9. Periodic Re-evaluation of Bowel Management Program

A step-wise approach to bowel management is recommended in primary care. Referral to SCI specialist may be needed periodically.

The Problem

The goals of bowel management for patients with spinal cord injury (SCI) are: continence, regularity, and reasonable evacuation time. The effectiveness of bowel management may be assessed in primary care in terms of: constipation, continence, and prolonged evacuation time, despite adherence to a consistent bowel care routine.

A bowel management program is highly individualized, depending on the details of bowel functioning and hand functioning. It is usually designed during rehabilitation, but may need to be modified periodically as bowel function changes with age and duration post-injury, or as personal circumstances change.

If problems with bowel management persist, overall re-design of the bowel program may be required. New methods of bowel management have been shown to be effective for some patients, such as trans-anal irrigation, electrical and magnetic stimulation and biofeedback

Evidence-based Best Practice

A step-wise approach to SCI bowel management in primary care includes the following:

  • First line treatment involves conservative management, such as diet and fluid management (see Nugget # 10), regular scheduling, manual techniques, suppositories, irrigation, and abdominal massage.
  • When conservative techniques are inadequately effective, pharmacological measures may be considered as second level treatments. These include: over-the-counter medications (laxatives and stool-softeners) and prescription medications (prokinetic agents such as metoclopramide).
  • Finally surgical intervention may be indicated, such as colostomy, anterograde catheterization, implanted electrical sacral nerve stimulation.

Key Reference

Qi, Z., Middleton, J. W., & Malcolm, A. (2018). Bowel Dysfunction in Spinal Cord Injury. Current gastroenterology reports, 20(10), 47.

Actionable Nuggets (4th ed., 2019)

Additional References (since 2016)

Stoffel, J. T., Van der Aa, F., Wittmann, D., Yande, S., & Elliott, S. (2018). Neurogenic bowel management for the adult spinal cord injury patient. World Journal of Urology, 36(10), 1587-1592. doi:10.1007/s00345-018-2388-2

Wheeler, T. L., de Groat, W., Eisner, K., Emmanuel, A., French, J., Grill, W., . . . Bowel and Bladder Workshop Participants. (2018). Translating promising strategies for bowel and bladder management in spinal cord injury. Experimental Neurology, 306, 169-176. doi:10.1016/j.expneurol.2018.05.006