From the Guidelines
Managing bowel movements in a paraplegic individual requires establishing a consistent bowel program that includes scheduled timing, proper diet, adequate fluid intake, and sometimes medications, with a focus on prevention and self-care strategies as outlined in the ESMO clinical practice guidelines 1. To develop an effective bowel management plan, several key factors must be considered, including:
- Ensuring privacy and comfort to allow the individual to defecate normally
- Positioning to assist gravity, which may involve using a small footstool to help the individual exert pressure more easily
- Increasing fluid intake and activity within the individual's limits to promote bowel motility
- Implementing anticipatory management of constipation when opioids are prescribed, as these can exacerbate constipation
- Considering the use of abdominal massage, which has been shown to reduce gastrointestinal symptoms and improve bowel efficiency, particularly in individuals with neurogenic problems 1
In terms of specific interventions, the use of osmotic laxatives (such as PEG, lactulose, or magnesium and sulfate salts) or stimulant laxatives (such as senna, cascara, bisacodyl, and sodium picosulfate) may be beneficial when laxatives are needed 1. However, it's crucial to use these medications judiciously and with caution, especially in individuals with renal impairment, as magnesium and sulfate salts can lead to hypermagnesemia 1.
Additionally, suppositories and enemas can be a preferred first-line therapy when a digital rectal examination (DRE) identifies a full rectum or fecal impaction, but their use must be carefully considered in light of potential contraindications such as neutropenia, thrombocytopenia, or recent colorectal surgery 1.
Overall, the goal of bowel management in paraplegic individuals is to establish a consistent and effective bowel routine that minimizes the risk of constipation, fecal impaction, and other bowel-related complications, thereby improving quality of life and reducing morbidity and mortality. This can be achieved through a combination of prevention and self-care strategies, careful use of medications, and individualized planning based on the person's specific needs and capabilities.
From the Research
Managing Bowel Movements in Paraplegic Individuals
To help a paraplegic individual have a bowel movement (BM), several strategies can be employed based on available research evidence.
- Medication:
- The use of docusate sodium mini-enemas has been shown to decrease total and left-sided colonic transit time and bowel evacuation time in individuals with spinal cord injury 2.
- Bisacodyl, a stimulant laxative, acts locally in the large bowel to enhance motility, reduce transit time, and increase the water content of the stool, and has been found to have similar efficacy to other laxatives for the primary endpoint of ≥3 complete spontaneous bowel movements (CSBM)/week 3.
- Digital Rectal Stimulation (DRS):
- There is moderate evidence for the use of DRS as an intervention in the management of upper motor neuron neurogenic bowels (UMN-NB) in persons with spinal cord injury, with evidence of its physiologic effect and support for combining it with other treatment regimens 4.
- Dietary and Hydration Changes:
- A therapeutic protocol based on a high residue diet and standardized water intake, combined with a sequential schedule of evacuating stimuli, has been shown to increase the frequency of bowel movements per week and decrease the total gastrointestinal transit time in spinal cord injury patients 5.
- Other Interventions:
- While the majority of the evidence focuses on adult populations, osmotic laxatives like polyethylene glycol 3350 (PEG 3350) and lactulose are noted for their effectiveness and safety in treating constipation, which might be applicable in managing bowel movements in paraplegic individuals, though the context provided is more pediatric 6.
Considerations for Implementation
When implementing these strategies, it's crucial to consider the individual's specific condition, the severity of their paralysis, and any other health complications they may have. A healthcare professional should be consulted to determine the most appropriate approach for each individual.