A spinal cord injury (SCI) can alter various bodily functions, with constipation being a challenging complication. This condition impacts daily life, often leading to discomfort and affecting overall well-being. Effective management of constipation after SCI is important, focusing on strategies that restore a predictable bowel routine. Addressing this issue involves understanding its causes and implementing tailored interventions to improve quality of life.
Understanding Constipation After Spinal Cord Injury
Constipation after a spinal cord injury stems from various neurological, physical, and secondary factors. Nerve damage directly disrupts communication between the brain and bowel. This impairs peristalsis, the muscle contractions that move stool through the colon, leading to slower transit and harder stools. Depending on the injury level, individuals may have a hyper-reflexic bowel with a tightly closed anal sphincter, or an a-reflexic bowel with a loose sphincter and poor muscle tone. Both contribute to evacuation difficulty.
Physical limitations also contribute to bowel dysfunction. Reduced mobility makes it difficult to assume an optimal toileting position, which aids bowel movements. The inability to voluntarily contract abdominal muscles hinders stool expulsion, requiring other methods.
Secondary factors also contribute. Medications for SCI symptoms, such as pain relievers or muscle relaxants, can slow intestinal motility. Changes in diet, often due to appetite or convenience, and insufficient fluid intake, can lead to less fiber and hydration, resulting in harder stools.
Developing a Comprehensive Bowel Management Program
A structured bowel management program is key to addressing constipation after a spinal cord injury, aiming for predictable elimination. Dietary adjustments are a foundational component, emphasizing high-fiber foods. Aim for 20 to 25 grams of fiber daily, introduced gradually, to add bulk and promote softer stool. Adequate fluid intake, typically 2 to 3 quarts (8 to 10 glasses) of water daily, is equally important to prevent hard stool.
Pharmacological interventions often include oral and rectal medications.
Oral Medications
Stool softeners, like docusate sodium, increase stool water content for easier passage.
Bulk-forming agents, such as psyllium, absorb water to create larger, softer stools.
Osmotic laxatives, like polyethylene glycol, draw water into the bowel.
Stimulant laxatives, such as bisacodyl or senna, directly stimulate bowel contractions. Use requires careful consideration due to potential for unplanned movements.
Rectal Medications
Bisacodyl suppositories, especially polyethylene glycol-based, irritate the rectal lining to induce contractions, typically acting in 15 to 60 minutes.
Mini-enemas deliver liquid to soften stool and stimulate the rectum, often producing an effect within 15 to 20 minutes.
Transanal irrigation, administering warm water into the colon via a rectal catheter, effectively clears the lower bowel and improves symptoms.
Manual techniques and consistent scheduling are also crucial elements. Digital stimulation involves gently inserting a lubricated, gloved finger into the rectum and rotating it for 10 to 20 seconds, repeated every 5 to 10 minutes, to stimulate a reflex bowel movement. Manual evacuation, physically removing stool, is used when necessary. Establishing a regular bowel routine, such as performing the program at the same time daily or every other day, often after a meal to utilize the gastrocolic reflex, helps train the bowel for consistent emptying.
Proper positioning during bowel care significantly aids the process, as gravity assists stool evacuation. Sitting upright on a commode or toilet is most effective. If in bed, lying on the left side can facilitate emptying due to the large intestine’s orientation. Even limited physical activity, like transfers or range-of-motion exercises, can stimulate bowel function.
Advanced Interventions for Refractory Constipation
For individuals whose constipation does not adequately respond to conventional bowel management, advanced interventions may be considered.
One surgical option is the Antegrade Continence Enema (ACE) procedure. This involves creating a small surgical opening, or stoma, usually in the abdomen, that connects to the large intestine. A catheter is inserted through this stoma to administer a fluid flush directly into the colon, allowing for controlled bowel emptying from above, bypassing the rectum. This procedure can significantly reduce bowel care time and improve continence for those with severe constipation or fecal incontinence.
Sacral neuromodulation is another potential treatment for neurogenic bowel dysfunction. This therapy involves implanting a device that sends mild electrical impulses to the sacral nerves, which control bowel function. While more commonly used for fecal incontinence, it has shown promise in some individuals with SCI by increasing bowel movement frequency and reducing bowel care time.
In severe cases, surgical options like colostomy or ileostomy may be considered as a last resort. A colostomy diverts a portion of the colon to an opening in the abdominal wall, where stool collects in an external bag. An ileostomy performs a similar function but uses the small intestine. While these procedures represent a significant lifestyle change, they can provide an effective and predictable method for managing bowel function, improving quality of life for individuals who have exhausted other treatments.