The spinal cord constitutes the main pathway through which the brain receives and sends information to the rest of the body. Its lesion causes muscle paralysis and absence of sensitivity below the level of injury, lack of voluntary control of the bladder and rectal sphincter and alterations in sexuality. The alteration of the sphincters, both urinary and rectal, has a very important impact on the quality of life of the affected person.
While urinary dysfunction has received much attention due to the important complications it can cause (urinary tract infections, renal lithiasis, renal insufficiency, etc.), intestinal function has been less studied.
Spinal cord injury and its relation to bowel function
Correct stool continence and evacuation requires that the colon, rectum and anal sphincter are not damaged, receive correct motor and sensory innervation and maintain good voluntary control of the anal sphincter.
When a spinal cord injury occurs, depending on its characteristics (level of injury – cervical, dorsal or lumbosacral – and severity – complete or incomplete), there may be an alteration of the sensory and motor innervation of the colon, the rectum and anal sphincter with an alteration of their function and a loss of voluntary control of defecation, causing fecal incontinence (involuntary passing of stool) or constipation (infrequent, difficult or prolonged defecation or hard stool) and as a consequence the appearance of anorectal problems such as hemorrhoids.
The goal of treatment of bowel dysfunction secondary to spinal cord injury is to achieve regular, predictable and timely bowel movements and to prevent fecal incontinence. The basis for achieving these goals is to establish a bowel program.
The evacuation program is the treatment plan to control bowel function and consists of different aspects: time, place of evacuation, position, assistance of another person, technical aids, diet and fluids, physical activity, laxative medication and evacuation method. Time, place, position, assistance of another person and technical aids: it is very important to evacuate at the same time and at a regular frequency, which can be every 24 or 48 hours and exceptionally every 72 hours.
The evacuation site will depend on the availability of an adapted toilet and the necessary technical aids, as well as the characteristics of the injury, which must allow comfortable and safe sitting. Ideally, evacuation should be performed while seated on the toilet with the aid of a toilet seat or toilet chair; if this is not possible, it should be performed in bed.
The characteristics of the lesion will also determine the need for help from another person to perform the maneuvers to provoke evacuation (insertion of the suppository, anal fingering, abdominal massage), which should be performed independently whenever possible.
Diet, fluids and physical activity
It is highly recommended, in order to maintain a correct bowel function, to perform physical activity, within the possibilities of each person, and to take a diet rich in fiber and plenty of liquids. This last recommendation will always be conditioned by the need for fluid restriction to control the amount of urine, as occurs when the patient requires intermittent bladder catheterization to empty the urinary bladder.
Laxative medication
It is very common for people with spinal cord injury to need to take laxatives, either orally or in the form of suppositories. The appropriate laxative and its dosage should always be prescribed by the physician.
Evacuation method
We call evacuation method to those maneuvers used to provoke the evacuation of feces. The methods available are suppository, anal fingering, manual evacuation and maneuvers to increase intra-abdominal pressure (abdominal press, abdominal massage).
The application of these methods should be guided by the medical team who will advise on the convenience of one or the other and will explain in detail how to perform them.
Sometimes, despite the application of the evacuation program, good control is not achieved or complications appear (incontinence, severe constipation, abdominal distension…). In these cases, the medical team should be consulted to review the usual program and modify it if necessary.