10. Diet and Fluid Management in Neurogenic Bowel

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

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

The Problem:

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.

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 Cord34(5): 277-83.
    Christensen, P., et al. (2006). A Randomized, Controlled Trial of Transanal Irrigation Versus Conservative Bowel Management in Spinal Cord-Injured Patients. Gastroenterology131(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 Medicine21(3): 248-93.
    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 Cord48(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 Cord47(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 Medicine21(3): 248-93.
    De Looze, D., et al. (1998). Constipation and other gastrointestinal problems in spinal cord injury patients. Spinal Cord36(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 Medicine36(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 Cord48(2): 154-159.
    Menardo, G., et al. (1987). Large-bowel transit in paraplegic patients. Diseases of the Colon & Rectum30(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 & Rectum48(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 Cord47(4): 318-22.