Your Bowel
Know about your bowel
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How the bowel normally works
The digestive system includes the mouth, oesophagus, stomach, small intestines and colon, rectum and anus.
When food or drinks are consumed, they travel through the digestive system and are eliminated as faeces in a bowel motion or stool from the anus.
Do you know?
The term “bowel” is used collectively to refer to the small intestine, colon and rectum. It can be further categorised into:
Small bowel: small intestine
Large bowel: colon and rectum
When the stool reaches your lower colon and rectum, nerve impulses travel from your rectum via the sacral nerves and along the spinal cord up to your brain. Your brain tells you that your bowel is ready to be emptied.
If you decide to delay your bowel movement, a message is sent from your brain to the spinal cord to tell the sphincter muscle, which is located near your anus, to stay closed until there is a better time to empty.
If you decide to empty your bowel, a message is sent back down your spinal cord to the sphincter muscle, telling it to relax and pass the stool.
This is how your bowel works when you do not have a spinal cord injury.
Effects of a spinal cord injury
After spinal cord injury, your bowel will usually not work like it did before the injury. This type of bowel is often referred to as a neurogenic bowel.
T12
Reflex bowel
At and above T12 vertebral level (sacral nerves are intact)
Due to the spinal cord being injured, the message does not reach the brain, but remains in the spinal cord. The brain does not send a message down the spinal cord about whether or not it is a good time
to empty your bowel.
The reflex activity generated in the sacral spinal cord causes the sphincter muscle to open when the rectum is full, and may be triggered by digital or chemical stimulation.
Non-reflex bowel
Below T12 vertebral level (sacral nerves are damaged)
Due to nerve damage at a lower spinal level, the message is not able to reach the spinal cord. No reflex contraction can occur, and the bowel does not squeeze to empty its content.
The sphincter muscle remains loose all the time and if too much stool collects in the rectum, it will come out causing a bowel accident.
Note: Sacral nerves are responsible for controlling the bowel.
Neurogenic Bowel
Diaries
Diaries
Keeping a Bowel Diary will provide you and your healthcare professionals with a good understanding of your bowel routine and factors affecting it to be able to manage it better.
Adequate fluid intake along with a good diet are essential components of any bowel program. Keeping a Fluid Diary will help you and your healthcare professionals to know whether you are drinking enough fluids. For example, if you don’t drink enough water, your intestine draws water from your food waste, making your stools very hard and difficult to pass.
It is recommended that you complete the diary for a minimum of 14 days to identify any pattern or trend. If completing the bladder and bowel diary, you only need to collect information on fluid intake once.
You can download editable pdf version of the diary or create a digital diary on your device using the SCI Health Toolkit app.
Please note: Diaries must be downloaded to be completed – they cannot be filled in online
The SCI Health Toolkit App
The SCI Health Toolkit app provides you with a bladder and fluid diary in your pocket, along with all of the other diaries available on The Health Maintenance Toolkit website.
You can quickly and easily track and monitor key bodily functions and activities using the interactive and simple to use diaries.
Toolbox
Bowel management toolbox
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Bowel management toolbox
Management of a bowel problem can be challenging because there are many factors that can cause problems. A single strategy, for example, adjusting your diet and fluid intake, may be less effective than using a combination of bowel management strategies.
The bowel management toolbox provide you with eight strategies to manage your bowel care and to help solve your bowel problems.
An individualised approach to bowel management is needed and includes:
- Modifying diet and lifestyle
- Adjusting medications
- Employing assistive techniques.
Important Note
It is unlikely that using just one strategy will fix a bowel problem, you need to use a combination of strategies.
The eight strategies
1. Assessment
For solving day-to-day bowel problems, it is helpful to have a way to assess the different types of bowel motion or stool consistency and where it is located in your gut.
Consistency
The Bristol Stool Chart is commonly used for describing the consistency of your bowel motion and identifies 7 types of stools.
Bristol Stool Chart
 Type 1 | Separate hard lumps | Severe constipation |
|---|---|---|
 Type 2 | Lumpy and sausage like | Constipation |
 Type 3 | A sausage shape with cracks in the surface | Firm |
 Type 4 | Like a smooth, soft sausage or snake | Normal |
 Type 5 | Soft blobs with clear-cut edges | Lacking form |
 Type 6 | Mushy consistency with ragged edges | Mild diarrhoea |
 Type 7 | Liquid consistency with no solid piece | Severe diarrhoea |
By Cabot Health, Bristol Stool Chart – http://cdn.intechopen.com/pdfs-wm/46082.pdf, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=41761316
Location
The stool is normally stored down in the rectum before it is pushed out of your body or ready to empty. However, a person with a spinal cord injury has slower bowel movements so the stool sometimes stays higher up in your colon and is not ready to empty.
Assessment
Establishing goals for an effective bowel management program begins with a thorough assessment. This can be done in collaboration with your healthcare team, including specialist nurse, GP, spinal specialist and allied healthcare professionals.
Assessment should include the following factors:
- Bowel type: reflex or non-reflex
- History and outcomes of your past bowel management routine
- Personal and lifestyle factors such as diet and fluid intake, activity levels, exercise patterns and pre-injury bowel pattern
- Functional ability, particularly strength, ability to transfer, arm reach and hand function
- Body size
- Sitting tolerance, balance and posture
- Presence of spasms and/or contractures (causing restricted movements in your joints)
- The medications you are taking (and their side effects)
- Problem-solving skills and motivation
- Availability of a carer with the required knowledge and skills
- Ability to direct others appropriately.
