Neurogenic bowel vs constipation

AskNurseLindaAskNurseLinda Posts: 74Moderator, Information Specialist Information Specialist
25 Likes 10 Comments Name Dropper 5 Awesomes
edited February 11 in Medical Issues

Often, I hear people talking about the working condition of their bowel after spinal cord injury. People might discuss their bowel function as constipation as opposed to neurogenic bowel. In fact, these are two separate issues. If you think about the old saying, a poodle is a dog but not all dogs are poodles, the same can be said for the bowel. A constipation can appear in a neurogenic bowel, but all neurogenic bowels are not constipated. Let’s break it down a bit.

A spinal cord injury affects the nerves that cause the bowel to function. The bowel is controlled by a variety of nerves that function automatically. The bowel will function to propel material through it after any level of spinal cord injury because it is under the influence of the autonomic (automatic) nervous system although it might be slower than prior to injury or disease. The bowel even has nerves within it that function when material is in the bowel. Your body will propel material through the bowel on its own without your thinking about it. Just like your heart beating, the bowel works. You cannot speed it or slow it through thinking.

Food, broken down in the form of a thick sludge called chyme, will work its way along the entire length of the really long bowel. The purpose of the small intestine is to extract nutrients from food and water at the molecular level, pass them through the bowel into the blood stream to power and hydrate the body. The large intestines also extract nutrients and water but will also mold the chyme into the stool that is expelled from the body.

The farthest end of the bowel is controlled by specific nerves. Sacral nerves S2, S3 and S4 causes your internal rectal sphincter to relax and the rectum and anus to contract to evacuate your lower bowel. If the message from the brain is not interrupted from injury or disease, these sacral spinal cord segments can contract the external rectal sphincter to expel or hold stool.

Spinal nerves T11-L2 (Thoracic 11- Lumbar 2) will contract your internal sphincter and tighten your rectum and anus to hold in stool until you find the appropriate time and place to evacuate your bowel unless interrupted by spinal cord injury. This is a marvelous process when messages are able to be transmitted. We don’t really think too much about the process until it is disrupted.

Neurogenic bowel is a disruption of the nerves that transmit the messages from the bowel to the brain and back again. Because nerve function to the bowel is complex due to the length of this huge organ, the type of spinal cord bowel injury is classified in two ways. Upper motor neuron (UMN) bowel is diagnosed in individuals with an injury or disease at the cervical or thoracic levels. The injury can be anywhere long this part of the spinal cord. This type of bowel function is typically spastic. The bowel will empty spontaneously whenever any amount of stool is formed in the rectum. This can lead to embarrassment if not in a socially acceptable venue for toileting. Typically, the body will be spastic below the level of injury as well.

The other bowel classification is lower motor neuron (LMN) bowel. In this case, the injury is typically in the lumbar or sacral area. This bowel is flaccid or ‘areflexic’ meaning that stool will collect in the rectum without spontaneous evacuation (no reflex release). The bowel just gets more and more dilated as it fills with stool. If left without evacuation, the stool will expand stretching the bowel so that it is difficult to snap back to its regular shape over time. Some stool might be evacuated as overflow, but the bowel does not empty. The stool remains in the rectum with constant water removed so it becomes very dry and very hard. In a lower motor neuron bowel, stool is manually removed during the bowel program.

Either diagnosis of upper motor neuron bowel or lower motor neuron bowel is treated with a bowel program to safely and effectively remove stool, to avoid social embarrassment, skin break down and to keep stool from bowel backing up into the bowel leading to impaction or nausea and vomiting of stool.

There are some diseases that affect the bowels. Almost any disease that affects the nerves will affect the bowels. This includes multiple sclerosis, ALS, Parkinson’s Disease and others. Diabetes affects nerve function commonly known in the feet and hands. However, diabetes actually affects nerve function throughout the body. This can include the bowel. You might not feel the tingling sensation that is felt in the feet and hands as nerves are affected with diabetes, but there is a change in bowel content and function. When sugar or carbohydrate hits the bowel from foods eaten, you will notice immediate need to evacuate your bowel. Diabetes has a higher incidence in individuals with spinal cord injury, so SCI and diabetes is a double risk for bowel problems.

Constipation is a different problem. Constipation is not necessarily a problem that has its origins in spinal cord injury. In fact, anyone can become constipated with or without a spinal cord injury. Constipation is stool that is too dry. The cause can be from too slow of transit of chyme through the bowel or not enough hydration in the body or both. Slow transit through the bowel or lack of fluid will dry stool as the entire time the chyme is in the bowel, water is being extracted. Constipation can also be caused by a stricture or narrowing of the bowel, colon cancer or other structural problem in the bowel.

Sometimes, people have a temporary constipation. You could be out of your routine and not take in enough fluid one day, over drink alcohol which will dehydrate the body or exercise or work with an overproduction of sweat. People become dehydrated for a variety of reasons, even illness such as fever. The result is seen in your stool which becomes very dry.

It is important to keep up with your fluid intake to keep your bowels moving efficiently and effectively. If you are sweating, you may need to take in a bit more fluid such as on a hot day. Don’t forget humidity can dry your body as well even if the temperature is not high. In the winter, you can dehydrate from being in a room with dry heat.

