Why is Bowel Care so Important after SCI?
A study published in the peer-reviewed Journal of Neurotrauma found that the number one concern of spinal cord injury patients is bowel care. The study was carried out by Victoria Claydon, a cardiovascular physiology researcher at Simon Fraser University in Canada.
Claydon’s research was international in scope, and involved around 300 people with spinal cord injuries, (mid thoracic or higher). Among the list of concerns, sexual function and pain management ranked highly - but bowel management and care came out on top.
Here’s what we’ll cover:
- The impact of SCI on bowel function
- Bowel management
- Managing diet: foods to eat and to avoid
- Alcohol, smoking and caffeine
- Keeping active
- Going to toilet: methods and techniques
- Managing accidents
The Impact of SCI on Bowel Function
So, why is bowel care such a big concern for people with SCI? For starters, it has an impact on socialising. Going to toilet isn’t the same as before injury and requires planning: a routine, strategies and new ways of working with your body. It can have a profound impact on your confidence to go out and do things, and at first can be unpredictable and difficult to get used to. And of course - it has a health impact.
How and Why Does the Bowel Change After SCI?
It’s all down to how the large intestine works with the nervous system and how the spinal cord controls it. Although the bowel largely does the job of extracting water and nutrients on its own, the last part of the digestive process (going to the toilet) relies on cues from nerves and the use of abdominal muscles to help push stool out.
Spinal cord nerves from the S3 to S5 vertebrae control the rectum and anus muscles, with sympathetic nerve assistance from the hypogastric nerve at T11 to L2. The hypogastric nerve carries signals to and from the sacral and pelvic splanchnic nerves, which control the pelvic organs. They also tell you when your bowel is full and it’s time to go to toilet.
Depending on the completeness of spinal cord injury, those cues from nerves are lost. Voluntary and involuntary muscle control is affected or lost. It can make going to toilet (and knowing when to go) more complicated. The medical name for the loss of nerve function is neurogenic bowel, and it has several symptoms beyond the loss of muscle control.
Let’s look at ways to manage your bowel movements positively, confidently and predictably, and what strategies you can employ to mitigate unusual situations and accidents.
Learning how your bowels work after SCI is an important step in gaining control and confidence. Before injury, digestion (from eating to going to toilet) takes on average 53 hours - after spinal cord injury it can take significantly longer (recorded at 96 hours in 80% of test subjects).
A process called peristalsis is responsible for food moving along the digestive tract. The nerves responsible for this are independent of, but regulated by, the spinal cord and brain. After SCI, this process is slowed down. Because bowel transit is slower, constipation is common after spinal cord injury. Self-regulating transit and reducing the impact of constipation and other blockages can be managed with diet and activity.
Your bowel management should have aims and goals:
- Regular, thorough bowel movements, either everyday or every other day
- Maintain continence
- Avoid and manage complications
Big factors in this will be diet, activity levels and techniques.
A good diet is especially important after injury. It’s a good idea to keep records of food and fluid intake - not just quantities, but times too. Knowing what you eat and when will help you manage predictable timings for toilet schedules and keep transit smooth.
Timing is especially important because of the gastrocolic reflex - a period of increased peristalsis experienced after eating food or having a hot drink. The effect is most pronounced after breakfast or a morning coffee, and within 20 to 40 minutes of your first meal of the day, a bowel movement is likely.
It’s important to eat plenty of fibre-rich foods: whole fruits (not juice), vegetables and grains are tasty natural sources of fibre. Fibre also helps retain water, which makes stool bulkier but easier to pass. As with any food, too much fibre can be a bad thing.
Some foods - like prunes - can accelerate the process a step further. Make a note of which foods have made digestion go faster for you, and use them to your advantage.
It’s best to eat fatty and sugary foods sparingly - but fish, meats and moderate dairy consumption are good for overall health. Water intake is important for digestive transit and how much you consume is dependent on your bladder care routine, the weather and how much you exercise - but generally, two litres of fluids per day is recommended.
Alcohol, Smoking and Caffeine
Alcohol and caffeine are diuretics, which cause you to lose fluid. While coffee and caffeinated drinks can help peristalsis, this has to be weighed up against the potential fluid loss they can induce.
With alcohol, avoid excessive drinking. Binge drinking can cause dehydration, loss of appetite and interruption of your bowel care routine. Enjoying an alcoholic drink after injury certainly isn’t off limits - but most of us know what the consequences of a heavy night of drinking are.
As for smoking - it’s bad for you at best. At worst, it’s an agent for cancer, heart disease, stroke, aneurysms and countless other fatal diseases. It can also wreak havoc with your digestive system: ulcers, reflux and even Crohn’s disease have been linked to smoking.
It’s never too late to quit.
Exercises appropriate for your injury level and stage of recovery can be discussed with your doctor. The increased blood flow around your body during exercise is good for relieving constipation. Side effects of keeping active can include better strength (even with reduced mobility) and the release of feel-good endorphins.
Empty your bowels before exercise if possible or if required, to avoid accidents.
Going to Toilet
Talking about the details of going to the toilet is a borderline taboo subject for most people - but when you have SCI, it’s pretty much essential to have the conversation.
A caring and understanding doctor (especially one familiar with spinal cord injury) will appreciate the difficulty and sensitivity of the conversation. It’s best to be open and honest to get the best results and most effective bowel management.
When it comes to going to toilet, your injury level and level of independence is a factor. People with injuries below or at C5 can usually use a toilet in the seated position. People with injuries at C4 or higher are usually managed in bed to overcome balance issues.
Sitting is an ideal position, because gravity can aid the process, but a good alternative position is laying on your left side, which naturally assists the direction of flow in your bowel.
Methods and Techniques
For most people with spinal cord injury, going to toilet requires stimulation or manual procedures. People with injuries that reduce arm mobility might need assistance or tools to start a bowel movement.
The following is an in-depth guide initiated by the Multidisciplinary Association of Spinal Cord Injured Professionals (MASCIP). It contains detailed information about neurogenic bowel and bowel management.
Accidents and How to Avoid Them
Accidents can happen. With a good bowel care routine, they’re much less common - which is why bowel care is so important after SCI. Your routine will largely develop from trial and error and won’t always go right at first - but don’t give up.
If you’ve kept a record of foods you’ve eaten and meal times, you may be able to estimate how unusual foods will transit your digestive system, so you’ll be more prepared.
Diarrhoea and bowel impaction can cause watery movements, which can’t be readily controlled, so treating and avoiding these ailments will reduce potential for accidents.
Fully emptying the bowel can help you avoid accidents, which may mean you need to spend a little longer evacuating your bowel. In people with a flaccid hypotonic bowel, the frequency of evacuations could need to be increased to avoid accidents.
When accidents happen, it’s really important to get cleaned up as soon as possible. Too long in stool can cause skin issues, so as soon as you notice try to get to a bathroom. Blocking stool flow can also trigger AD - so it’s important to get to a toilet as soon as possible.
Accidents can be awkward - but it can often be better to face it head on and relieve your own anxiety (and that of others), and explain what you’ve got to do.
It’s a good idea to keep some spare clothes on you with your usual toilet supplies.
Persevere with your bowel care routine and you’ll be able to confidently control your bowel movements, and reduce accidents. If they do happen, they’re not the end of the world - as long as you find a toilet and do what you need to do.
Here for You after Spinal Cord Injury
Aspire Law is a specialist law firm, just for people with SCI. We’re dedicated to providing information and support for everyone affected by spinal cord injury - from advice on bowel care, to legal help when you need it.
For information and spinal cord injury legal advice, get in touch: give us a call on 0800 030 20 40.