2. Bowel care routine
Bowel management aims to establish regular and predictable bowel emptying. This should be at a time and place that suits your lifestyle.
The TOP goals
Timing:
- A bowel care program is most effective and reliable when you follow a regular routine.
- Empty your bowel at set times.
- Reflex bowel – every 1 or 2 days, ideally 20-45 minutes after a meal to use the gastrocolic response.
- Non-reflex bowel – occurs a little more often, typically once or twice daily.
Outcomes:
- Achieve complete emptying of your bowel within 30 minutes or less, and no more than 1 hour.
Prevention:
Reduce and, if possible, prevent problems, such as bowel accidents, constipation and bowel-related autonomic dysreflexia.
How to achieve the TOP goals
- Have a regular bowel care program
- Eat a well-balanced, healthy diet with enough fibre
- Drink the recommended amount and type of fluids (6-8 glasses of water)
- Be active and exercise regularly
- Take your bowel medications regularly
- Maintain a soft, well-formed stool or a firmer stool for a non-reflex bowel type.
“If I had to advise younger people with spinal cord injury, I would say ‘stick to the rules’.”
Person with spinal cord injury
Bowel Maintenance
3. Diet and fluid intake
Two important factors for effective bowel movements are:
Consuming food with an adequate amount of fibre
Drinking enough fluid
Diet
Fibre holds fluid and is important for:
- Improving your bowel movements by adding bulk and form to the stool
- Moving your stool smoothly through the bowels
- Assisting evacuation with well-formed stools.
There are three types of fibre and your body needs them all.
Insoluble Fibre does not dissolve in water. This type of fibre adds bulk to the stool allowing active movement through the gut. This is beneficial in preventing constipation. See examples of insoluble fibre in the table below.
Soluble Fibre is a gentler bulking fibre which forms a gel by absorbing water. This type of fibre is helpful in managing both constipation and diarrhoea. Consume this type of fibre when you have a loose stool. See examples of soluble fibre in the table below.
Resistant starch is a prebiotic and a fibre which feeds the gut bacteria. Resistant starch promotes bacteria growth to maintain a healthier gut and reduces the risk of medical conditions such as bowel cancer and diabetes. Examples of resistant starch are whole grains, nuts and legumes, starchy vegetables, unripe bananas and some seeds.
Do you know?
- Most foods with fibre contain a mixture of soluble and insoluble fibre in different amounts.
- The amount of fibre in foods does not change with cooking, so food can be consumed raw or cooked.
- Your diet helps you to firm up or soften your stool.
What does research tell you?
- Individuals with a spinal cord injury should not necessarily be placed on a high-fibre diet, as this may further increase colonic transit time.
- Aim for a diet containing no less than 15 grams of fibre daily, with fibre intake gradually increased up to 30 grams, from a wide variety of sources.
- Symptoms of intolerance should be monitored, and fibre adjusted accordingly.
How to boost your fibre intake
Replace this | With this | To boost your fibre intake |
|---|---|---|
 35g oats = 2.4g |  40g high-fibre oats = 7.3g | + 4.9g |
 1 slice white = 0.7g |  1 slice multigrain = 1.8g | + 1.1g |
 1/2 cup cooked white rice = 0.8g |  1/2 cup cooked brown rice = 2g | + 1.2g |
 1/2 cup mashed potatoes = 1.1g |  1 jacket potato = 3.5g | + 2.4g |
 1 cup of pear juice (240ml) = 4g |  1 pear = 6g | + 2g |
Important Notes
- Consume at least 25-30 grams of fibre each day.
- If your fibre levels are not high, increase the amount gradually over a few weeks while drinking adequate fluids at the same time.
Fibre content in commonly eaten foods
Food category | Foods that harden stool (Soluble fibre) | Foods that soften stool (Insoluble fibre) |
|---|---|---|
Dairy | Milk, yoghurt made without fruit, cheese, cottage cheese
or ice cream | Yoghurt with seeds or fruit |
Bread and cereals | White bread or rolls, crackers, refined cereals, pancakes,
waffles, bagels, biscuits, white rice or noodles | Whole grain breads or cereals |
Fruits and vegetables | Strained fruit juice or apple sauce | All vegetables except potatoes without the skins |
Meat or legumes | Any meat, fish, or poultry | Nuts, dried beans, peas, seeds, lentils or crunchy peanut butter |
Soups | Any creamed or broth-based without vegetables, beans,
or lentils | Soups with vegetables, beans,
or lentils |
Fats | None | Any |
Desserts and sweets | Any without seeds or fruits | Any made with cracked wheat, seeds, or fruit |
Dairy |
|---|
Foods that harden stool (Soluble fibre) Foods that soften stool (Insoluble fibre) |
Bread and cereals |
Foods that harden stool (Soluble fibre) Foods that soften stool (Insoluble fibre) |
Fruits and vegetables |
Foods that harden stool (Soluble fibre) Foods that soften stool (Insoluble fibre) |
Meat or legumes |
Foods that harden stool (Soluble fibre) Foods that soften stool (Insoluble fibre) |
Soups |
Foods that harden stool (Soluble fibre) Foods that soften stool (Insoluble fibre) |
Fats |
Foods that harden stool (Soluble fibre) Foods that soften stool (Insoluble fibre) |
Desserts and sweets |
Foods that harden stool (Soluble fibre) Foods that soften stool (Insoluble fibre) |
See fibre calculator in the resources section for Your Bowel.
