense bowel fullness, move stool through the bowel, and control emptying.
- These changes can lead to constipation, inability to pass stools, and leaking or accidents (incontinence), which can have a major impact on health and well-being after SCI.
- There are two main types of bowel changes after SCI:
• Flaccid bowel (non-reflex bowel) occurs with injuries below T12 and involves loss of bowel reflexes and relaxed anal sphincters.
- Bowel care typically involves following a regular bowel routine of techniques like diet and lifestyle changes, hands-on emptying techniques, and medications to empty the bowel and prevent complications.
- If a bowel routine alone is not effective, more invasive techniques like surgeries may be considered.
To better understand how bowel function changes after a spinal cord injury, it is helpful to first understand how the bowel works when the spinal cord is not injured.
The gastrointestinal tract
The gastrointestinal tract (GI tract or digestive tract) is a long tube that runs from the mouth to the anus. It is a part of the digestive system, which is responsible for extracting energy and nutrients from food and getting rid of waste.
When food is taken in through the mouth, it travels down a tube called the esophagus into the stomach, where mechanical forces and acidic stomach juices begin breaking it down. It then travels into the intestines (also called the bowel) where it is broken down further to form a stool.
The bowel (intestine or ‘gut’) is the segment of the gastrointestinal tract that runs from just below the stomach to the anus. It has two main parts, the small intestine and the large intestine. The bowel is where nutrients are extracted from food and indigestible waste products are formed into a stool (also called feces, pronounced ‘fee-sees’).
The stool is moved through the bowel by a wave-like movement of the intestinal walls called peristalsis. The last part of the bowel is called the rectum. When stool reaches the end of the bowel and stretches the walls of the rectum, signals are sent through the spinal cord to the brain, which is felt as an urge to empty.
Bowel emptying is controlled by two muscles called anal sphincters, which surround the opening of the anus:
• The internal anal sphincter is smooth muscle that is controlled automatically by a reflex.
• The external anal sphincter is skeletal muscle that is controlled consciously by the brain.
These muscles tighten to close the anus and ‘hold in’ stool, and relax to allow the bowel to empty.
The pelvic area also has pelvic floor muscles, which are a group of muscles that support the internal organs from below. These muscles also help to control bowel movements by contracting and relaxing in a coordinated fashion.
When the spinal cord is injured, some or all of the nerve signals that would normally allow the brain and bowel to communicate with one another cannot get through. This can contribute to a number of bowel changes that are known as neurogenic bowel dysfunction.
When the rectum is full, the nerve signals that would normally communicate this sensation to the brain are blocked in the spinal cord by the injury. This can cause a loss of the ability to sense when the bowel is full or recognize other sensations from the bowel, like discomfort.
Slow movement of stool through the bowel
After an SCI, food continues to be digested and moved through the bowel, however, this movement happens at a much slower pace because the signals from the brain which normally help to coordinate this movement are blocked by the spinal cord injury. Slow movement through the bowel means that food takes much longer to digest, which can lead to dry, hard stools and constipation.
Loss of bowel control
Spinal cord injury can also interrupt nerve signals travelling from the brain to the anal sphincter muscles. This can lead to a loss of the ability to control when the anal sphincters tighten or relax, which cause difficulties emptying the bowel if they remain tightened all the time (stool retention) or leaking and accidents if they relax unexpectedly. The types of changes depend on whether you have spastic bowel or flaccid bowel (see below). SCI can also cause a loss of control over the pelvic floor and abdominal muscles, which also affects bowel control.
Charlie speaks about his initial fears of having a bowel accident while living in the community.
Spastic bowel (also called reflex bowel or upper motor neuron bowel) usually occurs when the spinal cord is injured at T12 and above.
With spastic bowel, the bowel’s natural reflexes are retained, but they no longer receive control from the brain. This causes increased muscle tension in the walls of the intestines, tightening of the anal sphincter muscles, and uncontrolled reflex emptying when something is present in the rectum. Spastic bowel is typically experienced as constipation and an inability to pass a stool (stool retention).
People with spastic bowel are usually able to empty the bowel by activating the bowel reflexes. This is usually done every other day through techniques like digital stimulation or the use of suppositories.
Flaccid bowel (also called non-reflex bowel or lower motor neuron bowel) usually occurs when the spinal cord is injured below T12. Flaccid bowel involves a loss of control from the brain and a loss of bowel reflex activity. This leads to a loss of muscle tension in the walls of the intestines and the anal sphincter muscles, which causes the bowel muscles to be floppy and loose. Flaccid bowel is typically experienced as involuntary leaking of stool (incontinence) and constipation.
