A healthy bowel stores faeces and then will empty at appropriate times. Most people living with Spina Bifida will have some loss of bowel control (neurogenic bowel). This means that the brain and the bowel are not working together as well as they should. The nerves that control the bowel, including the anus are located low in the spine. It may be difficult for your child to have normal continence. Some people will have complete bowel continence and others may need to try some different techniques to have social continence.
The two main problems that can happen with the bowel are:
- It doesn’t empty properly (constipation).
- It allows faeces to leak either some or all the time (incontinence).
An individual bowel program and regular toileting routine is important. There are several factors that affect a successful bowel program:
- Regular stool consistency (diet and fluids)
- Consistent toileting time
It is important that bowels are well managed. To help:
- Keep your child in good health including skin, kidney and bladder health
- Prevent chronic constipation which can cause problems later in life, and
- Encourage self-esteem and social development.
What goes in must come out
Stools (poo) that are too hard (constipation) or too soft (diarrhoea) can be very difficult to manage in Spina Bifida. Stool consistency can be managed through diet by adjusting the amount of fibre eaten. Fibre helps keep the bowel moving and creates soft, easy-to-pass stools.
Sometimes a good diet is not enough. In that case supplements or medications will be needed. Your doctor or nurse will guide you with an individual bowel program.
Water plays a key role in bowel management. Water is needed to make healthy stools. Adults and children need plenty of water for good bowel health.
Foods that may soften stools include:
- Whole grains, wild rice, cereal
- Leafy vegetables
- Fruit with skin, such as pears, apricots and berries.
Foods that may harden the stool include:
- White bread
- Cooked vegetables with low fibre such as potatoes, pumpkins and carrots
- Lean meats such as veal and chicken
- All types of milk.
Medications for bowels
Medications used to soften the stools are called laxatives. They restore the natural rhythm by using the body’s own water. These medications will gently make your child’s bowel movements more regular and will soften the stool so it is easier to pass. They come as powder and can be added to drinks (eg; water, juice, milk etc).
Alternatively bulking agents, lubricants or softeners can be used. We don’t recommend Senna based products (irritants or stimulants), as these will cause a reduction in bowel function in the long term.
The Bristol stool chart (see picture below) is used to describe the stool consistency and to monitor progress after changes to the routines are made.
Image from Continence Foundation of Australia
A regular routine for bowels
It is important to have a regular bowel emptying time to avoid any “accidents” and to stay clean. Normal sensation to warn that the bowels are about to open and it’s time to go to the toilet is damaged.
Toilet timing is when your child sits on the toilet at the times when they are most likely to pass a stool such as after a meal (habit training).
Sometimes rectal stimulants (medications), using digital stimulation (a finger gently in the back passage), suppositories or enemas (medications) need to be used to stimulate the anal sphincter and empty stool from the rectum.
The best time to use these methods is about 20 minutes after a meal e.g. breakfast or dinner when the gastro-colic reflex is working.
Enemas can safely be used daily to train the bowel to empty at a specific time. Approximately 10-15 minutes after insertion of the enema your child should sit on the toilet.
Position on the toilet matters
Your child needs to sit comfortably on the toilet. Their feet need to be supported on a stool so that their knees are higher than their hips. Their back should be straight and tummy pushed out. Ask them to push down and use their tummy muscles to try to pass a stool. Blowing, coughing or laughing may help. Try not to leave them on the toilet for more than 10 minutes as they will get bored and disinterested.
Image from National Continence Foundation
Positioning to help with the bowel program should be started as soon as it is safe for your child. The upright position allows gravity to help pass the stool out of the rectum. It also helps the person to learn to push out of the rectum.
The benefits of simple exercises such as turning in bed, lifting weight through the arms when in the wheelchair, taking deep breaths and standing can help to increase movement of stool through the bowel.
Other options for bowel management
For some people the bowels don’t empty completely. They might continue to have accidents after either a spontaneous movement or if they don’t respond well to the use of enemas. These people might benefit from a bowel washout with a “Large Volume Saline Enema” to have a more efficient motion and to stay clean the next day. Your clinic doctor and nurse will advise about this method.
Some people need surgical intervention to enable them to have their bowels emptied. Surgeries are recommended only when all other methods have not been successful.
Your clinic doctor and nurse will discuss these procedures before making a decision.
Learn about the things that affect bowel movement. It can take several weeks to have a regular program, however your child may have accidents, so it is important to always be prepared.
Once a toilet timing pattern has been established, it should remain constant.
Further information about Bowel Management and Spina Bifida is available at:
- The American Spina Bifida Association has a series of useful fact sheets and web based material. Download for free from: www.spinabifidaassociation.org
- Rock and Pop “Get Going” leaflet is available from the ERIC organisation’s website: www.eric.org.uk
- The Bristol Stool chart can be found on the Continence Foundation of Australia website: www.continence.org.au There is also other helpful information available on this website.
- The National continence helpline is 1800 33 00 66.
- The National public toilet map details accessible bathrooms and has information for how you can apply for a MLAK (Masters’ Locksmiths Association Key) which is a specially designed key to allow you 24 hour access to accessible public toilets. www.toiletmap.gov.au
- Regular bowel emptying is important. Aim for the same time every day.
- Position on the toilet matters.
- Diet makes a difference. Be honest about what you eat. Some foods will give you problems.
- Drinking water and regular exercise helps make healthy bowels.
- Medication can be useful.
- Avoid unnecessary changes to medication.
- Avoid constipation/impaction and avoid over distension of the bowels.
- A good bowel program in childhood will set up good routines for adulthood.
- The nurse or doctor can help develop a good bowel routine.