Fluids
- National guidelines recommend an average intake of 2.1 litres for women and 2.6 litres for men.
- Fluid requirements can also be calculated using 30-35mL/kg body weight.
- Water is the best fluid of choice.
Do you know?
About half a glass (125mL) of juice provides energy equal to one serve of fruit. Limit your consumption of fruit juices.
Have a whole piece of fruit instead of juice.
Bowel Management: Diet and Nutrition
4. Medications
Medications to manage your bowel can be:
- Taken by mouth, known as oral laxatives or oral stimulants.
- Inserted into the anus, known as rectal stimulants. Often both ways are needed.
Type of medication | Action | Common Medications |
|---|---|---|
Oral | ||
Bulk-forming laxatives | Add bulk to stool. You will need to drink extra fluid. | Agiofibe, Agiolax, Benefiber, Fybogel, Metamucil, Mucilax, Normafibe, Nucolax, Psyllium husks |
Osmotic laxatives | Increase stool bulk by pulling water
into the colon. You will need to drink extra fluid. | Actilax, Duphalac, Epsom salts, Movicol, Osmolax, Picolax, Sorbilax |
Stool softeners | Help stool retain fluid, stay soft and slide through the colon. | Coloxyl tablets or drops, Duphalac, Lactulose, Parachoc |
Stimulants | Increase the wave-like action of peristalsis to move stool through the bowel faster and keep it soft. | Coloxyl with Senna, Agarol, Durolax tablets, Normacol, Normacol Plus, Senokot granules or tablets |
Rectal | ||
Suppositories | Increases colon activity by stimulating the nerves in the lining of the rectum. | Bisacodyl or Durolax |
Stimulates peristalsis in the colon and lubricates the rectum to help pass stool. | Glycerine | |
Enemas | Lubricates the intestine and causes fullness in the rectum. | Microlax |
Stimulates the rectal lining and
softens stool. | Bisalax | |
Type of medication |
|---|
Oral |
Bulk-forming laxatives Action: Add bulk to stool. You will need to drink extra fluid. Common Medications: |
Osmotic laxatives Action: Increase stool bulk by pulling water into the colon. You will need to drink extra fluid. Common Medications: |
Stool softeners Action: Help stool retain fluid, stay soft and slide through the colon. Common Medications: |
Stimulants Action: Increase the wave-like action of peristalsis to move stool through the bowel faster and keep it soft. Common Medications: |
Rectal |
Suppositories/b> Action: Increases colon activity by stimulating the nerves in the lining of the rectum. Common Medications: Action: Stimulates peristalsis in the colon and lubricates the rectum to help pass stool. Common Medications: |
Enemas/b> Action: Lubricates the intestine and causes fullness in the rectum. Common Medications: Action: Stimulates the rectal lining and softens stool. Common Medications: |
Note: This is not an exhaustive list of medications.
What does research tell you?
Expert opinion strongly suggests avoiding the long-term use of Senna, although robust evidence is lacking to support this concern.
5. Assistive techniques
Assistive techniques can increase the speed of bowel care routines by promoting wave-like movements of your bowel, called peristalsis, which help to improve your bowel management.
The commonly used techniques are:
Abdominal massage uses a firm, slow and rhythmic action in a clockwise motion from the lower right side of the abdomen, across the top to the left and continuing down the left side of abdomen to assist the stool move along the large bowel towards the rectum and anus.
Gastrocolic reflex is an automatic response triggered by eating and drinking, particularly the first meal of the day, which stimulates the digestive process and causes contractions in the large bowel, helping to propel the formed stools down towards the rectum, ready for evacuation.
Digital stimulation involves gently inserting a gloved and well-lubricated finger into the rectum, up to the second finger joint. Rotate the finger in a gentle sweeping motion against the rectal wall. While digital stimulation can be repeated every 5-10 minutes until the bowel has evacuated, each stimulation usually takes only 15-20 seconds to perform and no longer than 1 minute. No more than 5 stimulations per bowel care routine should be required.
Manual removal involves the use of one or two gloved lubricated fingers to break up or hook stool and remove it from the rectum.
Optimal positioning for bowel care is with the knees bent and placed higher than the hips with the upper body bending forward, supported by elbows or hands on knees, if your balance allows this.
What does research tell you?
- Expert opinion recommends bowel care to be performed 30-45 minutes after a meal to take advantage of the gastrocolic reflex, which increases colonic activity.
- Expert opinion recommends the use of assistive techniques, such as abdominal massage and a seated or forward-leaning position (with foot stool) if mobility permits, to help the bowel to empty
The main techniques used for bowel management
Enemas
were used more often in people with tetraplegia, whereas digital stimulation with or without using an enema was more common in people with paraplegia.
15%
of people with an incomplete spinal cord injury had enough control to empty their bowel voluntarily.
6. Lifestyle factors
Our lifestyle choices can affect the function of our digestive system and bowel habits. For example, the gut can be easily upset by factors such as stress, alcohol and smoking.
Exercise regularly
Exercise helps your bowel to function better. Try to exercise regularly but do not overdo it. For example, pushing in a wheelchair, lifting weight through the arms when in a wheelchair and standing may help increase pressure in the abdomen and aid movement of stool through the bowel. Doing something you enjoy will keep you motivated. You should aim for 30 minutes of moderate activity at least 5 times a week. Drink plenty of water while exercising.