With flaccid bowel, the stool usually needs to be removed by manual evacuation (also called disimpaction) once or twice per day to empty the bowel.
Leaking and accidents (Fecal incontinence)
Fecal incontinence is the inability to control bowel movements, leading to involuntary loss of stool. Incontinence can range from leaking a small amount of stool to a full bowel accident.
Bowel accidents are common after SCI. Most people will experience accidents early on before bowel routines have been established. It takes time and trial and error to develop a routine that allows for consistent and effective emptying that minimizes the risk of accidents.
Constipation and stool retention
Constipation is when stools are dry and hard and take a long time to pass. Constipation is common after SCI because movement of stool through the bowel is slow, which dries out the stool. The stool may also be difficult to pass if the anal sphincter muscles do not relax enough (called stool retention).
Constipation is usually treated by making lifestyle changes, such as increasing fibre and fluid in the diet, increasing physical activity and reviewing your medications. Constipation may also be treated with medications like stool softeners and occasionally other techniques like bowel irrigation.
Understand the side effects of constipation through Josh’s experience.
Diarrhea is a loose watery stool that happens when the stool moves too quickly through the intestines. Although most people with SCI experience slow movement through the intestines, diarrhea may happen in response to certain foods, illnesses, other bowel conditions (such as stool impaction) or as a side effect of medications. It is important to speak with your health providers to determine the cause of diarrhea if it happens.
Fecal impaction (stool impaction)
Fecal impaction (stool impaction) is when a solid bulk of stool builds up within the bowel over time and gets stuck. The stool cannot be emptied through regular emptying methods. Fecal impaction happens when a person has constipation for a long time.
Although impaction involves a stool that is stuck in the bowel, it can sometimes result in leakage of stool, which is sometimes mistaken for diarrhea. This happens because watery stool may be able to get around the impacted stool and leak from the anus.
Fecal impaction can sometimes have the same symptoms as a bowel obstruction, which is a serious condition where the bowel is blocked. It is important to speak to your health team right away if you have had constipation for a long time.
Hemorrhoids (piles) are swollen or inflamed veins in the rectum and anus. They may be located inside or outside of the anus. Symptoms may include pain, blood or mucus in the stool, and swollen protrusions out of the anus. Hemorrhoids are usually treated with a combination of medicated creams, suppositories, and sometimes surgery.
Bowel changes after SCI can also lead to other problems such as loss of appetite, nausea, abdominal distension (a build-up of fluid or gas in the abdomen), ulcers, rectal fissures (cracks or breaks in the skin of the rectum), and rectal prolapse (a condition where the walls of the rectum slide out of place and can protrude out of the anus).
The main way that bowel changes are diagnosed is through a bowel history. Your health providers will ask you about your medical history, symptoms, and current management. They will ask you about your bowel routine, such as how often you have bowel movements, how long it takes you to complete your bowel routine and what the stool looks like when it is formed.
A physical exam, including a neurological exam and a rectal exam, will also be done. Your health providers will look and feel the abdomen and rectum, which may involve feeling the muscle tone in the anal sphincter muscles. They will also test your bowel reflexes.
Other testing may also be done if your health providers need further information.
- Medical imaging, such as x-ray, computed tomography (CT), and magnetic resonance imaging (MRI) of the abdomen may be used for further investigation of bowel problems
- A stool sample may be taken for analysis
- Blood tests may be done to screen for infections or cancer
A colonoscopy (the insertion of a small camera or ‘scope’ into the colon) may be done to look for colon cancer, polyps, and hemorrhoids.
Bowel care is an essential part of staying healthy after an SCI. For most people, a bowel routine is their main method of caring for their bowel health following SCI.
A bowel routine is a regular routine of bowel care techniques that is done every day or every other day to empty the bowel. There is a wide range of different components that may make up a bowel routine, such as hands-on emptying techniques, diet and lifestyle changes, and the use of suppositories, mini-enemas and medications.
Bowel routines are usually done at the same time each day so the body gets used to the program. The goal of bowel routines is usually to be able to complete the routine within one hour on a regular basis to empty stool from the bowel and prevent accidents.
Every person’s bowel routine is different and often involves some trial and error to find the methods that best meet the person’s unique symptoms, physical abilities, preferences, and lifestyle. Although bowel routines can be complicated and time-consuming, they are a very important part of bowel care to allow for regular emptying and to prevent complications.
Most people will need to use ‘hands-on’ (‘manual’) techniques to empty the bowel. Some people may need assistance from a care provider to use these techniques. They are usually done while sitting on a toilet or commode or while lying on your left side with the knees bent on an underpad.
