How to manage bowel incontinence caused by paraplegia?

Management of Bowel Incontinence in Paraplegia

A comprehensive bowel management program is essential for patients with bowel incontinence due to paraplegia, focusing on establishing regular bowel movements, preventing complications, and improving quality of life.

Assessment and Initial Management

Initial Assessment

• Evaluate prior bowel function, including stool consistency, frequency, and timing before paraplegia onset 1
• Assess for urinary retention through bladder scanning or intermittent catheterization 1
• Determine level of paraplegia (thoracic level is most common - 69% of cases) 2
• Evaluate cognitive awareness of need to void or having voided 1

Early Interventions

• Remove indwelling catheters within 24-48 hours to reduce urinary tract infection risk 1
• Consider diverting colostomy in patients with paraplegia who are incontinent of stool to prevent repetitive wound contamination 1
• Implement early mobility when hemodynamically stable to reduce risk of constipation 1

Bowel Management Program Components

Dietary Management

• Ensure adequate intake of fluid, bulk, and fiber 1
• High fluid intake during the day and decreased fluid intake in the evening 1
• Consider low-FODMAP diet and avoiding gas-producing foods for patients with bloating 3

Medication Management

• Stool softeners and judicious use of laxatives for constipation 1
• Suppositories are recommended (used by 50% of patients with chronic SCI) 2
• Loperamide can be considered for reducing intestinal motility and increasing anal sphincter tone in patients with incontinence 4
• Avoid long-term use of proton pump inhibitors as they can contribute to bowel dysfunction 3
• Exercise caution with opioids as they worsen intestinal dysmotility 3

Toileting Schedule

• Establish a regular toileting schedule consistent with the patient's previous bowel habits 1
• Offer commode, bedpan, or urinal every 2 hours during waking hours and every 4 hours at night 1
• Implement prompted voiding for patients with urinary incontinence 1

Advanced Management Options

For Refractory Cases

• Consider antegrade continence enema (ACE) procedure for patients with intractable constipation and fecal incontinence 5, 6
  • ACE procedure can reduce bowel care time from 2 hours to 50 minutes daily 5
  • Can eliminate fecal incontinence and reduce medication requirements 5
  • May resolve autonomic dysreflexia related to bowel issues 6

Surgical Considerations

• Evaluate for diverting colostomy in patients with persistent fecal incontinence 1
• Consider appendicocecostomy for antegrade continence enemas in selected cases 6

Monitoring and Complications

Common Complications

• Impacted stool is the most common complication, followed by hemorrhoids 2
• Constipation affects approximately 58% of patients with complete SCI above L2 7
• Regular abdominal pain occurs in one-third of SCI patients 7

Ongoing Assessment

• Regular assessment of bowel function 3
• Monitor for skin breakdown and pressure injuries related to incontinence 1
• Repeat assessment if there are changes in neurological status or medication regimen

Outcomes and Expectations

• Most patients with chronic SCI can manage their bowel well with conservative measures 2
• Good adherence to bowel rehabilitation programs improves outcomes 2
• Tetraplegic patients have higher prevalence of constipation compared to those with low paraplegia 7
• Patient-centered bowel management reduces impact on quality of life and minimizes complications 2

With proper management, most patients with paraplegia can achieve satisfactory bowel control, significantly improving their quality of life and reducing complications associated with bowel incontinence.