Regular sleep routine
Our sleep patterns can also affect our bowel habits. Ensure you get enough rest. Having regular times for going to bed and getting up each day can help your digestive system work more effectively and improve the regularity of your bowels.
Avoid stress
Stress is a common problem in today’s busy society. When life becomes too busy and stressful, our digestive system is one of the first parts of the body to react. Long-term stress can lead to changes in gut functioning over time which can cause your bowel to become more irritable.
Quit smoking
Smoking is bad for your health in every way, including your gut health. Smoking can affect the functioning of your gut, including decreased mucus production, altered gut bacteria and compromised immunity, and may contribute to problems such as heartburn and stomach ulcers.
Restrict or reduce alcohol intake
Drinking too much alcohol can cause irritation and inflammation of the lining of the gut, particularly the stomach. National guidelines recommend 2 standard drinks a day with no more than 4 standard drinks at any given time. One or two alcohol-free days in a week is recommended. For more information, check the ‘Standard drink guide’.
Getting older
As you get older, your bowels tend to become more sluggish. This is due to many factors including changes in our diet and less exercise.
7. Carer competence
Make sure your care provider or agency can provide the bowel care you need.
Some agencies have restrictions in relation to specific procedures, such as inserting an enema or performing manual evacuation, per-rectal (PR) checks or digital stimulation. It is important to ensure your carer is competent and familiar with your specific bowel care needs.
- It is your responsibility to instruct your carer.
- You need to be adequately prepared to teach your carer to carry out your bowel care program. Don’t hesitate to ask your nurse for help.
- If you feel your carer does not have the right skills or knowledge, talk to your case manager or coordinator.
- Make sure your carer is using the stimulation technique that is most effective for you.
- Ask your carer to tell you what they can feel when they are doing digital stimulation or a bowel check so you can decide what further action to take.
Access resources to help educate your carers.
8. Surgical treatment
Colostomy
A colostomy involves an operation to cut the colon and bring its end out through the abdominal wall.
The bowel contents can then pass out through an artificial opening, called a stoma, bypassing the rectum and anus. Stool collects in a waterproof bag worn over the stoma. The bag is adhesive and sticks to the area reducing the risk of leakage and protecting the skin.
Common reasons for a person with spinal cord injury to consider a colostomy include:
- Lengthy episodes of bowel management
- Unmanageable faecal incontinence
- Severe constipation
- Autonomic dysreflexia or pain associated with bowel evacuation.
Colostomy greatly reduces bowel care time, laxative use, accidents and bowel-related autonomic dysreflexia. Colostomy also leads to improved independence and better quality of life.
The common problems with a stoma include:
- Rectal mucous discharge
- Ballooning of the stoma bag
- Stoma bag sticking together called pancaking, preventing stool from moving to the bottom.
There is no agreement about when to have a colostomy. It is often only considered as a last resort when all other methods have failed. Yet, in most cases after having a colostomy, people report wishing they had had the procedure much earlier. It can be very helpful to talk to a peer who has already had a colostomy to find out more about how it has worked for them.
The stoma nurse plays an important role as your key contact during treatment. The nurse will meet with you before surgery to discuss positioning of the stoma and liaise with your surgeon and health professional team. The nurse will provide education and training in:
- Applying and removing your stoma bag
- Purchasing supplies (such as stoma bags, adhesive remover wipes, and so on)
- Providing dietary advice to minimise bowel problems
- Promoting healthy skin care.
What does research tell you?
Expert opinion recommends:
- A colostomy be considered at an earlier stage for an individual experiencing severe bowel problems despite comprehensive management.
- The decision to have a permanent colostomy should be based on a detailed assessment and the individual’s expectations.
Ileostomy
An ileostomy is like a colostomy. It involves bringing the ileum, the last part of the small intestine, out of the right side of your abdomen to form a stoma.
As the waste material has not been through the colon, there will be a lot of water that has not been absorbed. Faeces will therefore be runny with some wind. The stoma will appear to look like the inside of your mouth. Ileostomy surgery is usually chosen when the colon is so damaged that it cannot be treated any other way.
What does research tell you?
Create an individualised bowel program using a multifaceted, stepwise treatment approach. The following components are considered essential: appropriate diet, fluid intake and physical activity, timed bowel care routine, manual evacuation or digital stimulation with or without an enema or suppository, bowel medications, appropriate positioning over the toilet and the use of assistive techniques.
My bowel care
It is important to use a comprehensive approach when developing your bowel care plan, considering the following:
Medication
Be aware that certain medications may cause constipation, such as painkillers, anticholinergics (given for bladder management) or iron supplements.
Diet
Ensure you are eating a healthy and well-balanced diet with enough fibre.
Enemas and suppositories
Use an appropriate enema or suppository.
Bowel care routine
- Develop a regular routine – typically once or twice a day.
- Allow enough time on the toilet or commode, particularly if you rely on a carer. Do not hurry bowel care as it may result in an accident later in the day.
- If you think there are stools higher in the rectum, wait until the next scheduled bowel care to evacuate.
Assistive techniques
Combine the techniques below for best results:
- Timing of bowel care to use gastrocolic reflex
- Manual evacuation
- Abdominal massage
- Digital stimulation
- Forward and bending position.
Carer competence
Remember it is your responsibility to instruct them.
For more details about developing a specific bowel management program, please see ‘Solving Common Bowel Problems’ in resources.
Do you know?
Your digestive functions, particularly the emptying of your rectum, are more sluggish after a spinal cord injury.
