What is going on when your bowel program is not working? — Reeve Connect
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What is going on when your bowel program is not working?

AskNurseLinda Moderator, Information Specialist Posts: 170 Information Specialist
100 Comments 25 Likes First Answer Name Dropper
edited February 2019 in Health & Wellness

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.

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!


  • iamdadman
    iamdadman Moderator Posts: 195 Moderator
    100 Likes 100 Comments Second Anniversary 25 Awesomes
    I don't know if this is right for everyone and of course you should consult with your doctor but in 2014, I started using a product by Coloplast called Peristeen.  I learned of it while attending an Abilities Expo in Los Angeles.  The guy who was at the booth was a paraplegic who had been injured for 29 years.  He told me that since he started using Peristeen, he had not had one accident.  I consulted with my doctor and got a prescription for it and started using it.  For me personally, it has been amazing.  My bowel program has gone from 2-3 hours every day while in bed to 35 minutes every other day on the commode.  I have not had one accident and I swear by this product.  It's basically an enema deliverd through a system of inserting a rectal catheter into your rectum, pumping up a balloon that is at the end of the rectal catheter and then pumping 800-1000cc of warm water into your bowels.  Once you have emptied the water you deflate the balloon and whoosh.  Again, talk with your doctor before trying this product but it has worked great for me.
  • Emms
    Emms Member Posts: 37 ✭✭
    10 Comments 5 Awesomes 5 Likes Name Dropper
    edited February 2019
    I second using the trans anal irrigation systems! I only posted a huge sprawl on my 22 year program changes a couple of weeks ago on my Instagram @Littlegumnut!
     I started using the peristeen system in the trials, just after having been referred for a m/ace procedure in 2005. I'm T12, and I had been using sups and dig stim for years. I was in the bathroom everyday for over two hours, and still having  accidents. This new system gave me a new life, and a 25-30 minute routine every other day! have since switched to the Qufora system and adapted it for longer term use and for my desire for everything to take up less room for backpacking...it uses cone instead of the rectal catheter. There is an option also of a catheter and an in bed 'clean' system which allows a caregiver to administer the flush and contain the output in a bag attached. Braun do an electronic system with a cone too, but there's quite a few on the prescribable market now. It really was a game changer! 

    “Inhale the future. Exhale the past.”

  • AskNurseLinda
    AskNurseLinda Moderator, Information Specialist Posts: 170 Information Specialist
    100 Comments 25 Likes First Answer Name Dropper
    Much like any bowel program, some people like the Peristeen and others not so much. It is quick. It is easy. 1000ccs of fluid flushes out the bowel but does not necessarily allow the bowel to evacuate in it's normal manner. It will be interesting to see how the system is working over time, 10+ years or more. I am all for anything that will cut the time to complete a bowel program.
    Healthcare professionals will stress the importance of natural function as much as possible. Flushing out the bowel can lead to complications when the bowel can no longer work without the flush process.
    Other alternatives include the enemeez mini enema which works mostly in the rectal vault, not in the lower bowel.
    What people want is a product that is quick and dependable. The Peristeen provides this. Stay tuned for follow up information as more people use the product. There is interest in new products coming down the line so we will soon have more information. 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!

  • kike
    kike Member Posts: 1
    First Comment
    Hello NurseLinda,

    My name is Carlos , I have been injured since 1992 level C6-C7, I am 46 years old and for a long time used dulcolx suppository for my bowel program, in the last three or four month I have been struggeling with the dulcolax suppository, not only they are not helping me to evacuate but also I am having some side effect issues after using them. Reading your first post maybe the position of the suppository had been impacting the effectiveness, but why now having side effects, dont now why?

    So my problem now is that I am having problem finding the better way to replace the suppositories and continue with my normal bowel program and my normal life. My doctor send me dulcolax drops, but these is acting as a laxative  an I cannot determine when is going to act and how many time in the day I will go to the bathroom and the rest of the day I feel stomache fatigue, these unpreadtuble results is giving me problem in my work. For that reason now the doctor is changing it for Moviprost (Lubiprostone) but I dont know if these medicine will have the same effect of the other I was using because i think they are made to work exactly the same. 

    I will like to know what recomendation you can give me in these matter , if Enemeez is a better alternative in my case, and if there is a difference between mini-enema and full enema So I can understand it.  I have been also reading about a equipment for massaging Mowoot , I dont know if these can help or not. And there is another alternative I have been reading about that is an Implantation of a sacral anterior root stimulator, because I suffer also from a neurogonic bladder.

    I Appreciate the help in this importante matter because is having a big impact in my quality life.

    Carlos Enrique Juliao


  • AskNurseLinda
    AskNurseLinda Moderator, Information Specialist Posts: 170 Information Specialist
    100 Comments 25 Likes First Answer Name Dropper
    Hello, Carlos, Thank your for your questions as these are the similar to a lot of readers. The bowel program can be a challenge for many.
    All medications, regardless of the delivery method can be effective for long periods of time and suddenly not work so well.  Our bodies are changing and ageing all of the time. This can make medication act differently. The bowel is a key system that changes frequently. Lack of movement in the abdomen, slowing from long term spinal cord injury and just getting older are three factors that can affect the bowel.  Changes in diet and fluid intake also affect bowel processing. 
    Sometimes, just a simple change in suppository can make a difference. The dulcolax suppository has a vegetable coating which first has to dissolve.This can cause the irritation and stomach upset for some people.  The magic bullet does not have the coating, so that just might do the trick to clear up your stomach upset. Another possibility is to try the less stimulating glycerin suppository.  It has a much gentler action but is often not strong enough for some people to have effective results. Individuals who have been on a well established bowel program often can eliminate the suppository all together and use digital stimulation to release the stool. If you try a glycerin or no suppository, be sure to check the amount of output to ensure you are having effective results. 
    The next higher step to bowel evacuation is the mini enema that you describe. These work just in the lower bowel for evacuation. Regular or full enemas work by flushing out the large intestine which does not allow the bowel to work by stimulation of the colon. Individuals that use full enemas tend to have more issues over time as with the flush of the bowel, it tends to slow or even stop working. We try to keep with suppositories or that process to make the bowel work. The mini enemas are used by many people. Full enemas are typically not recommended unless as a last resort or to remove an impaction that cannot be manually removed. I hope this gives you some thoughts about your next steps. 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!