A Stimulating Topic...The Ins and Outs of Bowel Care

By Patty Kunze, RN, BSN and Roberta Palmer, RN

There has been a huge amount of discussion about bowels on a spinal cord injury Facebook group lately, so we thought we would confront the subject. There was no easy way to make this topic “stimulating.” Hahahaha!! A bit of nursing humor.

First off, allow us to discuss the anatomy, as it may make the discussion easier to understand. The small intestine is the section of your digestive tract where the majority of food digestion and nutrient absorption takes place. The main function of the large intestine is to absorb water and remove solid waste from the body. The key role of the rectum is to act as a storehouse for feces. The anus is the opening where the gastrointestinal tract ends and exits the body.  The organ takes approximately 16 hours to complete the digestion of food.

We decided to tackle the methods of bowel programs for those of us needing this procedure. We know everyone’s body is unique, so the bowel program that works for one person may not always work for another. However, a good diet including fiber with plenty of water consumption is extremely important.

But why is “fiber” so important? A high-fiber diet has many benefits, which include:

·          Normalizes bowel movements. Dietary fiber increases the weight and size of your stool and softens it. A bulky stool is easier to pass, decreasing your chance of constipation. If you have loose, watery stools, fiber may help to solidify the stool because it absorbs water and adds bulk to stool.

·          Helps maintain bowel health. A high-fiber diet may lower your risk of developing hemorrhoids and small pouches in your colon (diverticular disease).

·          Lowers cholesterol levels. Soluble fiber found in beans, oats, flaxseed and oat bran may help lower total blood cholesterol levels by lowering low-density lipoprotein, or "bad," cholesterol levels. Studies also have shown that high-fiber foods may have other heart-health benefits, such as reducing blood pressure and inflammation.

·          Helps control blood sugar levels. In people with diabetes, fiber — particularly soluble fiber — can slow the absorption of sugar and help improve blood sugar levels. A healthy diet that includes insoluble fiber may also reduce the risk of developing type 2 diabetes.

·          Aids in achieving healthy weight. High-fiber foods tend to be more filling than low-fiber foods, so you're likely to eat less and stay satisfied longer. And high-fiber foods tend to take longer to eat and to be less "energy dense," which means they have fewer calories for the same volume of food.

Drinking water while sitting in a wheelchair is multifunctional – it aids the urinary system, assists the gastrointestinal system, and waters the entire body. But why should we drink lots of water to prevent constipation? The intestines are greedy little fellows, they will take the water one way or the other. The food you eat makes its way from your stomach to the large intestine, or colon. If you don't have enough water in your body already, the large intestine soaks up water from your food waste.

The other piece of the puzzle is to figure out timing that works best for you. Daily, every other day, etc. and time of day depending on your body and your schedule. It's easier for the body to do a bowel program sitting on the toilet or shower chair to let gravity help out but if laying in the bed, lay on the left side as this works best with our anatomy. From there, talk with your doctor to discuss what supplements, suppositories, enemas, etc. might make your routine more consistent, faster, and oops free.

Enemas: Another method of stool removal frequently discussed is the use of enemas. An enema administration is most commonly used to clean the lower bowel. However, this is normally the last resort for constipation treatment. If diet and exercise are not enough to keep you regular, your doctor might recommend a laxative before trying an enema. Enemas are not without risks, especially to spinal cord injured. Forcing an enema into the rectum can cause irritation and damage to surrounding tissue. Never force the tube into the rectum. If problems persist, try administration at a later time or call your doctor. Take into consideration when your routine is different such as when traveling, diet changes, illness etc. as this can certainly make a difference and may require a slight and temporary change in your routine.

Stool softeners: They soften stools, making them easier to pass. Stool softeners come as a capsule, tablet, liquid, and syrup to take by mouth. A stool softener usually is taken at bedtime or 12 hours prior to bowel program. Follow the directions on the package or your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take stool softeners exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.

Magic Bullet suppository: There is also a lot of discussion on the use of the magic bullet suppository. Magic Bullet is a product is used to treat constipation. Bisacodyl is a stimulant laxative that works by increasing the amount of fluid/salts in the intestines. This effect usually results in a bowel movement within 15 to 60 minutes. Side effects of the Magic Bullet is rectal irritation/burning/itching, mild abdominal discomfort/cramps, or nausea may occur. If any of these effects persist or worsen, contact your doctor or pharmacist promptly.