Important Note
Keep a bowel diary to record the frequency (date and times) of your bowel movements. Record stool consistency, episodes of soiling or bowel accidents, fluid intake and other information such as medication use, diet and other symptoms. Download the bowel diary pdf, download the care plan or download the SCI Health Toolkit app to use the digital version.
Quiz
Quick quiz
You may wish to see how much your knowledge has grown by taking this quick quiz.
Manage problems
Management of bowel problems
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Manage a problem ‘just-in-time’
Serious complications can arise if bowel problems are not managed in a timely way.
In the long term, you could experience:
- Severe constipation, which can contribute to other unpleasant complications, such as haemorrhoids, bloating, worsening of pain or spasms.
- Rectal prolapse, a medical condition that occurs when part of your lower intestine pushes out through the anus from too much straining.
- Bowel obstruction with a severely dilated and distended colon, called a mega colon.
- Polyps and cancer.
‘Just-in-time’, or the right care at the right place at the right time, will reduce risk and prevent serious bowel complications. As a result, you will maintain your quality of life, independence, health and wellbeing.
Be proactive and take responsibility for managing your own health risks.
This involves:
- Education to understand how your spinal cord injury affects your bowel functioning and what research tells us.
- Becoming a partner in decision-making and learning to problem solve with your doctor and health professionals.
- Developing an individual bowel program that works for you.
- Engaging in ongoing health and wellness activities for a healthy bowel:
- Exercising as much as you can.
- Watching your weight, since obesity is linked to bowel cancer, especially in men.
- Drinking more water.
- Eating a healthy high-fibre diet with a variety of fruit vegetables and grains.
- Reducing saturated fats, found in animal products, processed foods and takeaway.
Managing your bowel
What does research tell you?
Constipation
19%
The occurrence of constipation was 21-28% from 6 to 20 years post-injury
Faecal incontinence
16%
Duration of bowel care was observed to be longer, more than 30 minutes, in people with spinal cord injury who were more than 15 years post-injury
Haemorrhoids
14%
The presence of haemorrhoids was highest (25%) in people with spinal cord injury who were over 10 years post-injury
2015 Rural Spinal Cord Injury Project survey of 681 people living with spinal cord injury in rural NSW
Constipation
Everyone’s bowel habits are a little different. One person might go to the toilet as often as 3 times per day, while another goes just 3 times per week.
Constipation includes:
- Less frequent bowel movements
- Hard stools
- Difficulty opening your bowels.
What causes constipation
After a spinal cord injury, constipation can happen for several reasons:
- Loss of control and coordination of peristalsis (propulsive bowel waves) and abdominal wall contractions, leading to a delay in food emptying from your stomach and slower transit through the bowel.
- Medications – constipation is a side effect of some commonly used medications, such as opioids for pain.
- Not drinking enough fluids – being dehydrated can make the stool harder and difficult to pass.
- Not eating a balanced diet with enough fibre or missing meals.
- Being less active than before – exercise stimulates the bowel and can help you go to the toilet more often.
It may not always be recommended to increase the amount of fibre in your diet, for example, if your appetite is poor or you aren’t drinking enough. Always check with your nurse or doctor.
You should talk to your nurse or doctor if you:
- Have longer-than-usual periods of not going to the toilet (for example, more than three days) or problems with evacuating your stool
- Have pain in your stomach or bottom
- Feel sick or have been sick
- Have bleeding from your bottom
- Pass a watery stool after
having constipation.
A nurse or doctor can assess what the cause may be and give you advice about the need for treatment.
Taking laxatives
Laxatives, also called aperients, are a type of medication that can help you to open your bowels.
There are different types of laxatives, which work in slightly different ways to draw in water, form or loosen the stools and/or stimulate bowel movements.
It might take a while to find the right type and amount of laxative for you. Talk to your doctor or specialist nurse if your constipation doesn’t improve.
If you are taking opioids − such as morphine, codeine or oxycodone − you can take laxatives at the same time to prevent constipation occurring as an unwanted side effect.
If you are prescribed laxatives, it is important to keep taking them regularly, even after you have had a bowel movement. This will help to stop you getting constipated again.
Do you know?
Occasionally, long-term constipation
can lead to faecal impaction. This occurs when your colon becomes blocked by a mass of very hard stool and your bowel movements cannot propel along your colon.
Faecal impaction can cause pain and/or vomiting, and this may require urgent hospital treatment.
Diarrhoea
Diarrhoea can mean either very loose, wet stools or opening your bowels more often than usual. If you have diarrhoea you may also have:
- Abdominal (tummy) pain
- The need to go to the toilet urgently
- Nausea or vomiting
- Headaches
- Loss of appetite
- Feeling thirsty or dehydrated
- Loss of control over when your bowels open (faecal incontinence).
What causes diarrhoea
There are many causes of diarrhoea, including:
- An acute or chronic infection
- Side effects of medications, including taking too many laxatives
- Overflow diarrhoea, particularly if you have been constipated before
- Anxiety
- Food intolerances
- Diseases, including inflammatory bowel disease, bowel cancer and diabetes.
How to treat diarrhoea
Most cases of diarrhoea will clear up within
a few days without any specific treatment.
But if you have frequent or ongoing diarrhoea, or if you see blood or pus in
your stool, you should talk to your nurse or doctor. You may need to provide a stool sample to be tested for different causes.
It is not recommended to take an
anti-diarrhoeal medication without first seeing a doctor or nurse. In some cases, these medications can make things worse.
