Bowel management toolbox
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
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.
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
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.
- 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
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.
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.
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.
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.
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.