Digital Stimulation: Digital stimulation is a way to empty the reflex bowel after a spinal cord injury. It involves moving the finger around in a circular motion inside the rectum. By doing this, the bowel reflex is stimulated and the rectal muscles open and allow the stool to leave the body. Pressure may be felt in the rectal area, but it should not be painful. The stimulation should be done at the same time every day or every other day to stay on a schedule and avoid bowel accidents. The time and how often this procedure is done depends on the individual.  To avoid Autonomic Dysreflexia (AD) during procedure, do not rush the stimulation. 

Avoid Imodium: This medication is used to treat sudden diarrhea. It works by slowing down the movement of the gut. This decreases the number of bowel movements and makes the stool less watery. Here’s our take on Imodium, if you MUST take Imodium, do so carefully. The last thing you want is to cause constipation. If diarrhea occurs from a simple intestinal bug, try resting the gut first, prior to downing an Imodium. Avoid fried, spicy foods and review your past 24-hour diet. You may find out the diarrhea was started by your previous food choices.  Try BRAT diet, Bananas, Rice, Applesauce, and Toast diet to see if diarrhea slows down or subsides prior to taking Imodium. Newly spinal cord injured individuals should avoid Imodium until a bowel pattern has been established. 

Pain medications: Why does pain medications (opioids) cause constipation? Interesting findings from WebMD – “Unlike other side effects from these drugs, like feeling sleepy or nauseated, constipation doesn’t go away after a few days on the medication. Scientists think this is because your gut doesn’t get used to opioids the way the rest of your body does. The longer you take the drug, the bigger the chance it will block you up.” So be careful with pain meds and causing of constipation.

Bottom line.....finding a bowel program that works best for you or your loved one takes time.  Just because one program works for someone else doesn’t mean it would work for you.  Take your time, experiment, and see what fits into your schedule.  Changing or adjusting bowel care days is similar to training a puppy, close attention to details or cues and take your time. As many know, our body finds ways to tell us something is about to happen. So, pay attention and take action. There's a lot that goes into finding what works best for you but over time with some experimenting hopefully you'll find what works best for you and your body and then tweak it as you go.

Little accidents will occur.  Sh*t happens.

Hopefully finding the best bowel program method will alleviate those “Code Browns” in life.

It’s all good and roll on,

Patty, RN and Roberta, RN

References:

Absorption of water and electrolytes. http://www.vivo.colostate.edu/hbooks/pathphys/digestion/smallgut/absorb_water.html.

Digital Stimulation. http://www.myshepherdconnection.org/sci/bowel-care/digital-stimulation.

How do opioid pain medications cause constipation? https://www.webmd.com/pain-management/qa/how-do-opioid-pain-medications-cause-constipation.

How drinking fluids can help you manage constipation. https://www.webmd.com/digestive-disorders/water-a-fluid-way-to-manage-constipation.

Magic Bullet Suppositories, Rectal. https://www.webmd.com/drugs/2/drug-974/the-magic-bullet-rectal/details.

Nutrition and healthy eating. https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/fiber/art-20043983.

Stool softeners. https://medlineplus.gov/druginfo/meds/a601113.html.

What is the main function of the large intestines? https://www.reference.com/science/main-function-large-intestine-279203d8d4bcdf11.

What is the small intestine. https://study.com/academy/lesson/small-intestine-anatomy-and-functions.html

 About the Authors:

Patty Kunze has been a Registered Nurse since 1983.  She holds a Bachelor’s of Science Degree in Nursing and worked several years in a Spinal Cord Injury Unit at the local Veterans Administration Medical Center as a new graduate.  She has been a flight transport nurse for Neonatal Intensive Care, an assistant manager of Labor and Delivery, and an instructor of nursing students. In 2009, she was involved in an auto accident which left her paralyzed (T3-4 complete paraplegic) from chest down.  But she continues her nursing career while sitting in her wheelchair as a nurse paralegal and writing articles for others with spinal cord injuries as The Rollin RN ™.

Roberta Palmer has been a Registered Nurse for 20 years.  She has knowledge in Family Practice, Allery and Immunology, Special Pharmacy Medication and Counseling, and she is a RN Health Coach. In 2014, she was involved in an ATV accident which also left her paralyzed (T3-4 complete paraplegic) from chest down.