Common Issues with Bowel Programs
There are issues that individuals might have with bowel programs. Last week, slow transit time was discussed. Speeding transit time can improve the length of time to complete the bowel program. Other issues can affect the body. These include constipation, rectal issues, and excess mucous production after the bowel program.
Constipation
After spinal cord injury, some brain injuries, and other neurological diseases, neurogenic bowel occurs. This is a miscommunication of messages to and from the brain to the bowel for functioning. It is an issue with the nerves. Many people misunderstand this as constipation. Constipation is a different issue that involves too little moisture in the stool for it to pass. Neurogenic bowel is a nerve messaging issue. Constipation is a stool hydration issue. Such as life is, a person can have both. However, the treatments are different.
Neurogenic bowel requires a bowel program for the removal of stool from the body. This is done using a suppository and digital stimulation for a reflexive bowel. Manual removal is used in a flaccid bowel. Neurogenic bowel is retaining stool because messages are not communicated effectively to and from the brain.
As stool enters the bowel, it is very moist, more like a thick liquid. When the stool travels through the bowel, water is removed, so the stool becomes a soft solid consistency for pushing it out of the body. Water is constantly being removed, so the longer stool is in the bowel, the drier it becomes.
Constipation is too much fluid removed from the stool as it passes through the bowel. It can occur with or without neurogenic bowel. Constipation can occur as the stool moves through the bowel or is held in the rectal vault for too long. This makes the passage of stool more difficult and rougher on bowel tissue.
Constipation comes from a variety of issues. Dehydration is one source of constipation. Keeping the body well hydrated is a first-line defense for constipation. However, if you have a neurogenic bowel, the stool will move much more slowly, allowing more time for the bowel to extract fluid. The stool will need to contain more fluid inside it. Increasing the diet in fiber is helpful. This helps retain fluid within the stool as it passes through the bowel and adds bulk to help the sluggish bowel more quickly move the stool along, increasing the transit time discussed last week.
Stool that is hard and difficult to pass can lead to an impaction. This is an actual clog of stool in the bowel. If the stool is not eliminated, the bowel backs up, leading to an enlarged bowel with stool moving up into the stomach or even vomited. Impactions can be difficult to remove. If the hard stool is low enough in the bowel, it may be able to be broken up and manually removed. Hard stool, higher in the bowel, might be removed by a series of enemas given by a health professional to monitor your condition while this aggressive process occurs. On rare occasions, surgical intervention is required.
A bowel that is not emptied can lead to overstretching the bowel wall of the large intestine. This causes a loss in function as the bowel wall will not re-conform to its typical size, which causes an inability to move stool along the gastric passage. The bowel becomes chronically dilatated and dysfunctional. This condition is sometimes called megacolon. The bowel is effectively not functioning.
Rectal Issues
Other anatomical issues can be affected by the bowel program. Injury to the rectal area can occur from overzealous stool removal. The tissue of the rectal area is very fragile. Internal tissue is not necessarily welcoming to dry or rough treatment. Since the rectal tissue is delicate, hemorrhoids or fissures can develop. When tissue becomes damaged, inflammation occurs, which is extra blood and body fluid to the area.
Hemorrhoids are rectal blood vessels that are overstretched or over dilatated with blood. They are like varicose veins seen in the legs, but these are in the rectum. They can be caused by aggressive, not well lubricated digital stimulation as used in bowel programs by individuals with reflexive neurogenic bowel or from straining or not well lubricated manual removal as used in bowel programs by individuals with flaccid neurogenic bowel. Sitting too long on the toilet or commode can increase your risk of hemorrhoids because your body weight is unsupported in the rectal area. An extremely hard, dry, or constipated stool can contribute to hemorrhoids due to pressure in the area.
You might feel hemorrhoids internally when performing your bowel program. They might protrude out of the rectum. Blood might be seen on the outside of your stool as it is passed. For those with sensation in the rectal area, you might feel pain, burning or itching. For those with higher-level spinal cord injury or lack of sensation in the rectal area, you might have increased spasticity or episodes of autonomic dysreflexia (AD).
First-line treatment is to reinsert the hemorrhoid into the rectum with a well-lubricated finger gently. This will keep the hemorrhoid moist with less drying of the tissue. Check with your healthcare professional to see if you can use over-the-counter hemorrhoid reducing cream to help shrink it.
If there are many hemorrhoids, excessive bleeding, a clot (thrombosed hemorrhoid) or the issue lasts for more than a week, you may want to consider further medical attention. Non-excision techniques such as freezing or banding of the hemorrhoids should be used. Surgical excision should be avoided for those with spinal cord injury.
