Neurogenic Bowel Program Alternative Options and Alerts - Reeve Foundation

With patience, neurogenic bowel programs work. For various reasons, some individuals have difficulty completing or mastering an effective bowel program. This can be because they are unable to perform the bowel program due to mobility limitations, health reasons, or even personal preference. The neurogenic bowel program is the treatment of choice for neurogenic bowel, as it stimulates the bowel to work in its natural manner, thereby imitating and perhaps preserving function. There are alternatives that some individuals prefer. Be sure to discuss options with your healthcare provider as you do not want to deter function later in life or reduce your bowel care options.

Bowel flushing systems such as enemas are not recommended for neurogenic bowel, as they flush out the bowel. They do not mimic normal bowel function, so this process can be lost, as well as loss of normal gut bacteria that assists with digestion, and over time reduce the natural stretch in the bowel wall for propelling digested food through it.

Transanal irrigation is a device that ‘pumps’ water into the rectum and lower colon only. This process does require hand and some finger function for independent use or can be performed by a caregiver. Be sure the water temperature is lukewarm. Too cold of water will cause the bowel to constrict, making the process more difficult or even triggering episodes of autonomic dysreflexia. Too hot of water and the bowel lining can be burned. If stool in the lower rectum stops the irrigation catheter from entering, it must be manually removed before insertion, as with any neurogenic bowel program. The time for a transanal irrigation bowel program is 20 minutes or about the same as other bowel programs.

Individuals who have reflexive neurogenic bowel as the result of brain injury or have a spinal cord injury above T6 (or even as low as T10) must consider the possibility of episodes of autonomic dysreflexia and will need to discuss their ability to use transanal irrigation systems. Complications include perforating the bowel, should not be used if you have fluid restrictions, are on kidney dialysis, have had recent surgery on your bowel, have diverticulitis, Crohn’s disease, ulcerative colitis, or are pregnant.

There is a bit of a learning curve to the use of these types of devices. Company representatives will assist you with questions you may have. You should check with your payor to ensure there is financial support before considering transanal irrigation. Obtaining equipment is a process.

Transanal irrigation devices include Peristeen and Navina Smart. An interesting article about best practices of transanal irrigation is located here. Please note that the device company funded the study.

A colostomy is an option that some individuals consider an alternative to the bowel program. This is a surgical procedure where the bowel is connected to the outside of the body, bypassing the rectal area. When an elective colostomy is performed, that is one requested by an individual, and you have options of where you would like the colostomy to be located on your abdomen. Differing locations of the colostomy on the abdomen will result in different consistencies of waste output. The closer to the rectum, the stool output will be more solid. Further up the bowel, the output will be more watery.

With a colostomy, the bowel is attached to an opening in the abdomen called a stoma. This stoma is part of your bowel, so management must be considered. Bowel tissue is much more delicate than skin. A bag is placed over the stoma to keep the tissue moist through natural fluids. The skin on the abdomen must be protected from the caustic nature of stool, which can vary in texture from watery to more solid stool depending on the location of the stoma. The stool will come out of the stoma as it is produced which is collected into a bag. The bag is attached to the area around the stoma. It needs to be changed and the stoma and skin cleaned but there is no bowel program performed. You have no control over the expulsion of your waste.

There are many individuals with neurogenic bowel that find a colostomy to be the most freeing thing they have ever experienced. There are equally many individuals who have difficulty with maintaining the colostomy, have complications from the surgery, or have died. This includes individuals who have difficulty in maintaining the bag on their abdomen, which leads to stool accidents. Sometimes, the colostomy requires irrigation to work. The bag may be difficult to maintain attached to your abdomen.

The decision to have a colostomy should not be lightly made. Be sure to discuss any procedure with your healthcare professional to ensure whatever you choose is a good option for the unique being that you are.

Hemorrhoids can be a complication of a bowel program. This can be from constipated stool, impactions, rough stimulation during the bowel program, and not using enough lubricant with finger insertion. If hemorrhoids appear, tucking them back into the rectum with a well lubricated, gloved finger will keep the tissue moist, avoiding drying and cracking of the delicate tissue. If caught early, you can reduce hemorrhoids using specified creams and medicated pads. Be sure to lubricate well and use a gentle approach to your bowel. Remember, tissue inside your body is not as tough as skin. That can be easy to forget when you just want to be finished with the bowel program, but slow and steady makes the bowel program faster as well as protects that delicate internal tissue.

Other precautions to avoid hemorrhoids are reducing your sitting time on the toilet or commode, which has no support for the rectal area. All your upper body weight is resting on your rectum when sitting on a toilet-style seat. Reducing your time can be done by inserting the suppository in your bed or your chair and not relocating to the toilet until time for evacuation. For success with timing, you must know how long it takes for your bowel program to work. Doing pressure releases also helps break the pressure on the rectal area.

When hemorrhoids become an issue, the least invasive treatment is necessary. Surgical removal is not recommended due to the complications of the surgery, excessive bleeding, positioning of the body for this type of surgery, and respiratory complications. However, conservative treatments, as mentioned above, or consideration of occlusion procedures (banding) can be considered.

Silent Autonomic Dysreflexia is AD without the characteristic symptoms. Blood pressure elevates, but other bodily symptomatic clues are not present. Find a moment to take your blood pressure at various times during your neurogenic bowel program. If you do have silent AD, notify your healthcare professional for treatment. Medications to prevent AD may be needed just before your bowel program or rectal anesthesia ointments may take care of the issue. Gentle digital stimulation also reduces episodic AD development.

You do not have to do this every time but periodically, check your blood pressure in various activities, especially during the various steps of your bowel program. Silent autonomic dysreflexia or AD without symptoms except for elevated blood pressure has been determined to occur more frequently than previously known. For your cardiac health and overall well-being, periodically check your blood pressure during all activities.

Developing and perfecting the bowel program can be a challenge when you have issues with mobility or thinking. Writing out the steps to the bowel program can assist with being sure you have done them in the right order until they become second nature, as this process is normal for you. Quality of life is significantly affected if your bowel program is not working as you would like. It does take a significant amount of time to perfect the bowel program, but it can be done, and you will master it as well.

Pediatric Consideration:

Options for children in neurogenic bowel care are similar to adults. There are opportunities for alternative bowel treatments as well however, thinking about these should not appear as an easy escape from the bowel program. Children’s bodies are developing, not developed. As your child grows, their bowel needs may change. Development may lead to improvements in bowel functioning. Jumping right into alternative paths for bowel evacuation can alter your child’s adulthood. Be sure to discuss options carefully with an older child and especially with their healthcare professional to obtain their opinion about treatments.

P.S. Just in case you haven’t seen the Bristol Scale, attached is a copy. This is a way to discuss stool in a common language with your healthcare professional. There is even an app for it to track your bowel program progress. The app is free. There are other stool tracker apps as well.

The Bristol Stool Chart

Linda Schultz is a leader, teacher, and provider of rehabilitation nursing for over 30 years. In fact, Nurse Linda worked closely with Christopher Reeve on his recovery and has been advocating for the Reeve Foundation ever since.

In our community, Nurse Linda is a blogger where she focuses on contributing functional advice, providing the "how-to" on integrating various healthcare improvements into daily life, and answering your specific questions. Read her blogs here.

And if you want more Nurse Linda, sign up for her monthly webinars here. Don’t worry, we archive her answers so you can refer back and sift through her advice. Consider it Nurse Linda on-demand!