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Spinal injury and bowel management

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VOL: 98, ISSUE: 04, PAGE NO: 61

Ray Addison, RN, FETC, Cert.H.Ed, BSc, is nurse consultant in bladder and bowel dysfunction, Mayday Healthcare NHS Trust, Croydon, Surrey; Mary White, MA, RN, is an independent specialist continence adviser

Bowel function is a major physical and psychological problem for patients with spinal cord injuries, and bowel dysfunction is perceived by them to be a major disability (Glickman and Kamm, 1996). Menter et al (1997) state that long-term bowel management outcomes are among the least discussed topics in the spinal cord literature. Yet, excluding bladder dysfunction, gastrointestinal disorders are the most common complication of patients with spinal cord injuries (Longo and Ballantyne, 1995) and faecal impaction is the most common gastrointestinal problem (Gore et al, 1980).

Bowel function is a major physical and psychological problem for patients with spinal cord injuries, and bowel dysfunction is perceived by them to be a major disability (Glickman and Kamm, 1996). Menter et al (1997) state that long-term bowel management outcomes are among the least discussed topics in the spinal cord literature. Yet, excluding bladder dysfunction, gastrointestinal disorders are the most common complication of patients with spinal cord injuries (Longo and Ballantyne, 1995) and faecal impaction is the most common gastrointestinal problem (Gore et al, 1980).

Causes of bowel dysfunction
Patients with lesions above T12 are likely to have reflex bowel activity, whereas those with lesions below T12 will have a flaccid bowel (Spinal Injuries Association, 1996). Digital stimulation is indicated to achieve a reflex colonic contraction (Irvine, 1996), whereas manual evacuation is one option when the bowel is flaccid with no reflex (Spinal Injuries Association, 1996). Irvine (1996) states that spinal cord-injured patients may get indirect indications of faeces in the rectum/anus, such as tachycardia, sweating and/or flushing.

Longo and Ballantyne (1995) state that the gastrocolic reflex remains active in some patients and that rectal compliance is normal, but sigmoid compliance is decreased in spinal cord injury. The sacral arc maintains the rectoanal inhibitory reflex, and spinal cord injured patients lose the ability to delay reflex evacuation of the rectum (Longo and Ballantyne, 1995).

Other factors that cause bowel dysfunction in patients with spinal cord injuries include lack of sensation (Irvine, 1996) and loss of the urge to defecate (Longo and Ballantyne, 1995). Immobilisation, motor paralysis of the abdominal and perineal muscles, dehydration and patient negligence of their bowel care regime are also common causes of bowel dysfunction (Longo and Ballantyne, 1995).

Longo and Ballantyne (1995) recommend that full colorectal investigations are initiated in patients with spinal cord injuries only if bowel inertia is not suspected as the cause of bowel dysfunction.

Bowel management methods
Nurses need to be aware of the range of bowel care interventions available, the research evidence to support them and the complications associated with specific interventions. The nurses role is to assess the patient (Box 1) and explore with the patient all the options and establish an agreed, acceptable, appropriate, effective and safe individual programme that achieves satisfactory defecation and minimises faecal incontinence and impaction.

All patients will need to establish an individual regime with regular bowel emptying, although this does not have to be every day (Longo and Ballantyre,1995; Spinal Injuries Association, 1996). Irvine (1996) is of the view that reflex activity can cause faecal incontinence and that patients need to learn to control this. Patients need to enhance this reflex activity to empty their bowel and maintain their faecal continence (Longo and Ballantyre, 1995). Although every effort should be made to establish a system that enables daily evacuation, for some patients this may be unrealistic because of the presence of megacolon. As gravity aids defecation, sitting on the toilet may be useful (Spinal Injuries Association, 1996).

The Spinal Injuries Association (1996) suggests that rectal medication can be administered in the upright position, but there is a risk that faeces or enema solution could be expelled, contaminating the nurse's skin. In the upright position it is difficult to visualise the anus to administer rectal medication and, combined with the patient's altered sensation, trauma may occur. If rectal medication administered while the patient is upright is successful, it is important to consider whether the digital stimulation combined with position is actually stimulating the reflex, rather than the rectal medication. This practice has not been researched by randomised controlled placebo drug studies.

Stimulant suppositories may be used to trigger reflex activity (Longo and Ballantyne, 1995; Edwards, 1997), but they may be effective only if the anal sphincters are functioning effectively. Edwards (1997) suggests that micro-enemas may be helpful, but Longo and Ballantyne (1995) state that patients may have difficulties retaining an enema, particularly if administered in the upright position. Some patients who experience difficulty retaining rectal medication may find it helpful to lie down and raise their bottom on a pillow. In this position suppositories and micro-enemas may be more easily retained by use of gravity. Rectal medication should be used with caution, as its role in spinal injured patients is unclear.

