What is going on when your bowel program is not working?
From Nurse Linda: Nothing is more annoying as when your bowel program is not working to your desires. Performing a bowel program can take time, accidents occur and you may need to adjust your schedule to accommodate special needs. Disruption to the established routine happens just because of everyday life. Not always will you know why your bowel program is not functioning well but there are some things you can do to help move it along.
Slow bowel programs can be very annoying especially when you have other things to do. Even in a regulated, well-functioning bowel program, time is needed to complete the process. Just getting supplies together and waiting for the bowel program to work, ensuring an empty rectum and cleanup is time consuming.
A good start is to have a space where your supplies are kept so they are handy and you are not hunting for some of your equipment. Keeping supplies in the bathroom next to the toilet is a good arrangement but be certain suppositories or other chemicals and gloves are out of the reach of children. Eating suppositories has happened and gloves are choking hazards. Children are curious as with all medications.
As mentioned last week, performing a bowel program in an upright, sitting position will help use gravity to ensure stool is evacuated out of the body. This cannot be emphasized enough. For some individuals, sitting cannot be tolerated so laying on your left side to take advantage of the natural position of the bowel is a start. Over history, mankind has used the upright position for evacuation of bowel so take advantage of the sitting position if you can. It will make a huge difference.
Sitting for long periods of time on a commode or toilet does tend to lead to pressure injury and hemorrhoids. One step to reducing this time is to insert the suppository and wait where you are before moving to the toilet. Typically, suppositories need to melt before they work so you have about 15 minutes before any action will start. You will need to see how long it is for you before your suppository will work. Some will be a little faster and some slower.
If the suppository is not working within 15 to 20 minutes review your suppository placement. Most people will slide the suppository in the rectum straight in. This could place the suppository in the middle of stool that is collected in the rectum. The suppository will not melt there. It will not stimulate the bowel to work.
The suppository only works when it is gently placed against the bowel wall. It needs to be far enough in to be above the inner sphincter of the rectum. That is a full finger’s length. Push the well lubricated suppository in and a little to the side so it is against the bowel wall. Your natural internal body heat will melt the suppository and as it melts, the action of the suppository will stimulate the movement of the bowel, at first just where it is placed but as it melts, the stimulant in the suppository will engage the bowel to start contractions to bring stool to the rectum and expulsion.
There are several types of suppositories. Most individuals will be presented with the bisacodyl suppository in the rehabilitation center. Typically, people will stick with this product but there are other suppositories as well. The Magic Bullet is another type of suppository. Both the bisacodyl and Magic Bullet brand suppositories have the same active ingredient. The bisacodyl suppository is coated in a vegetable based substance which is melted by body heat for dissolving. The Magic Bullet has a water soluble coating so body heat melting is a bit faster. It is personal preference for which of these suppositories is chosen. Some individuals find the bisacodyl fast enough, others think the Magic Bullet is the better. It is up to you to decide.
If your bowel program is not working well with the suppository, there is a product called the mini-enema that works only in the rectum to remove stool. Some individuals like the convenience and speed of the mini-enema. The mini enema is more expensive so you will have to check with your payor to see if it is covered. You can have your health professional write a letter of necessity, highlighting your lengthy bowel program, to ask for an exception for payment which may or may not be approved.
Full enemas should not be used as they do not mimic the natural action of the bowel. Instead, they wash out the bowel, not engaging the bowel movement function. If you do not make the bowel move, the function eventually becomes weaker leading to even more difficulty in completing the bowel program.
For those will lower motor neuron injury as a result of spinal cord injury a suppository will not be effective. You can begin with digital stimulation and manual removal. Individuals with lower motor neuron injuries are those with injury at the lumbar or sacral levels of the spinal cord.
Of course adjusting your bowel program by diet is an often overlooked treatment. Adding fiber and fluid helps stool travel through the long course of the bowel. Fluid should only be added in small amounts so as not to overwhelm your health or bladder program. Add just a few swallows throughout the day to increase your fluid intake. Taking in a large amount of fluid at one time can overwhelm your cardiac function and lead to urinary issues. One time flooding of water will not help your bowel program because it is the continual small amount of fluid added throughout the day that is helpful.