People with spastic bowel typically use a technique called digital stimulation, digital rectal stimulation, or rectal touch to empty the bowel. Digital stimulation is a technique in which a gloved and lubricated finger (known in anatomy as a ‘digit’) is gently inserted into the anus and moved in circular motions along the walls of the rectum. This triggers a reflex that causes rectal contractions and loosening of the anal sphincters to allow emptying.
Digital stimulation is one of the most common techniques used for bowel emptying after SCI, however very little research has been done to determine if it is effective. There is weak evidence that this form of stimulation helps move stool along the bowel in people with SCI.
Manual removal of stool
People with flaccid bowel do not have bowel reflexes, so digital stimulation is not effective. Instead, the stool needs to be removed manually. This is called manual evacuation, digital disimpaction, or a rectal clear. This technique involves the use of a gloved and lubricated finger, which is inserted into the anus and used to remove stool. It may be done in conjunction with use of a lubricating suppository.
There is weak evidence that manual evacuation helps to reduce the number of bowel accidents, however, there is conflicting evidence on whether it helps to reduce time spent on bowel care.
Abdominal massage is a technique where a person massages the abdomen by stroking or kneading the lower torso in a clockwise motion to increase movement within the colon. However, it is not clear whether abdominal massage is effective for helping with bowel care after SCI since research studies have been conflicting. Use caution when using abdominal massage after a recent surgery or if you have an abdominal stoma.
Diet and fluid intake play a very important role in maintaining stools that can be moved easily through the bowel. Altering diet and fluid intake is often one of the first changes that are made to try to improve the consistency of stool and manage problems like constipation and diarrhea.
Fibre plays an important role in maintaining stool consistency so the stool can be moved easily through the bowel. Different types of fibre have different effects in the body. Soluble fibre, such as oatmeal and psyllium fibre, helps to trap waste and water along the digestive tract. It is important to increase water intake together with soluble fibre because it needs to absorb water to work. Soluble fibre may help improve stool consistency if stools are too loose or too hard. Insoluble fibre, such as whole grains, helps push the contents out more quickly.
There is weak evidence that diets high in fibre may actually slow down digestion after SCI. The optimal amount of fibre intake for people with SCI has not yet been studied and is highly variable between individuals, however, most health providers recommend moderate fibre intake to help with bowel care after SCI.
Water is important to bulk up the stool to allow it to move more easily. Health providers often recommend drinking at least 2 litres of healthy fluid per day, however, the optimal amount of fluids for improving bowel movement after SCI has not yet been studied.
Foods contributing to other symptoms
Some people find that certain foods and drinks affect their bowel function in different ways. For example, some foods may cause loose stools or constipation. Every person is different and it may take some trial and error to find the best diet for you.
Find out how Charlie manages his fiber and fluid intake depending on the season.
Medications and suppositories may be added to your bowel routine if hands-on techniques and diet changes are not enough.
Stool softeners are a type of laxative that increases the moisture in the stool to make it easier to pass. Stool softeners are usually taken once or twice per day or as needed. Some common stool softeners include Polyethylene glycol 3350 (PEG) and Docusate sodium (Colace).
Stimulant laxatives (including Stimulant suppositories)
Stimulant laxatives increase the movements in the intestinal wall that help move the stool along. There are many different stimulant laxatives that may be taken by mouth or as a suppository or micro-enema. Some common stimulant laxatives include Bisacodyl (Dulcolax) suppositories and Sennosides (Senokot).
Although it depends on the type of medication used, stimulant laxatives are usually taken about 8-12 hours before a planned bowel program (often the night before a bowel routine) so it is easier to empty the bowel later on. The dose and exact timing depend on the medication used.
Stimulant suppositories contain medications (such as Dulcolax) which stimulate the bowel reflex. Suppositories are usually inserted 15 to 30 minutes before planned bowel emptying. However, the medication used and even the base that the medication is dissolved in can affect how quickly the medication is absorbed. For example, Dulcolax in a water-soluble polyethylene glycol base (such as a Magic Bullet) allows shorter times to emptying than Dulcolax in a vegetable oil base.
Lubricating suppositories contain non-medicated substances (such as glycerin) which holds water in the bowel to make the stool softer so it is easier to pass.
Similar to stimulant laxatives, prokinetic agents are medications that increase digestive tract muscle activity to move the stool through digestion. However, prokinetic agents also speed up movement through the upper digestive tract as well as the bowel. Prokinetic agents are not routinely used and considered as a last resort for constipation or in preparation for a bowel procedure, such as a colonoscopy.