In addition to fluid intake, the bowel is affected by movement and diet. Those with slower moving digestive systems might become constipated more frequently. Your bowel might function more slowly if you are not using your abdominal muscles in movement or have a diet that lacks roughage. Movement can include walking but also, just moving your extremities actively or passively. People who are sedentary through work, choice or, disability might have slower bowel movement. Roughage can help the bowel work by eating foods with increased fiber or use of fiber adding products.

Medication is a common culprit in constipation. Certain medications have constipation as a side effect. Medications known as constipation culprits are narcotics, calcium channel blockers used to treat high blood pressure, antiseizure medications and antispasmodic medications. You might develop constipation soon after starting these medications or constipation may develop after being on them for awhile so don’t overlook them in your constipation assessment. You can check with your healthcare professional about changing to another, less constipating medication or add fluid and fiber to your daily routine. Whichever you decide, it is critical that you do not stop these medications without consulting with your health care professional.

Chronic constipation can be found in anyone. Chronic constipation is defined as having less than three bowel movements per week. You will note that in a typical bowel program after spinal cord injury, a bowel movement occurs every other day so chronic constipation is avoided. Chronic constipation is also considered when the stool is dry or very hard. Straining is another factor. Sitting on the commode or toilet to lengthy periods of time can put a similar effect as straining on the anatomy of the lower bowel.

Because of a slower, neurogenic bowel, limitations with fluids, some medications and lack of mobility, individuals with spinal cord injury can become constipated. Because you have a neurogenic bowel, it does not mean that you will have constipation. A neurogenic bowel is a risk factor but not a criterion.

I'm online in this community every Wednesday from 8-9 PM ET to answer your SCI and paralysis related questions.

Leave a comment any time below. Let's get the discussion going!

Nurse Linda

Register for my next webchat! Sign up here!

Comments

  • Monica.TMonica.T Posts: 98Member ✭✭
    25 Likes 10 Comments 5 Awesomes Photogenic
    My son requires a feeding-tube (liquid diet) and still is regularly constipated. So far the medical suggestions have been Miralax and if he doesn't go after three days, an enema. The Miralax is often unpredictable and often results in accidents and leakage. We are still adjusting the daily dosage, a little less, a little more but still can't seem to find just the right balance for him to have regular (non-watery) bowel movements.
  • AskNurseLindaAskNurseLinda Posts: 74Moderator, Information Specialist Information Specialist
    25 Likes 10 Comments Name Dropper 5 Awesomes
    Hi, Monica, you might want to ask your healthcare provider if a mixture of diluted fiber can be flushed through the tube. It cannot be dripped in because it will clog the tube. Something like Metamucil or any other brand. You will have to follow with a bolus of water. This usually firms and bulks up the stool which makes it easier for the bowel to push along.
    Another question is to see if the formula for the feeding comes with a bulk additive already mixed in. (Then you don't need to add the metamucil.)
    Working from the other end, suppositories typically work better than oral laxative because of the problem you are having-unpredictability. Glycerin for under 12 years and dulcolax for over 12 years. Sometimes the suppository is even cut in half length wise if too harsh. The enemeez is an enema that works just in the lower bowel.
    It is almost impossible to regulate miralax because each day the body metabolizes just a little differently especially if your son is on a regular diet that you puree before putting it into the tube.
    These are just some questions that might help. I am sorry if I am suggesting things you have already tried. That can be quite frustrating. I don't know about your son's situation but these are some of the general things people do.  Be sure to ask your healthcare professional before trying any of these ideas because there could be a medical problem unique to your son of which I am unaware. Nurse Linda

    I'm online in this community every Wednesday from 8-9 PM ET to answer your SCI and paralysis related questions.

    Leave a comment any time below. Let's get the discussion going!

    Nurse Linda

    Register for my next webchat! Sign up here!