The Spinal Injuries Association (1996)) advises bending forward and applying abdominal pressure to achieve defecation. However, this can result in a higher incidence of rectal abscess formation (Menter el al, 1997). This many also lead to urinary complications if bladder pressure is high and/or reflux is present.

Longo and Ballantyne (1995) suggest assisted defecation within 30 minutes of breakfast by combining digital stimulation with the gastrocolic reflex for a better outcome. Abdominal massage along the course of the large bowel may also help (Longo and Ballantyne, 1995; Spinal Injuries Association, 1996). Manual evacuation for faecal impaction or to empty non-reflex bowel is a common intervention.

Fibre, fluids and laxatives can all be used to keep the bowel empty (Longo and Ballantyne, 1995; Spinal Injuries Association, 1996) but should be combined carefully to avoid faecal incontinence. Longo and Ballantyne (1995) also recommend avoiding greasy and spicy foods, as they can cause diarrhoea.

More unusual and complex interventions include the following:

- Use of nerve stimulators to aid defecation and maintain faecal continence (Binnie et al, 1991; Edwards, 1997);

- Bowel irrigation to empty the contents of the large bowel;

- High colonic irrigation to clear the bowel from impaction (Longo and Ballantyne, 1995);

- Shandling catheter has been used to irrigate the bowel in children with spinal injuries (Shandling and Gilmour, 1987). A Shandling catheter is required when mega-rectum is present; in other situations conventional irrigation can be used;

- Stone et al (1990) found in a follow-up evaluation of 20 patients with spinal cord injuries that colostomy was an acceptable solution for 19 respondents and that they declined reversal;

Whatever bowel care regime is agreed with the patient, a copy of the full assessment and care plan should be made available to the patient, carer, and primary health care team.

Psychological care
For an individual with spinal cord injury independence may be put beyond reach by invasive bowel care interventions. When carers - for example, parents, partners or siblings - are involved in bowel care the relationship is altered. The implications for the carer in providing bowel care should be considered. For example, can the carer take the responsibility for long-term bowel management and can bowel care be compromised by the carer's willingness to provide only certain interventions?

From the patient's perspective there are also psychological issues. Invasive bowel interventions may affect libido, physical sexual activity, body image, dignity, self-awareness, self-esteem, confidence, respect and independence.

Retrospective studies of bowel care
Only a few studies have recently focused on long-term bowel activity in patients with spinal cord injuries.

Glickman and Kamm (1996) followed up 115 patients with spinal cord injuries, with an average duration of injury of 62 months. The authors concluded that nausea, diarrhoea, constipation and faecal incontinence were all common. They found that 68% of patients used manual evacuation, 53% digital stimulation and 49% suppositories, and a combination of interventions were practised. Half were dependent on others for toileting and 54% of these patients were distressed by their bowel function.

Menter et al (1997) followed up 221 spinal cord patients in two UK centres. All had been injured for over 20 years. They found that 142 patients used some form of digital stimulation or manual evacuation technique, and this did not relate to the type of injury. Thirty-three per cent of patients used chemical stimulation and had a 21% rate of haemorrhoids, compared to manual evacuation, which only had a 9% rate. Only 13 patients used abdominal pressure, and of these 23% had a rectal abscess, compared to 6% in the manual evacuation group.

De Looze et al (1998) undertook a randomised study of 90 patients with long-term spinal cord injuries in Belgium. This team had an 87% response rate. They found that 82% used anal stimulation and only 15 patients required manual evacuation, and this was not related to the type of injury or disability.

Singh et al (1999) interviewed 110 spinal injured patients from one UK centre about their bowel dysfunction. Fifty-six per cent of patients reported faecal incontinence, 36% constipation and 37% haemorrhoids. Most (97%) required at least one intervention to stimulate defecation, and 51% required three or more.

A wide range of interventions was used in these studies to achieve defecation. The evidence base to practise bowel care for patients with spinal cord injuries is not strong. The four studies have shown a continuum of bowel problems even 20 years after injury. But what does not emerge is the best method or combination of interventions to manage the problem. More research is required into this health issue and, while manual evacuation is an accepted intervention, how appropriate and safe it is remains to be answered from a patient and nursing perspective.

Short- and long-term bowel dysfunction is common in patients with spinal cord injuries, and this is a major cause of disability for a proportion of them. Digitalisation in some form is widely practised and a proportion of patients perform manual evacuation. As patients often use a combination of therapies to aid efficient defecation, it is unclear what interventions are effective and why.

In the case of manual evacuation the practice varies and again it is unclear if it is the best solution. Evidence-based practice relating to manual evacuation is weak and is only based on expert opinion and historical practice. Long-term follow-up of this patient group has started to indicate that bowel care is an ongoing problem and that further investigation into this area may offer solutions and improve the quality of life for patients with spinal cord injuries.

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