Fiber can be added in your diet. There are products that will aid with fiber which are called fiber laxatives. Laxatives is an unfortunate choice of words because laxatives will lead to diarrhea. However, these fiber supplements, when taken with adequate amounts of water will build bulk in your stool. This makes it easier for the bowel to move and digest your food as well as the extra fluid helps keep the bowel hydrated until the expulsion. Dry stool is hard to impossible for the bowel to push along.
The fiber supplements come in a choice of flavored or tasteless powder that is mixed with water or other liquids, cookies and bars. The important thing to remember is to read on the package how much fluid should be taken in with these products. Too little fluid can cause a bowel blockage. Most individuals make the error of not ingesting enough fluid with these products which leads to a dry stool or even an impaction or blockage of hard stool in the bowel.
Another overlooked enhancement to the bowel program is activity. Our bodies use movement to propel stool along in the bowel. When movement is reduced or eliminated due to paralysis, a big component of bowel function is affected. You can add movement to your daily routine when you do your skin pressure releases. These activities will engage your abdomen in passive movement which will assist in shifting the contents of your bowels around, assisting the propulsion of the bowel and eliminating the buildup of gas. Including passive range of motion exercised though out the day for keeping the body active and even for the reduction of spasticity will assist as well.
Remember that your rectum has two sphincters that help control the expulsion of stool. Both can be affected by spinal cord injury from trauma or disease. Sphincters are muscles. Muscles can be affected by spasticity. Too aggressive digital stimulation can trigger a spasm in your rectal sphincters, create damage to the fragile internal bowel tissue which can lead to hemorrhoids and other rectal issues. So, be gentile with digital stimulation. The results will be far more effective with gentile stimulation.
Slow bowel programs are the most often complaint but there are times when the bowels work too quickly resulting in diarrhea or incontinence after you thought the bowel program was complete. This is just as much an issue for maintaining the integrity of your bowel program as well as your skin integrity.
If you have cramping, discharge after the bowel program is complete or find the bisacodyl or Magic Bullet to be too harsh, you can try a glycerin suppository. For adults, the bisacodyl or Magic Bullet is satisfactory but for older adults or especially pediatric aged individuals, a more gentle glycerin suppository will be suitable. Suppositories can be cut in half, thirds or quarters depending on the size of the individual. To maintain the best action, cut them long ways. That allows more contact with the bowel wall.
Diet can be a major factor in bowel program success. Just as you can add fiber to your diet, you should be looking for foods that tend to give your loose stools or even diarrhea. Some individuals find they have to make a quick trip to the bathroom when they eat certain foods. This will be true after injury as well.
If you have trouble digesting a certain food or have loose stool after eating too much fruit, for example, be wary of eating these foods. You can incorporate them into your bowel program day but adjusting your bowel program by eating certain foods can be tricky as when you control your bowel program by mouth, your bowel program will be affected by unpredictability. When you ingest food, the time for digestion is never certain.
Laxatives were mentioned as a product not to be used to manage bowel programs. These products have the same unpredictable results after spinal cord injury as well as not mimicking the natural movement of the bowel. Use of laxatives generally lead to diarrhea.
Illness can lead to diarrhea for anyone. If you have the flu or cannot for some reason sit up for your bowel program when you normally would, you bowel program can be affected. If you do have diarrhea, you will not want to perform your bowel program that day but restart the next day so you do not become impacted. If you have diarrhea without illness, you could have an impaction of stool in your bowel which is allowing only leakage around the blockage.
A big factor in bowel control is our own mental health. Bowel accidents present more often in times of stress or anxiety. They always come at the least opportune moment. You can prepare yourself when you know a stressful situation is approaching by using relaxation techniques. Remember stress can be from tense situations but also happy events such as weddings and birthdays. Never overlook the power of your emotions when thinking about your bowel success.