There is moderate evidence that the prokinetic agents fampridine, neostigmine, and metoclopramide help provide relief from constipation in people with SCI. There is also moderate evidence that prucalopride can also help SCI individuals with impaired bowel emptying but may cause abdominal pain.
Standing and Exercise
Standing and exercise have long been thought to assist with bowel management after SCI. Standing and exercise are thought to help move abdominal contents toward the rectum. However, there is not enough evidence at this time to determine whether standing and exercise are effective to help with managing bowel changes after SCI.
A number of devices also exist to help with bowel management. These devices are typically used together with regular bowel care techniques, and may include:
- Commodes, raised or padded toilet seat, or automated toilet seat
- Suppository inserter or digital stimulator
- Anal plugs
- Bowel irrigation systems
However, limited research has been done on assistive devices for bowel care, so we do not yet know if these treatments are useful to help manage bowel changes after SCI.
Colostomy and Ileostomy Surgery
Most people are able to manage their bowel function effectively with a bowel routine made up of conservative techniques and medications. However, some people may require the use of additional treatments to achieve optimal bowel care.
Colostomy and ileostomy are surgical procedures that may be used if conservative techniques do not work well or as a way to streamline bowel care. Both of these procedures involve a surgically-created hole between the intestine and the outside of the abdomen. Once the opening is formed, a pouch (collection bag) is attached to allow stool to be collected outside of the body, bypassing the rectum and anus entirely.
A colostomy is when the hole (or stoma) is created between the colon (large intestine) and the outside of the body. An ileostomy is when the hole is created between the ileum (last part of the small intestine) and the outside of the body.
Although these types of surgeries are invasive, a number of different studies have shown that there are many benefits for bowel care. There is weak evidence that colostomy surgery:
- Simplifies bowel routines and reduces the amount of time spent on bowel care
- Reduces the need for use of laxatives and dietary changes in bowel care
- Reduces the number of hospitalizations related to bowel problems
- Improves independence and quality of life
These studies showed that, while there were some complications related to stoma surgeries, such as opening of the surgical wound, these were uncommon and the majority of people were satisfied with the results of their surgery.
Bowel irrigation is the use of water or other fluids (including medications) to stimulate the bowel muscles and flush stool from the bowel. This is done to help loosen stools and treat constipation. Bowel irrigation is sometimes referred to as an enema, although it typically uses more fluid than an enema. The fluid may be introduced into the bowel through the anus (called transanal irrigation) or through a surgically created stoma (called antegrade irrigation).
Transanal irrigation is done through a catheter that is inserted into the rectum through the anus. The catheter may be surrounded by a balloon that can be inflated to hold the catheter in place and prevent leaking of water. The catheter is connected by a tube to a hand pump or electrical pump system to push water into the bowel. Pulsed water transanal
irrigation involves quick pulses of water into the rectum to help loosen stools. There is weak evidence that transanal irrigation and pulsed water transanal irrigation helps improve bowel function after SCI.
When fluid is introduced through a stoma (antegrade irrigation), it is usually done through a small stoma into the beginning of the large intestine (the cecum) called a cecostomy or as part of a surgical technique called the Malone Antegrade Continence Enema (MACE) procedure, where the appendix is made into a stoma. Irrigation is not usually done through an ileostomy because this can cause dehydration. There are several studies which provide weak evidence that Malone Antegrade Continence Enema is a safe and useful alternative for bowel irrigation after SCI.
Caring for bowel changes and establishing a bowel routine after SCI is one of the highest priorities for recovery after injury. Without proper care, bowel changes can lead to a number of health-related and lifestyle problems that can interfere with daily life.
Bowel dysfunction can contribute to other health problems
Poorly managed bowel problems can lead to severe constipation, fecal impaction and other serious bowel complications. Bowel changes can also contribute to other medical conditions like skin breakdown, pressure wounds and autonomic dysreflexia.
Bowel dysfunction can interfere with important life activities
Bowel problems can also interfere with important activities like work, socializing and sexual intimacy. Poorly managed bowel care can lead to unexpected accidents and other problems; which can be embarrassing and distressing. Even when well managed, bowel care can take up a lot of time and energy each day, which may interfere with maintaining a regular schedule. This can have a big impact on life satisfaction and quality of life.
Evidence for “Hands-on bowel techniques” is based on the following studies:
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Evidence for “Diet and fluids” is based on the following studies:
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Evidence for “Medications and suppositories” is based on the following studies:
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Colostomy and Ileostomy surgery
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Electrical and magnetic stimulation
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