Normal Bowel Function
The bowel is the last portion of your digestive tract. The digestive tract as a whole is a hollow tube that extends from the mouth to the anus.
The function of the digestive system is to take food into the body and to get rid of waste.
Two Types of Bowel Problems with Spinal Cord Injury
With a spinal cord injury, damage can occur to the nerves that allows a person to control bowel movements.
Reflex Bowel: In some children, the ability to feel when the rectum is full may be lost. The anal sphincter muscle remains tight and bowel movements will occur on a reflex basis. This means that when the rectum is full, the pooping reflex will occur, emptying the bowel. It can be managed by causing the pooping reflex to occur at an appropriate time and place.
Flaccid Bowel: Other children may have what is called a flaccid bowel. This type of bowel problem both affects the pooping reflex and it relaxes the tiny muscle that keeps the bowel closed. Management of this type of bowel problem may require more frequent attempts to empty the bowel and bearing down or removing stool with a greased finger.
Bowel Training
Children without disabilities typically begin toilet training around the age of two to three years old. It is expected that children with spina bifida will be delayed. If a child with spina bifida shows readiness, a bowel program can be initiated around this time. It’s reasonable to set goals for a bowel program to be in place by the time the child is five.
Methods for emptying the bowel
Each child’s bowel program should be individualized to fit his/her own needs. A bowel program can include any combination of the following:
Manual removal: Physical removal of the stool from the rectum using a greased finger. This can be combined with a bearing down.
Digital Stimulation: Circular motion with the index finger in the rectum, which causes the muscle around the anus to relax.
Suppository: A small bullet shaped tablet placed in the rectum, for example Dulcolax or glycerine.
Mini-Enema: Small bottle of liquid squeezed into the rectum. Only about a teaspoon of fluid.
Bowel Programs
Parents should assist children to perform their bowel program at a time of day that fits in with their current lifestyle.
- The program usually begins with insertion of either a suppository or a mini-enema.
- Wait approximately 15-20 minutes to allow the stimulant to work. This part of the program should, preferably, be done on a potty chair or toilet seat.
- After the waiting period, digital stimulation (placing a clean greased finger in the anus) is done every 10-15 minutes until the rectum is empty. In order to avoid damage to the delicate rectal tissue, no more than four stimulations should be performed in any one session.
Children with a flaccid bowel often need no suppository or mini-enema. The child’s bowel programs should begin with digital stimulation or manual removal. Most bowel programs require 30-60 minutes to complete.
Bowel programs vary from child to child according to their individual preferences and needs. Some children need only half of a suppository, some require two suppositories, and some use no suppository or mini-enema at all. Some choose to do the entire program in bed, while others sit on the toilet from the beginning. Some find that the program works better if they can eat or drink a warm beverage while it is in progress; others find that this is not helpful.
Factors that can affect the success of the bowel program
Any one of the factors listed below, or a combination of factors, can affect the success of a bowel program. For best results, alter one factor at a time.
Routine: Routine refers to a child doing their bowel program daily at about the same time. Meals and medications should also be eaten or taken at about the same time each day. Some kids are able to do their program every other day. Once per week is not enough. Buildup of stool in the rectum can cause: damage to nerves in the rectum, diarrhea, and bladder infections
Privacy and comfort: Does the child have a private place to complete their bowel program?
Emotional stress: Is the child relaxed? Know that it takes months not days to master a bowel program. Encourage parents to be patient.
Positioning: Where does the child do their bowel program, on the toilet, potty chair, or in bed? It will probably work better when you are sitting up because of gravity.
Fluids: How much and what type of fluid does the child drink? (Prune juice or orange juice can stimulate the bowels.)
Food: How much fiber or bulk (such as fruits and vegetables, bran, whole grain breads and cereals) does the child eat? Some foods (such as dairy products, white potatoes, white bread and bananas) can contribute to constipation, while others (such as excess amounts of fruit, caffeine, or spicy foods) may soften the stool or cause diarrhea.
Medication: Some medicines can cause constipation, while others (including some antibiotics), can cause diarrhea.
Illness: A case of the stomach flu, a cold may affect a child’s bowel program. (Even if the digestive system is not directly affected, eating habits, fluid intake or mobility may change, which can alter a bowel program.)
Activity level/mobility: How much exercise does the child get? How much time does he/she spend out of bed?
Weather: Hot weather increases sweating, which can lead to dehydration and constipation.
Massage: Massaging the belly in a circular, clockwise motion from right to left increases bowel activity.
Bearing down: Helps push the stool out.
What to Avoid
Regular use of stimulant laxatives: These include bisacodyl (Dulcolax) tablets, phenolphthalein (Ex-Lax), cascara, senna and magnesium citrate. Laxative use on a regular basis will cause bowels to become dependent on them. When this happens the bowel will not work well without the laxative, and eventually the “lazy bowel” that results will require more and stronger laxatives to work at all.
Enemas: Any full-size enema (such as Fleet’s, soap suds or tap water) is too irritating to the bowel to be used on a regular basis and will cause the same problem with dependence as a stimulant laxative. A “mini-enema”, which has only a few drops of liquid stool softener, does not fall into this category and can be used regularly. Occasionally, the doctor may prescribe a full-size enema for treatment of severe constipation.
Skipping or changing the time of the program: Bowels will move more predictably if the bowel care program is carried out on a regular, predictable schedule. Skipping the program can also result in constipation or accidents.
Rushing: The more tense a child is, the more difficult it will be for him to empty his bowels. A hurried program will increase the likelihood of an unplanned bowel movement later in the day.
More than four digital stimulations at a time: This can cause trauma to the rectum, resulting in hemorrhoids or fissures (cracks or breaks in the skin).
Long fingernails: They can damage the rectal tissue and cause bleeding, even through a glove.
What to do if…
Stool is too hard (constipation): Continue the bowel program on a daily basis until constipation resolves. Increase fluid intake. Encourage the child to increase their activity level and intake of dietary fiber. Avoid giving children foods that can harden their stool, such as bananas and cheese.
Stool is liquid or runny (diarrhea): Temporarily discontinue giving any stool softeners. Continue the bowel program at the regular time and frequency. (If the child is having accidents, increase the frequency of the program.) If the diarrhea seems to be related to illness, change to a liquids only or very bland diet for 24 hours (avoid milk, however). If diarrhea persists for more than three days or if the child has fever or blood in the stool, call the doctor.
A frequent cause of diarrhea is a blockage or impaction of stool (liquid stool leaks out around the blockage). If you suspect impaction, call the doctor.
Frequent bowel accidents: Be sure the child’s rectum is completely empty at the end of his program. Increase the frequency of the program (some children with a flaccid bowel may need to empty their bowels twice daily). Monitor the child’s diet for any foods that may over stimulate the bowel, such as spicy foods.
No results in 3-4 days: Call the doctor.
Rectal bleeding: Keep the stool soft. Be very careful to do digital stimulation gently and with a well-greased finger. Keep fingernails short. If the child has known hemorrhoids, you may treat them with an over-the-counter hemorrhoidal preparation such as Anusol or Anusol HC. If bleeding persists or is more than a few drops, call the doctor.
Gas: Avoid constipation. Increase the amount of times per day that the child does the bowel programs. Avoid gas-forming foods, such as beans, corn, onions, peppers, radishes, cauliflower, turnips, cucumbers, apples, melons.
Takes a long time to complete: Try switching from a suppository to mini-enemas. Have the child eat more fiber (greens, papaya, oranges). Try switching the program to a different time, and be sure to schedule it after a meal.