10. Diet and Fluid Management in Neurogenic Bowel

Actionable Nuggets for SCI (2nd ed., 2013)

The Problem:Man using power chair

An estimated 39-58% of patients with spinal cord injury (SCI) suffer from constipation. Unlike in the general elderly population, increased dietary fibre and fluids does not uniformly improve constipation in individuals with a neurogenic bowel. It may in fact exacerbate bowel problems by increasing overall transit time and the probability of both bowel and bladder incontinence.

Actionable Nugget

Refer spinal cord injured patients with persistent constipation to a specialist with experience with spinal cord injury or neurogenic bowel.

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

Types 3 and 4 are ideal, as they are easy to defecate without containing any excess liquid.

Key reference:

    Spinal Cord Injury Centres of the United Kingdom and Ireland (2009). Guidelines for management of neurogenic bowel dysfunction in the community after spinal cord injury. United Kingdom: Coloplast.

Additional References:

    Cameron, K.J., et al. (1996). Assessment of the effect of increased dietary fibre intake on bowel function in patients with spinal cord injury. Spinal Cord, 34(5): 277-83.
    Christensen, P., et al. (2006). A Randomized, Controlled Trial of Transanal Irrigation Versus Conservative Bowel Management in Spinal Cord-Injured Patients. Gastroenterology, 131(3): 738-747. http://dx.doi.org/10.1053/j.gastro.2006.06.004
    Clinical practice guidelines: Neurogenic bowel management in adults with spinal cord injury (1998). Spinal Cord Medicine Consortium. Journal of Spinal Cord Medicine, 21(3): 248-93.
http://www.pva.org/site/News2?page=NewsArticle&id=7651
    Coggrave, M. J., & Norton, C. (2010). The need for manual evacuation and oral laxatives in the management of neurogenic bowel dysfunction after spinal cord injury: A randomized controlled trial of a stepwise protocol. Spinal Cord, 48(46): 504-510.
    Coggrave, M., Norton, C., & Wilson-Barnett, J. (2009). Management of neurogenic bowel dysfunction in the community after spinal cord injury: A postal survey in the United Kingdom. Spinal Cord, 47(4): 323-30; quiz 331-3.
    Consortium for Spinal Cord Medicine (1998). Clinical practice guidelines: Neurogenic bowel management in adults with spinal cord injury. Journal of Spinal Cord Medicine, 21(3): 248-93.
    De Looze, D., et al. (1998). Constipation and other gastrointestinal problems in spinal cord injury patients. Spinal Cord, 36(1): 63-6.
    Krassioukov, A., Eng, J. J., Claxton, G., Sakakibara, B. M., & Shum, S. (2010). Neurogenic bowel management after spinal cord injury: A systematic review of the evidence. Spinal Cord (of Publication: October 2010), 48(10): 718-733.
    Krogh, K., & Christensen, P. (2009). Neurogenic colorectal and pelvic floor dysfunction. Best Practice and Research. Clinical Gastroenterology (of Publication: August 2009), 23(24): 531-543.
    Lim, Y.H., Kim, D.H., Lee, M.Y., & Joo, M.C. (2012). Bowel dysfunction and colon transit time in brain-injured patients. Annals of Rehabilitation Medicine, 36(3): 371-8.
    Lombardi, G., Del Popolo, G., Cecconi, F., Surrenti, E., & Macchiarella, A. (2010). Clinical outcome of sacral neuromodulation in incomplete spinal cord-injured patients suffering from neurogenic bowel dysfunctions. Spinal Cord, 48(2): 154-159.
    Menardo, G., et al. (1987). Large-bowel transit in paraplegic patients. Diseases of the Colon & Rectum, 30(12): 924-8.
    Ng, C., et al. (2005). Gastrointestinal symptoms in spinal cord injury: relationships with level of injury and psychologic factors. Diseases of the Colon & Rectum, 48(8): 1562-8.
    Walters, J.L., Buchholz, A.C., Martin Ginis, K.A., & SHAPE Research Group (2009). Evidence of dietary inadequacy in adults with chronic spinal cord injury. Spinal Cord, 47(4): 318-22.