Refer SCI patients with persistent constipation to a specialist with experience with spinal cord injury or neurogenic bowel.
An estimated 39-58% of patients with spinal cord injury (SCI) suffer from severe constipation. Unlike in the general elderly population, increased dietary fibre and fluids does not uniformly improve constipation in individuals with a neurogenic bowel. Studies have shown that dietary fibre does not have the same effect on bowel function in individuals with SCI as in those whose bowels function normally. It may in fact exacerbate bowel problems by increasing overall transit time and the probability of both bowel and bladder incontinence.
Evidence-based Best Practice
Bowel management in SCI is aimed at maximizing independence, maintaining social continence, and increasing efficiency and satisfactory results (see Nugget #8). Studies have shown that dietary fibre does not have the same effect on bowel function in individuals with SCI as in those whose bowels function normally. A recommendation of 15-18 gms. of fibre per day is a general rule. Fluid intake must also be monitored to take into account the manner and frequency of bladder emptying, since neurogenic bowel and bladder often occur coincidentally. A diary of intake (diet and fluid) and output (urine and stool) may provide useful information for monitoring in primary care.
For those with an Upper Motor Neuron lesion (UMN; above T12), diet and fluid management is usually aimed at producing softer stools, whereas for those with a Lower Motor Neuron lesion (LMN; T12 or lower), slightly firmer stool is preferred to avoid incontinence. The Bristol Stool Scale describes seven types of stool:
- Type 1: Separate hard lumps, like nuts (hard to pass)
- Type 2: Sausage-shaped, but lumpy
- Type 3: Like a sausage but with cracks on its surface
- Type 4: Like a sausage or snake, smooth and soft
- Type 5: Soft blobs with clear cut edges (passed easily)
- Type 6: Fluffy pieces with ragged edges, a mushy stool
- Type 7: Watery, no solid pieces. Entirely liquid
McClurg, D., & Norton, C. (2016). What is the best way to manage neurogenic bowel dysfunction? BMJ, 354, i3931-i3931. doi:10.1136/bmj.i3931
Actionable Nuggets (4th ed., 2019)
Additional References (since 2016)
Brundrett, D. (2016). Food Choice as a Management Strategy in Bowel Dysfunction. In Bowel Dysfunction (pp. 161-172). Springer, Cham.