Diarrhoea can dehydrate so drink plenty of fluids. Eat solid foods as soon as you feel
able to. Start with small amounts and
avoid fatty, spicy or heavy foods.
Overflow diarrhoea
Severe constipation can cause a blockage in your bowel. As a result, the bowel begins to leak watery stools that flow around the blockage from higher up in the bowel. The leak from the bowel can look like diarrhoea. It is called overflow or spurious diarrhoea.
If you have had severe constipation and then develop diarrhoea, you should talk
to your doctor or nurse before taking
any more medicine for constipation
or diarrhoea.
Alternating constipation and diarrhoea
Episodes of alternating constipation and diarrhoea can result from severe constipation with episodes of bowel impaction and overflow, but sometimes may indicate another problem, such as irritable bowel syndrome.
Signs and symptoms may include:
- Abdominal pain or cramping that is often relieved by passing wind or faeces
- A sensation that your bowel is not emptied after passing a bowel motion
- Abdominal bloating
- Mucus present in the stools
- Nausea.
How to treat alternating constipation and diarrhoea
Diet
Review your diet and consider:
- Increasing the amount of vegetables,
fruits and nuts. - Reducing foods that make the stools too hard, such as large amounts of meat or dairy products.
Note: Be aware that too much fibre can also be a problem, making the stools either too hard or soft.
Stool bulking and softening agents
You may consider modifying your bowel medications by:
- Adding or increasing the amount of
fibre supplement, and/or - Adding or increasing the amount of a
stool softener.
Fluids
- Increase the amount of water you drink (aim to drink 6-8 glasses of water per day in addition to other beverages).
- Moderate the number of drinks you have that contain caffeine, such as tea or coffee, as well as your alcohol intake. These drinks have a diuretic effect causing your body to produce urine, which may make your constipation worse.
Bowel care routine
You may need to modify your bowel
routine and/or the use of assistive
techniques to avoid having accidents in between bowel evacuations.
Carer competence
Check that your carers are performing
your bowel care correctly.
“I am more regular now than I was before, after taking the advice from the nurses.”
Person with spinal cord injury
Haemorrhoids
Haemorrhoids or piles are swollen or inflamed veins in your rectum and anus.
They are due to increased pressure in your rectum. Haemorrhoids may occur inside your rectum (known as internal) or outside of the anus (known as external).
Signs and symptoms of haemorrhoids may include:
- Pain or discomfort when sitting for
a long time - Pain or sweating during bowel movements, (a symptom of mild autonomic dysreflexia)
- Bright red blood on the outside of your stools, toilet paper or in the toilet bowl
- Irritation or mucus around your anus
- One or more swellings near your anus.
You should consult your doctor if:
- Your haemorrhoids bleed often or a lot.
- Your haemorrhoids do not improve with self-management.
- Bleeding is associated with a major change in your bowel habits.
- You pass black, tarry stools, that can be caused by bleeding.
- Blood is mixed in with your stool.
How to treat haemorrhoids
- Non-prescription ointments, creams and suppositories
- Cold compresses to relieve swelling
- Non-surgical procedures, which can include:
- Applying a rubber band, called ligation, to cut off the blood flow to the haemorrhoids. The haemorrhoids will then shrivel and dry up.
- Injection of a chemical solution into the haemorrhoid to cause it to harden, shrink and drop off.
- Surgery under general anaesthetic to remove the haemorrhoid/s, known as a haemorrhoidectomy.
Note: Haemorrhoids can recur after treatment, particularly if you remain constipated.
Precaution:
Bleeding during bowel movements is the most common sign of haemorrhoids. However, rectal bleeding can also flag a more serious problem, such as bowel cancer.
Other problems
Faecal impaction/pseudo-bowel (false) obstruction
in person with spinal cord injury at/or above T6 level
Abdominal bloating and discomfort
Bloating occurs when part of your bowel fills with air or gas, causing the abdomen to become distended and uncomfortable.
Constipation can often worsen symptoms of bloating. You may also experience dyspepsia (indigestion), acid reflux and early satiety, a feeling of fullness when eating. In addition, abdominal bloating can affect your breathing with shortness of breath from a distended bowel pressing up on your diaphragm, a muscle that draws air into your lungs.
Causes of bloating may include:
- Consuming gas-producing goods that are high in sugar, fizzy or carbonated drinks, or taking certain medications, e.g., Lactulose
- Swallowing air while chewing gum, drinking through a straw and eating while talking or eating too quickly
- Snoring
- Irritable bowel syndrome
- Food allergies and intolerances, including lactose, fructose, wheat, gluten and eggs
- Infections, such as from helicobacter pylori, responsible for most stomach ulcers.
How to treat bloating
The following strategies may help relieve wind, gas and bloating:
- Taking over-the-counter gas-reducing medications, such as simethicone tablets or digestive enzymes (for example, lactase for lactose intolerance).
- Avoid taking pain medications, such as aspirin, ibuprofen, and other non-steroidal anti-inflammatory drugs called NSAIDs if you have an abdominal condition, such as a stomach ulcer or a blockage of your bowels.
- Slowly increasing the amount of fibre in your diet and checking if gas and bloating become worse.
- Trying to eat smaller portions or adding an extra meal, if you feel uncomfortable after a large meal.
- Keeping a food diary to work out if certain foods seem to make you more gassy or bloated.
- Avoid foods containing FODMAPs. Both lactose and fructose are a part of a larger group of indigestible carbohydrates known as FODMAPs. FODMAP intolerance is one of the most common causes of bloating and abdominal pain. Foods to avoid include wheat, onions, garlic, broccoli, cabbage, cauliflower, artichokes, beans, apples, pears and watermelon. It may be helpful to see a dietitian.