Fissures are a tear in the delicate tissue of the rectal lining. They occur in children more than in adults but are especially possible with aggressive bowel programs. These can be slight, like a paper cut or deep within the tissue. Fissures are avoided by a high fiber diet, drinking fluids, exercise to help move stool along in the bowel and a gentile approach to the bowel program. Conservative treatment is used to allow the tissue to heal. Monitoring for infection is important. A colorectal surgeon can repair extremely deep fissures.
Polyps which are bumps of tissue, can also form within the bowel. These might be felt while doing a bowel program, but mostly they go unnoticed unless large in size. A colonoscopy should be done every ten years or less as directed. Many polyps can be removed during this procedure.
Anal abscesses can occur as a pocket of pus anywhere in or around the rectal opening. They form for a variety of reasons, from irritation to infection or even for unknown reasons. They can be treated, but sometimes anal fistulas can occur when the tract of the abscess remains open with pus draining from it. They are usually treated with antibiotics and wound care. A qualified colorectal surgeon might be needed for surgically clearing the abscess or fistula.
Rectal prolapse occurs when the lower part of the bowel protrudes out of the rectum. It can occur from straining as a technique in bowel emptying in flaccid neurogenic bowel or from sitting with an unsupported rectal area for long periods of time. To avoid this situation, speak with your healthcare professional about the use of straining for toileting. This technique has been removed from current treatment plans, but you might still be using it if you were injured some time ago. Also, notice your emptying times so you can sit on the toilet or commode when it is time to empty your bowel and not while you wait.
Mucous
Mucous production after a bowel program is often a concern for individuals. In this situation, the bowel program is complete, but mucous is evacuated at the end of the bowel program or sometimes hours later. This is a particular issue for those who use suppositories.
Suppositories are used for individuals who have a reflexive bowel as a stimulant to cause the lower bowel to work to evacuate stool. When the suppository is placed in the bowel, it must be placed next to the bowel wall to melt and stimulate bowel tissue. A suppository placed in the center of stool will not trigger the bowel to function.
Because the suppository stimulates the bowel, it causes a reflexive movement. Suppositories do this because they slightly irritate the bowel, not as a negative but as a tickle to get going. The stool is expelled with the help of digital stimulation to relax the internal sphincter of the rectum. The stool might be evacuated prior to the work of the suppository being completed. In other words, sometimes the suppository is still stimulating the bowel even though the stool is gone. This results in the expulsion of mucous. This is very frustrating when the bowel program is complete, especially if it occurs hours later.
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There are several ways to manage mucous discharge. One way is to try other products. Most individuals will use a Dulcolax or magic bullet suppository. The Dulcolax has a vegetable coating that must be dissolved in the bowel prior to its working. This can delay the work of the active ingredient that stimulates the bowel. The magic bullet does not have the coating, so it begins working right away. You may find one of these products works better for you than the other. People tend to like one of these brands over the other. There does not seem to be any predicting that you will like, but people favor one or the other.
If both of these products are too stimulating, resulting in mucous, you could try a less stimulating glycerin suppository. These are generally used in children or older adults because it is more gentile. Typically, the higher stimulating suppositories are used in teens and adults because the stimulation is needed, but that might not be your individual need.
Another option is to cut any of the suppositories in half, the long way of the suppository. Not in half like a loaf of bread. The long cut leaves the suppository at its manufactured length providing the stimulation to the bowel but with only half of the irritation time. Others might opt for one of the mini enemas (Enemeez or Theravax) that work just in the rectal vault but still must reach the bowel wall to work. They use a different trigger which results in less mucous production.
Even with a higher-level injury, you may be able to stimulate stool evacuation without a suppository after a long period of time from injury. The idea of a bowel program is to train the bowel to empty at a specific time. This is why bowel program timing is so extremely rigid. Eventually, it is hoped that a suppository will not be needed, but the stool will be ready for evacuation with digital stimulation. Speak with your healthcare professional to see if this is an option for you. Check to make sure you are ready for this process as you do not want a resulting impaction.
Next week, we will discuss how to talk about bowel movements and colostomy decisions. Nurse Linda
Pediatric Consideration: Children have many of the same bowel issues as described above. They typically begin with glycerin suppositories due to the gentle nature of the stimulant. Depending on the child's age and size, they may be cut in half or even in fourths, the long way, to ensure effectiveness.
Even infants with neurogenic bowel require a bowel program. The stool may be spontaneously expelled, but the bowel will not be empty. Not providing a bowel program leads to backed-up stool and impaction. This can have long-term consequences as the child grows, especially into adulthood.
Transition to independence in doing the bowel program is done anywhere between ages 3 and 5 years. The bowel program needs to be established and functioning prior to going to school to avoid accidents. Start by explaining what you are doing and then have the child join in with gathering supplies, then adding suppository insertion or manual removal and so forth. Plan a stepwise progression to independence. Praise your child for a job well done, perhaps not perfect, but you will get there.