Neurogenic Bowel Management Arlene Wilde – Specialist Nurse Spinal Injuries

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

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

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

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

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

Management of the UMN bowel Warm drink and something to eat 20-30 mins before you start Perform digital rectal examination Insert suppositories, micro-enema or rectal solution Wait for 20-30 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

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

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

Example of digital rectal stimulation

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

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

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

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

Complications Autonomic Dysreflexia Constipation Faecal impaction Diarrhoea Frequent accidents Haemorrhoids

Transanal Irrigation

Who? – Patient or Nurse/Carer?

When? – Twice daily, daily, alternate days?

Where? – Toilet or Bed?

Ability to transfer Balance Spasm Old Age Carer intervention Hypotension

Hand function Access

Equipment Skin Condition

Thank You Any questions?