  • annie10annie10 Posts: 1Member
    First Comment
    My son is a C-7 quadriplegic.  He has been having chronic diarrhea for 2 years.  It is oily and foul-smelling.  He ended up having a colostomy about 1 1/2 months ago but the colostomy bags will not stick due to the oiliness of the stool. He is beginning to get skin breakdown.  He has tried diet modification and has had a colonoscopy and stool cultures.  I have done a lot of research and am wondering of he baclofen he is on (6 per day) could be causing this.  Any input would be very helpful.  Thank you.
  • samsilly1946samsilly1946 Posts: 1Member
    First Comment Photogenic
    Is it possible for a person to suffer from UMN that has a lower level injury?  I have all the symptoms/issues described with UMN. And suffer from chronic constipation as well.  I use fiber supplements daily and found that mirilax makes the stool like pudding consistency and this causes accidents every time I transfer..I can not seem to find a happy medium 😢😢
  • AskNurseLindaAskNurseLinda Posts: 74Moderator, Information Specialist Information Specialist
    25 Likes 10 Comments Name Dropper 5 Awesomes
    Samsilly1946, yes, many people have a lower level injury but have an UMN bowel and bladder.  The body is unique to every individual, so exact cut off levels often don't work out precisely. In addition, the spinal cord injury can be higher for just one functional nerve although the body might function below that particular nerve. The complication could just show up in that one function.
    People can have both an UMN and a LMN bowel and bladder. Oh, the combinations!
    It can take a long time to find the right combination of bowel products that work just right in your body and as soon as you do, your body changes requiring something else. Bowels are never an exact science. If you are taking fiber and miralax is too loose, you might not need the miralax but just a suppository with your fiber routine. Another option is to cut the miralax in half. Check with your healthcare professional before changing medications because there might be a reason unique to you for this particular regimen.
    However, you do not need to have bowel accidents, especially when transferring. That can really damage your skin. The good news is that if transferring changes the pressure in your abdomen, you can use that when attempting a bowel movement, Try a suppository and dig stim AND then do a push up on the toilet. That will create the same pressure in your abdomen that pushes out the stool when you don't want it to happen. Take advantage of the change in abdominal pressure when you do want stool to come out. Once the lower bowel is empty, you should not have further accidents. Work around with it. You might find a daily or every other day suppository bowel program with changing your abdominal pressure to work well with out the miralax. Typically, LMN bowels will not be affected by changing abdominal pressure but you have the evidence that yours does so use it to your advantage. Nurse Linda

    I'm online in this community every Wednesday from 8-9 PM ET to answer your SCI and paralysis related questions.

    Leave a comment any time below. Let's get the discussion going!

    Nurse Linda

    Register for my next webchat! Sign up here!

  • foodpro07foodpro07 Posts: 5Member
    Name Dropper First Comment
    @AskNurseLinda
    my son has been using Peristeen for 3 years successfully. He needs to now do a bowel routine in bed since he is getting flap surgery and will be on bed rest.  He is T6 complete para. 
    He became paralyzed by an illness (Transverse Myelitis) with lesions throughout his spinal cord lower than T6. We have been trying to use Magic Bullet and it doesn’t work. Even when he sits in the commode. I’m pretty sure I am inserting it correctly and cleaning out anything that is in the rectum before inserting. He usually retains feces in his rectum and does not have accidents. I have also been trying digital atom with the suppository but have had little success. Any advice?
    Thanks. 
  • AskNurseLindaAskNurseLinda Posts: 74Moderator, Information Specialist Information Specialist
    25 Likes 10 Comments Name Dropper 5 Awesomes
    Hello, @foodpro07, your can convert to a regular bowel program but it will take some time. The bowel wants to work naturally, even with spinal cord injuries as your son has. The suppository will work when placed against the bowel. It causes the cilia or fine fibers in the bowel to bring the stool down and out. You will probably have to do digital stimulation twice, first about 10 minutes after the insertion of the suppository and then 10 minutes later again. Be sure you well lubricate your gloved finger, and do a gentle swirl. Your goal is to relax the internal sphincter which is up higher in the bowel.
    You might need to add fiber such as Metamucil or any of the fiber products and perhaps a stool softener by mouth. Increase fiber in his diet. Try to add just a swallow or two of extra water over time. All of these things will help the stool form and pass.
    Laxatives will be unpredictable and messy which should not be near the newly repaired flap graft. You will need to be careful to keep that surgical area free of stool even when the wound heals to be sure nothing slips in to infect the area.
    It can take time to convert from water products which flush out stool to suppositories which cause the bowel to do the work. You are wise to start early.
    Since your son will not be able to sit, plan his turning schedule so he is on his left side for the bowel program. This anatomically will help.
    Do the bowel program daily until you get results. Then you can switch to every other day. Be on the look out for impaction of stool if there are no results for several days. Keep in contact with your son's healthcare provider to regulate any medication like the stool softener. Not every one will need that. The goal is for a soft bowel movement but too soft and the stool cannot push out.  Stool that is too hard can lead to impaction and hemorrhoids.
    Be sure to do the bowel program at the same time daily until results and still at the same time when you change to every other day. This is critical to success.
    Sometimes, it will seem like it will never work until it all of a sudden does. Patience is the key but fiber, fluid (water, avoid caffeine), suppository and digital stim will work. If there are no results in 2 or 3 days, call your son's healthcare professional as you do not want an impaction. This will work with time. Nurse Linda

    I'm online in this community every Wednesday from 8-9 PM ET to answer your SCI and paralysis related questions.

    Leave a comment any time below. Let's get the discussion going!

    Nurse Linda

    Register for my next webchat! Sign up here!

  • foodpro07foodpro07 Posts: 5Member
    Name Dropper First Comment
    @AskNurseLinda
    Thanks so much for your response. This is very helpful. 
  • AskNurseLindaAskNurseLinda Posts: 74Moderator, Information Specialist Information Specialist
    25 Likes 10 Comments Name Dropper 5 Awesomes
    Please feel free to write back should you have additional questions.  Sometimes, things come up in the middle of it all. Nurse Linda

    I'm online in this community every Wednesday from 8-9 PM ET to answer your SCI and paralysis related questions.

    Leave a comment any time below. Let's get the discussion going!

    Nurse Linda

    Register for my next webchat! Sign up here!

Sign In or Register to comment.