Neurogenic Neurogenic Bowel ManagementBowel Management

Arlene Wilde – Specialist NurseArlene Wilde – Specialist NurseSpinal InjuriesSpinal Injuries

Aims of Bowel ManagementAims of Bowel Management

Reflex or Flaccid?Reflex or Flaccid?

Transanal IrrigationTransanal Irrigation

Who?Who?

When?When?

Where?Where?

Aims of Bowel ManagementAims of Bowel Management

►Regular and predictable emptying at a Regular and predictable emptying at a socially acceptable time and place, socially acceptable time and place, avoiding constipation unplanned avoiding constipation unplanned evacuations and autonomic evacuations and autonomic dysreflexia.dysreflexia.

Aims of Bowel ManagementAims of Bowel Management

►Completed in under one hourCompleted in under one hour►minimum necessary physical or minimum necessary physical or

pharmacological interventionspharmacological interventions► Individual to the personIndividual to the person►Comfort, safety, privacy, dignityComfort, safety, privacy, dignity

Neurogenic Bowel FunctionNeurogenic Bowel Function

Reflex or flaccid?Reflex or flaccid?

Reflex – Reflex – T12T12 or above or above

Flaccid – Flaccid – L1L1 or below or below

UMN BowelUMN Bowel

► Lesions at T12 and aboveLesions at T12 and above► Reflex defecation centre remains intactReflex defecation centre remains intact► Spastic paralysis of the bowel with inability to Spastic paralysis of the bowel with inability to

control defecationcontrol defecation► Uninhibited reflex activityUninhibited reflex activity► Individual unable to feel the urge to defecateIndividual unable to feel the urge to defecate► Cannot control external anal sphincter activityCannot control external anal sphincter activity► Rectal contractions to expel the stool are Rectal contractions to expel the stool are

blocked by external sphincter contracting at blocked by external sphincter contracting at the same timethe same time

Management of the UMN bowelManagement of the UMN bowel

► Warm drink and something to eat 20-30 mins before you startWarm drink and something to eat 20-30 mins before you start► Perform digital rectal examinationPerform digital rectal examination► Insert suppositories, micro-enema or rectal solutionInsert suppositories, micro-enema or rectal solution► Wait for 20-30 minsWait for 20-30 mins► Use abdominal massageUse abdominal massage► Reflex bowel action will usually have taken placeReflex bowel action will usually have taken place► Perform digital stimulationPerform digital stimulation► Await further reflex emptyingAwait further reflex emptying► Repeat digital stimulation every 10 mins until reflex emptying Repeat digital stimulation every 10 mins until reflex emptying

stopsstops► A manual evacuation will only be necessary if faeces will not A manual evacuation will only be necessary if faeces will not

reflex emptyreflex empty

Reflex Bowel ManagementReflex Bowel Management

► Alternate days, regular times Alternate days, regular times

► Bristol Scale 4Bristol Scale 4

► Stimulant laxatives 8 hours beforeStimulant laxatives 8 hours before

► Hot food or drink 20 – 30 minutes Hot food or drink 20 – 30 minutes beforebefore

Reflex Bowel ManagementReflex Bowel Management

► Suppositories/enema Suppositories/enema

► Digital rectal stimulationDigital rectal stimulation

► Digital removal of faeces if requiredDigital removal of faeces if required

► Digital rectal check to see if Digital rectal check to see if evacuation is complete evacuation is complete

Example of digital rectal stimulationExample of digital rectal stimulation

LMN BowelLMN Bowel

► Lesions below T12Lesions below T12► Reflex defecation centre is damagedReflex defecation centre is damaged► Flaccid paralysisFlaccid paralysis► Loss of anal toneLoss of anal tone► Lack of tonic external sphincter contraction Lack of tonic external sphincter contraction ► Ineffective peristaltic movementsIneffective peristaltic movements► Individual doesn’t feel the urge to defecateIndividual doesn’t feel the urge to defecate►No control over external anal sphincterNo control over external anal sphincter

Flaccid Bowel ManagementFlaccid Bowel Management

► Daily or twice daily at regular timesDaily or twice daily at regular times

► Bristol Scale 2 to 3 Bristol Scale 2 to 3

► Laxative 8 to 12 hours beforeLaxative 8 to 12 hours before

Flaccid Bowel ManagementFlaccid Bowel Management

► Hot food or drink 20 to 30 minutes Hot food or drink 20 to 30 minutes beforebefore

► Digital removal of faeces Digital removal of faeces

► Digital check to see if evacuation is Digital check to see if evacuation is completecomplete

Stimulants used on the G. I. tractStimulants used on the G. I. tract► OsmoticOsmotic

e.g Movicole.g Movicol

► StimulantsStimulants e.g Sennae.g Senna

► SoftenersSofteners e.g. Dioctyle.g. Dioctyl

► Bulk forming agentsBulk forming agents e.g. Fibogele.g. Fibogel

► SuppositoriesSuppositories e.g. Bisocodyl, Glycerinee.g. Bisocodyl, Glycerine

► Micro-enemasMicro-enemas e.g. Microlaxe.g. Microlax

ComplicationsComplications

► Autonomic DysreflexiaAutonomic Dysreflexia► ConstipationConstipation► Faecal impactionFaecal impaction►DiarrhoeaDiarrhoea► Frequent accidentsFrequent accidents►HaemorrhoidsHaemorrhoids

Transanal IrrigationTransanal Irrigation

Who? – Patient or Nurse/Carer?Who? – Patient or Nurse/Carer?

When? – Twice daily, daily, alternate When? – Twice daily, daily, alternate daysdays??

Where? – Toilet or Bed?Where? – Toilet or Bed?

► Ability to transferAbility to transfer► BalanceBalance► SpasmSpasm► Old AgeOld Age► Carer interventionCarer intervention► HypotensionHypotension

► Hand functionHand function ► AccessAccess

► EquipmentEquipment ► Skin ConditionSkin Condition

Thank You Thank You

Any questions?Any questions?