Management of bowel problems
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.
- 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?
The occurrence of constipation was 21-28% from 6 to 20 years post-injury
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
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
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.
- 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
A nurse or doctor can assess what the cause may be and give you advice about the need for treatment.
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 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
- 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
- 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.
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
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
How to treat alternating constipation and diarrhoea
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
- 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.
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 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.
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.
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
- 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
- Using peppermint oil has been shown to be effective against bloating.
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.
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.
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.