Paraplegia is paralysis affecting the lower half of the body, typically resulting from a spinal cord injury (SCI) in the thoracic or lumbar region. This damage disrupts communication between the brain and the body below the injury site, impacting automatic functions like elimination. Bowel and bladder dysfunction is a significant health concern following SCI. While external collection devices are sometimes considered, a colostomy is not the standard or default method of bowel management for most individuals with paraplegia.
The Core Issue: Neurological Bowel Dysfunction
The bowel problems experienced after a spinal cord injury are collectively known as Neurogenic Bowel Dysfunction (NBD). NBD arises because the injury interferes with the autonomic nervous system signals that govern the digestive tract’s motility and the muscles responsible for holding and releasing stool. The loss of voluntary control and the disruption of coordinated muscle contractions are the central mechanical issues that must be addressed. The specific type of dysfunction depends largely on the level of the spinal cord injury.
Reflexive (UMN) Bowel
Injuries that occur above the conus medullaris (typically above T12-L1) result in a reflexive or upper motor neuron (UMN) bowel. In this situation, the reflex arc within the sacral spinal cord remains intact. This means the anal sphincter is tight or spastic, and the bowel retains the ability to empty reflexively, though without conscious control. This reflexive emptying can lead to unexpected accidents.
Areflexic (LMN) Bowel
Conversely, injuries that affect the conus medullaris or cauda equina (at or below T12-L1) cause an areflexic or lower motor neuron (LMN) bowel. This damage directly affects the nerves supplying the bowel and sphincters, resulting in a flaccid, low-tone anal sphincter and a lack of reflex activity. Stool tends to accumulate in the rectum, increasing the risk of constant, passive leakage or incontinence. Both forms of NBD can lead to severe constipation, fecal impaction, and unplanned bowel movements.
Standard Management: The Bowel Program Approach
The primary treatment for NBD in paraplegia is a comprehensive, scheduled Bowel Program designed to achieve predictable and timely evacuation, thereby ensuring social continence. This structured routine is highly individualized and relies on a combination of specific techniques rather than continuous external collection. The goal is to empty the bowel completely at a set time, typically every one to three days, to prevent accidents between sessions.
Foundational Elements
Dietary and fluid management are foundational elements of a successful program. Consuming a high-fiber diet, which includes plenty of fruits, vegetables, and whole grains, helps create a soft, formed, and bulky stool, ideally correlating to a Type 3 or 4 on the Bristol Stool Chart. Adequate fluid intake, generally eight to ten glasses of non-caffeinated fluid daily, is also necessary to keep the stool soft and moving through the colon. Medications are often used to modulate stool consistency and stimulate motility.
Oral agents, such as stool softeners, bulk-forming agents, or gentle stimulant laxatives, are taken at specific times to prepare the bowel for evacuation. The timed nature of the program often seeks to utilize the gastrocolic reflex, the natural wave of colonic movement that occurs about 20 to 30 minutes after a meal. Rectal stimulants, such as suppositories containing bisacodyl or glycerine, or small-volume enemas, are then used to trigger the reflexic action needed for emptying.
Evacuation Techniques
Specific techniques are employed based on the type of NBD. For individuals with a reflexive (UMN) bowel, digital rectal stimulation is a common technique used to initiate the defecation reflex. This involves gently inserting a lubricated, gloved finger into the rectum and rotating it against the rectal wall for a short period. This encourages the sphincter to relax and the colon to contract.
For those with an areflexic (LMN) bowel, who do not respond to stimulation, the technique of manual evacuation may be required. This involves physically removing stool from the rectum.
A more advanced technique is Transanal Irrigation (TAI), which involves flushing the colon with water via a catheter inserted into the rectum. This method cleans out the lower bowel and can establish a period of continence for up to 48 hours, often providing greater independence and improved quality of life compared to other manual methods. The success of a bowel program is measured by its ability to provide a full evacuation within a reasonable time frame, usually under 60 minutes, without unplanned leakage.
Colostomy Use in Paraplegia: Indications and Decision-Making
A colostomy is a surgical procedure that creates an opening in the abdomen to divert the colon and collect stool in an external pouch. It is generally reserved as a management option of last resort for people with paraplegia because standard Bowel Program methods are highly effective for the majority of patients. Surgical intervention is typically considered when conservative management has failed to provide acceptable continence and quality of life over a sustained period.
Specific indications for a colostomy include:
- Chronic, intractable constipation or fecal impaction leading to frequent hospitalizations or bowel obstruction.
- Recurrent Autonomic Dysreflexia (AD), a dangerous spike in blood pressure common in injuries above T6, which is triggered by rectal distension. A colostomy eliminates this trigger by keeping the rectum empty.
- Chronic, severe skin breakdown or pressure ulcers that cannot heal due to persistent fecal incontinence.
- Situations where the daily, time-consuming nature of the traditional bowel program is unsustainable or lacks necessary caregiver support.
The decision to proceed with a colostomy is complex, weighed against potential complications and the significant improvement in predictability and quality of life it can offer when other methods prove inadequate.