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Conservative Bowel Management

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Due to loss or impairment of sensation of rectal fullness and voluntary control of anorectal function in upper motor neuron SCI with intact anorectal reflex, bowel evacuation must be stimulated for bowel movements to occur on a regular and predictable basis. This facilitates continence and reduces constipation. As many SCI individuals need assistance with activities of daily living, and in many cases care has to be scheduled, a regular bowel program ensures evacuation occurs when that assistance is available. Prevention of constipation will avoid symptoms such as abdominal pain and bloating and minimize the development of anorectal morbidities associated with neurogenic bowel dysfunction including haemorrhoids, anal fissure, rectal abscess and rectal prolapse.

A conservative bowel program will combine a number of interventions in an individualized routine and may include dietary manipulation to ensure adequate fibre and fluid, digital rectal stimulation, digital removal of stool, abdominal massage, stimulation of the gastrocolic reflex, use of oral or rectal (suppositories, enemas) pharmacological interventions. Such a program will usually be performed on a daily or alternate day basis depending on the needs of the individual. Undertaking physical activity, including standing and passive movements, may also help to reduce constipation. Polypharmacy may also contribute to constipation so wherever possible medications that adversely affect bowel function should be minimized or avoided. Where this is not possible and when appropriate dietary intake is not practicable, oral laxatives may be used to modulate stool consistency and promote stool transit.

The Consortium for Spinal Cord Medicine guidelines (1998) and the Multidisciplinary Association of Spinal Cord Injury Professionals guidelines (MASCIP 2012) recommend that a conservative bowel program should be developed initially in the rehabilitation phase following injury and that a comprehensive evaluation of bowel function and management is undertaken at least annually. The evaluation may include a patient history (including level and completeness of SCI, detailed history of current bowel routine management, stool form, continence and time spent on evacuation, diet and fluid intake, relevant medical conditions and medications, extent of care provision and home adaptations) and a detailed physical examination (including neurological examination to ascertain upper motor neuron vs. lower motor neuron type of neurogenic bowel and a rectal examination).