- Taking a probiotic supplement may help
to improve the bacterial environment in your gut and reduce symptoms of gas
and bloating. - Using peppermint oil has been shown to be effective against bloating.
Gallstones
The gallbladder’s function is to store bile,
a substance secreted by the liver to assist with digestion of fats and the absorption of
certain vitamins. Gallstones are small
stones made up of a mixture of cholesterol, bile pigment and calcium salts that form in the gallbladder. They often cause no symptoms and may be discovered by accident through an ultrasound or CT scan performed for another reason.
Gallstones occur more often after spinal cord injury due to the sluggish movement of the bile along its tract called stasis. Other risk factors for gallstones include diabetes, obesity and/or family history.
Signs and symptoms may include:
- Sudden severe pain or discomfort in your upper right abdomen – just below the rib cage – or right shoulder.
Note: Your symptoms may be less localised with dull aching or colicky type of visceral pain when you have a higher level of injury.
- Pain, bloating or discomfort may increase after eating a fatty meal.
- Yellowing of your skin or eyes, called jaundice, occurs when bile pigments spill over into your bloodstream from blocked gallbladder and ducts.
- Nausea and vomiting.
- Fever and pain if gallbladder, bile ducts or pancreas become inflamed or infected.
- Changes to the colour of bowel motion (clay colour).
How to treat gallstones
- Surgery to remove the gallbladder, called a cholecystectomy, if severe or current attacks occur. This is usually done by laparoscopic or keyhole surgery.
- Lithotripsy is a procedure using sound waves via a focused ultrasound from outside the body to shatter the gallstones into pieces to pass safely down the bile duct. Lithotripsy may be used alone or along with a tablet containing bile acids that helps dissolve cholesterol. Unfortunately, gallstones are likely to recur.
Heartburn
Depending on the level of your spinal cord injury, you may or may not have heartburn or oesophagitis, experienced as pain in your chest, especially after bending over, lying down or eating. Heartburn is more common after a spinal cord injury due to reduced movement of the upper digestive tract resulting in delayed emptying of the stomach.
Other common symptoms are burping, a burning sensation in the throat, a sour or acidic taste at the back of the throat, a dry cough, hoarse voice or sore throat. Factors increasing your chances of heartburn include slower emptying of your stomach, lying down, immobilisation and certain drugs, such as anticholinergics used for your bladder. Heartburn is treated with a medication that blocks acid production.
Bowel cancer
The risk of developing bowel cancer is NOT increased after sustaining a spinal cord injury. Your genetic makeup, however, can play a big role in bowel cancer.
About one in five people who develop bowel cancer have a relative with the disease. For this reason, it is important to find out if any of your relatives have had bowel cancer or polyps, which are growths in the colon or rectum, and if so, how old they were when they were diagnosed.
Studies have shown that people with spinal cord injury are less likely to have routine tests done for bowel screening and may therefore be at risk of a delayed diagnosis.
Important Notes
- Schedule an annual check-up to get screened. Most bowel cancers develop slowly from pre-cancerous growths called polyps. Early detection and removal of these pre-cancerous polyps prevents the development of bowel cancer.
- Reduce consumption of red and processed meat, and avoid charred meat.
- Drink alcohol in moderation.
- Know your family history.
Check if you have a problem
Check if you have a problem
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Quick Health Check
If you are experiencing a health issue, to support you to identify the problem, check the seriousness of the problem and understand what action to take to manage it, we have provided easy-to-use tools to help you.
The Tools
The Quick Health Check is an automated version of these 5 tools. These tools work together to help you with bladder and kidney problems.
- Checklist
Answer a few simple questions to help you to quickly identify a problem - Warning Signs
Check whether you have a serious problem that needs immediate attention by a healthcare professional - Severity Scale
Quickly assess how severe the problem is - Interference Scale
Select one number to determine how much the problem interferes with your daily life - Action to Take
The severity and interference scale ratings combine to provide you with the recommended action you need to take to manage the problem.
You can use the 5 manual tools below if you prefer this approach to using the automated Quick Health Check in the top right-hand corner of the page.
1. Checklist
Check if you have a problem
If you answer ‘yes’ to any of the questions below, refer to the Severity scale to see whether your problem is mild, moderate or severe, and then the interferance scale and action to take table, to understand whether you can self-manage or whether you need to manage with the support of a healthcare professional.
- Have you been experiencing any recent problems or changes in bowel emptying/routine?
- Having episodes of alternating constipation and diarrhoea?
(note: this can result from severe constipation with episodes of bowel impaction and overflow. It may sometimes indicate another problem, such as irritable bowel syndrome) - Having frequent bowel accidents, occurring once a fortnight or more often?
- Having either very loose, watery stools (diarrhoea) or opening your bowels more often than usual?
- Having harder stools that are difficult to remove, emptying your bowel less often than usual, feeling your lower bowel has not been fully emptied or needed to take more laxatives?
- Having episodes of alternating constipation and diarrhoea?
Have you been experiencing bleeding during or after bowel care?
Have you been experiencing any problems with abdominal discomfort, pain or bloating? Is it relieved by emptying your bowel?
Have you been experiencing any difficulty swallowing, or having a burning sensation in your chest or acid taste in the mouth after meals or when lying down, occurring more than once a week?
Do you have a family history of bowel cancer or inflammatory bowel disease?
