The role of a healthy bowel is to store faeces and to empty at suitable times. Most people living with Spinal Cord Injury 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. It may be difficult to achieve normal continence. The nerves that control the bowel, as well as the anus, are located low in the spine. Some people will achieve complete bowel continence and others may need to try several techniques to achieve social continence.
The two main problems that occur with the bowel are:
- It doesn’t empty properly (constipation), or
- It allows faeces to leak either some or all the time (incontinence).
An individual bowel program and regular toileting routine is essential. The Spinal Cord Injury nurse and doctor can help make a suitable bowel program.
There are several factors that affect a successful bowel program:
- Consistent toileting time
- Position
- Medication
- Exercise and a standing program
- Regular stool consistency (diet and fluids).
It is important that bowels are well managed:
- To ensure good health including skin, kidney and bladder health.
- Prevent chronic constipation that can cause problems later in life.
- To maximise self-esteem and social development.
- To prevent bowel accidents, autonomic dysreflexia and other complications.
What goes in must come out
Stools (poo) that are too hard (constipation) or too soft (diarrhoea) can be very difficult to manage in Spinal Cord Injury. 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, however too much fibre can do the opposite.
Water plays a key role in bowel management. Water is needed to make healthy stools. Adults and children need sufficient water for good bowel health.
Sometimes a good diet is not enough. In that case supplements or medications will be required. Your doctor or nurse will guide you with an individual bowel program.
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. This will gently increase the frequency of bowel movements and soften the stool so it is easier to pass. They come as powder and can be added to various liquids (water, juice, milk etc) to drink.
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 is used to describe the stool consistency and to monitor progress after changes to the routines are made.
A regular routine for bowels
It is important to have a regular bowel emptying time to avoid any “accidents” and to stay clean. The normal sensation to warn that the bowels are about to open and it’s time to go to the toilet have possibly been damaged as a result of the Spinal Cord Injury.
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. This helps create a good hygiene habit (habit training).
Sometimes rectal stimulants (medications), using digital stimulation (a finger gently inserted 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 be placed on the toilet.
Position on the toilet matters
Your child needs to be comfortably placed on the toilet. Their feet need to be supported on something like a foot stool so their knees are higher than the hips. Their back should be straight and tummy pushed out. They should be encouraged to push down and use their tummy muscles in an attempt to pass a stool using the defecation reflex (see picture below). Blowing, coughing or laughing may help the process and the “Rock and Pop method” is also very effective. Avoid leaving them on the toilet for more than 10 minutes as they will get bored and disinterested.
Positioning to help with the bowel program should be started as soon as safe to do so. The upright position allows gravity to assist passing the stool out of the rectum. It also helps the person to learn to push out of the rectum.
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 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.
Occasionally some people require surgical intervention to enable them to have their bowels emptied. Surgeries are recommended only when non-surgical methods have not been successful. Your clinic doctor and nurse will discuss these procedures before making a decision.
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.
Be prepared
Become familiar with the things that affect bowel movement. It can take several weeks to establish a regular program however accidents may still occur so it is important to always be prepared for this by having spare clothing or underwear in a bag.
Once a toilet timing pattern has been established, it should remain constant.
Further information about Spinal Cord Injury is available at:
- The Children's Hospital Network has a series of fact sheets about Spinal Cord Injury.
- The Agency for Clinical Innovation have a series of fact sheets available under the Spinal Cord Injury tab.
Further information about bowel management is available at:
- “Solving Common Bowel Problems” is an easy to use guide. Download for free from
- ParaQuad NSW fact sheet Your Bowel
- The Bristol Stool chart and other helpful information is available on the Contience Foundation Australia 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.
Things to remember:
- Regular bowel emptying is important. Aim for the same time every day.
- Position on the toilet matters.
- Diet makes a difference. Some foods will give problems.
- Drinking water and regular exercise helps make healthy bowels
- Medication can be useful but avoid unnecessary changes to medication.
- Avoid constipation/impaction.
- A good bowel program in childhood will set up good routines for adulthood.
- The nurse or doctor can help develop a good bowel routine.
Written by The Children's Hospital at Westmead, Sydney Children's, Randwick, Kaleidoscope Hunter Children's Health Network and Northcott
