1. Neurogenic Bowel Management
Arlene Wilde – Specialist Nurse
Spinal Injuries

2. Aims of Bowel Management
Reflex or Flaccid?
Transanal Irrigation
Who?
When?
Where?

3. Aims of Bowel Management
Regular and predictable emptying at a socially acceptable time and place, avoiding constipation unplanned evacuations and autonomic dysreflexia.

4. Aims of Bowel Management
Completed in under one hour
minimum necessary physical or pharmacological interventions
Individual to the person
Comfort, safety, privacy, dignity

5. Neurogenic Bowel Function
Reflex or flaccid?
Reflex – T12 or above
Flaccid – L1 or below

6. UMN Bowel Lesions at T12 and above
Reflex defecation centre remains intact
Spastic paralysis of the bowel with inability to control defecation
Uninhibited reflex activity
Individual unable to feel the urge to defecate
Cannot control external anal sphincter activity
Rectal contractions to expel the stool are blocked by external sphincter contracting at the same time

7. Management of the UMN bowel
Warm drink and something to eat mins before you start
Perform digital rectal examination
Insert suppositories, micro-enema or rectal solution
Wait for mins
Use abdominal massage
Reflex bowel action will usually have taken place
Perform digital stimulation
Await further reflex emptying
Repeat digital stimulation every 10 mins until reflex emptying stops
A manual evacuation will only be necessary if faeces will not reflex empty

8. Reflex Bowel Management
Alternate days, regular times
Bristol Scale 4
Stimulant laxatives 8 hours before
Hot food or drink 20 – 30 minutes before

9. Reflex Bowel Management
Suppositories/enema
Digital rectal stimulation
Digital removal of faeces if required
Digital rectal check to see if evacuation is complete

10. Example of digital rectal stimulation

11. LMN Bowel Lesions below T12 Reflex defecation centre is damaged
Flaccid paralysis
Loss of anal tone
Lack of tonic external sphincter contraction
Ineffective peristaltic movements
Individual doesn’t feel the urge to defecate
No control over external anal sphincter

12. Flaccid Bowel Management
Daily or twice daily at regular times
Bristol Scale 2 to 3
Laxative 8 to 12 hours before

13. Flaccid Bowel Management
Hot food or drink 20 to 30 minutes before
Digital removal of faeces
Digital check to see if evacuation is complete

14. Stimulants used on the G. I. tract
Osmotic
e.g Movicol
Stimulants
e.g Senna
Softeners
e.g. Dioctyl
Bulk forming agents
e.g. Fibogel
Suppositories
e.g. Bisocodyl, Glycerine
Micro-enemas
e.g. Microlax

15. Complications Autonomic Dysreflexia Constipation Faecal impaction
Diarrhoea
Frequent accidents
Haemorrhoids

16. Transanal Irrigation

17. Who? – Patient or Nurse/Carer?

18. When? – Twice daily, daily, alternate days?

19. Where? – Toilet or Bed?

20. Ability to transfer
Balance
Spasm
Old Age
Carer intervention
Hypotension

21. Hand function
Access

22. Equipment
Skin Condition

23. Thank You
Any questions?