Have you experienced unplanned weight loss?
Have you been experiencing episodes of sweating, headache, blotchy skin/rashes or blurred vision during your bowel care, which may indicate autonomic dysreflexia?
2. Warning Signs
The following symptoms are warning signs indicating there may be a serious problem that requires further investigation and/or treatment:
- Severe sweating or headache (autonomic dysreflexia) during or after bowel care
- Significant rectal bleeding, passing dark tarry stools or vomiting of blood
- New rectal bleeding of unknown cause
- Unexplained weight loss
- If you are feeling unwell due to having not opened your bowels and are experiencing symptoms such as bloating, nausea, vomiting or abdominal pain
- A major change in your bowel habit, including:
- severe constipation, incontinence or altered stool consistency
- Prolonged time for bowel care
- Reduced ability or endurance to self-manage bowel care.
If you experience any of these issues there may be a serious problem requiring further investigation – seek medical attention immediately
3. Severity scale
To check how severe your problem is, use the Severity Scale to assess the intensity, duration and frequency of your signs and symptoms.
Problems | Mild | Moderate | Severe |
|---|---|---|---|
Constipation | Less than 3 bowel movements per week; firm to
hard stools (BSC* type 2-3) Less than 25% of time | Less than 3 bowel movements per week; hard stools (BSC* type 2) 25%-50% of time | Less than 3 bowel movements per week; prolonged (>1 hour) or incomplete evacuation, very hard stools (BSC* type 1-2) More than 50% of time |
Bowel accidents and/or diarrhoea | Occasional – once or twice a year | 1 to 3 times a month | Once or more a week |
Alternating constipation and diarrhoea | Occasional – once or twice a year | Every few months | Once or more a month |
Haemorrhoids | Bleeding occurs less than once a month | Bleeding occurs several times a month | Bleeding occurs more than once a week AND/OR large amounts of blood |
Abdominal bloating and discomfort | Infrequent – less than once every few months | 1 to 3 times a month | Once or more a week |
Heartburn | Infrequent – less than once every few months | Occurs some of the time | Occurs most of the time |
Constipation |
|---|
Mild Less than 25% of time Moderate 25%-50% of time Severe More than 50% of time |
Bowel accidents and/or diarrhoea |
Mild Moderate Severe |
Alternating constipation and diarrhoea |
Mild Moderate Severe |
Haemorrhoids |
Mild Moderate Severe |
Abdominal bloating and discomfort |
Mild Moderate Severe |
Heartburn |
Mild Moderate Severe |
*BSC: Bristol Stool Chart
Any bowel-related symptoms of any severity associated with autonomic dysreflexia are considered SEVERE and require URGENT MEDICAL ATTENTION.
4. Interference scale
To determine to what extent your problem interferes with participating in everyday activities, use the scale below:
5. Action to take
This table provides a way to combine your severity and interference ratings from above scales to help you decide what level of support you may need to most effectively manage your problem.
Severity rating | Interference rating | Management strategies |
|---|---|---|
Mild problem | (0) Not at all | Self-manage without support |
Mild problem | (1) A little of the time | Self-manage without support |
Mild problem | (2) Some of the time | Self-manage with support from your GP or other healthcare professional |
Mild problem | (3) A lot of the time | Self-manage with support from your GP or other healthcare professional |
Moderate problem | (0) Not at all | Self-manage with support from your GP or other healthcare professional |
Moderate problem | (1) A little of the time | Self-manage with support from your GP or other healthcare professional |
Moderate problem | (2) Some of the time | Self-manage with support from your GP or other healthcare professional |
Moderate problem | (3) A lot of the time | Manage with specialist support |
Severe problem | (0) Not at all | Manage with specialist support |
Severe problem | (1) A little of the time | Manage with specialist support |
Severe problem | (2) Some of the time | Manage with specialist support |
Severe problem | (3) A lot of the time | Manage with specialist support |
Note: If you are self-managing without support and your problem has not been resolved, you should seek help from your GP, other healthcare professional or involve a spinal cord injury specialist in your management plan.
Prevent problems
Prevention
How to prevent problems and maintain a healthy bowel
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Self-management tips
Stick to a routine
Avoid major changes to bowel care
Maintain a good diet and exercise program
Some foods may increase the risk of bowel problems
Know about your gastrocolic reflex
Recognise an unhealthy bowel routine
Ensure you stick with a routine and try to go to the toilet at the same time every day.
Action: Develop a successful routine that is regular, reliable and completed within a reasonable length of time.
Stick to a routine
Ensure you stick with a routine and try to go to the toilet at the same time every day.
Action: Develop a successful routine that is regular, reliable and completed within a reasonable length of time.
Avoid major changes to bowel care
Ensure consistency in your diet and avoid making major diet changes, take your medications and moderate your alcohol intake.
Action: Only change one thing at a time when adjusting your routine at home. Wait about 7-10 days before making another change.
Maintain a good diet and exercise program
Ensure you have a good healthy diet with plenty of fluid and regular exercise.
Fluid is good for your bladder too, and exercise helps you to maintain a healthy bowel as well as a healthy heart.
Food with poor nutritional value or low in fibre, as well as too much alcohol, contribute to bowel problems.
Actions: Eat a balanced high-fibre diet, drink well and avoid too much alcohol.
Go around the block or do a workout in a gym.
Some foods may increase the risk of bowel problems
Some spicy food, fruits and certain vegetables can cause stomach and bowel problems.
Action: