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Bowel Problems

As a children’s book says, "Everyone poops." Although you may not talk about it or even think about it much, it’s important to your body and, yes, even your happiness. In fact, one study showed bowel function was a source of distress for more than half of people with spinal cord injuries. Are you one of those people? Does it have to be that way? Probably not.

Many spinal cord injury (SCI) survivors were taught early on to combine different techniques for their bowel programs – especially the use of digital stimulation, medications, and/or suppositories. Surveys show that while people do tend to stick with the combination approach, they make changes as well. Why? Researchers don’t know for sure, but it’s likely that some, if not most people make changes because of various complications or problems they’ve had with their bowel programs. The most common problems they seem to report are constipation, incontinence, hemorrhoids, bleeding, and pain.

Constipation
One study found that 40% of people with spinal cord injury experience constipation. Why is something like constipation so common among people with spinal cord injury? Because the SCI itself changes how the intestines work. Lab and special X-ray studies show that SCI makes your food take longer to travel through your colon. The longer it takes to go through your digestive tract, the more fluid gets absorbed there. This makes a drier stool, which can increase constipation. And, along with working more slowly, your digestive tract just may not empty right or get stopped up.

Incontinence
Incontinence is unplanned bowel movements or bowel accidents. Incontinence and constipation often go together. What do they have in common? Both mean that food is not moving smoothly through the digestive tract. About one-third of SCI survivors complain of problems with incontinence or leakage from their bowels.

Constipation and incontinence can occur at the same time when fluid leaks around stool that is stuck or moving too slowly. And, sometimes what you do to try to relieve constipation – diet changes, laxatives, etc – can lead to more accidents or leaking. So, the message is this: having a bowel accident doesn’t necessarily mean you’ve solved your constipation problem.

Incontinence doesn’t necessarily mean that you’re ill or unhealthy. However, having to deal with bowel accidents – or even just having to worry about the possibility of them – can affect how confidently you can move about in public. Unfortunately, incontinence is one of those things that, for some people, seems to get worse with age. Just as aging eyes and ears have a harder time doing as well as when they were young, your anal sphincter has an increasingly hard time doing its thing too. In a classic double whammy, your bowel muscles lose strength, not just to hold things back, but to keep them moving as well.

Staying "Regular"
Whatever the cause of incontinence or constipation, staying regular may be the best and easiest solution. Although it may be inconvenient, more frequent bowel programs can be helpful.

To help maintain your bowel regularity, you may already have a high fiber diet. Fiber comes from fruits and vegetables – like apples, bananas, and salad greens – as well as from grains. A good diet includes 25 to 30 grams of fiber a day. Fiber works by absorbing water. This increases the weight and bulk of your stool, which helps move things faster, and, hopefully, lessens constipation.

Eating more fiber is likely to be helpful. However, remember that you’ve got to keep your fluid intake up, too. Fiber takes lots of fluid with it down the digestive tract. Too much fiber without additional fluid can lead to loss of important dietary minerals. It may not solve your constipation problems, and it can also leave you with a stool that’s too hard, that doesn’t move easily, and that can irritate your sphincter and any hemorrhoids you might have. If you have questions about what kind of fiber or fiber supplements to use, or about how much to use, talk to your doctor.

Bleeding
One study showed that about 15% of people with SCI have rectal bleeding at times. While many people may worry that this bleeding comes from cancer, most rectal bleeding – particularly in SCI survivors – is not caused by cancer. In fact, there’s no evidence showing that people with SCI have a greater risk for bowel cancer.

Still, blood in the stool shouldn’t be ignored. One thing to notice is the appearance of the blood. If it’s bright red, it’s probably coming from something closer to the anus, like hemorrhoids or anal fissures. Fissures are really nothing more than cuts or cracks in and around the anal opening. Anal fissures and hemorrhoids can come from repeated irritation and pressure, as occurs during both ordinary emptying of the bowels and with bowel programs involving digital stimulation. As a result, both of these problems will be more likely to occur as you age.

If you notice darker and blackish or tar-colored blood in your stool, it’s probably coming from some place higher up – perhaps your stomach or intestine. Ulcers, intestinal infections (called "gastroenteritis"), or pockets that form in the sides of the intestines (called "diverticulitis") are three of the possibilities. Diverticulitis is more common with age in people without SCI, so there’s no reason to believe it’s any different for people with SCI.

In short, blood in the stool may be caused by many different problems, many of which SCI survivors – particularly as they grow older – may be susceptible to. Regardless of where it’s coming from, blood that occurs with your bowel program should not send you into a panic, but it is important enough to consult with your physician as soon as possible if you notice blood with your bowel program.

Hemorrhoids
These are the risk factors for hemorrhoids in people who are NOT disabled:

  • lots of time spent sitting or lying down
  • rectal manipulation
  • excessive laxative use
  • obesity

You probably noticed that most of these are things that affect people with SCIs even more than non-disabled people. SCI survivors spend a lot more time sitting down. Many more use digital stimulation and laxatives. And, because they are often not physically active, obesity is a problem, too. What this means is that SCI survivors do face an especially high risk for hemorrhoids. And, this risk seems to increase the longer you’ve been injured, so even if you don’t have problems now, there’s always a chance that you will in the future.

How do you know if you have hemorrhoids? If you have sensation, hemorrhoids may cause a burning, itchy sensation. Otherwise, you or your attendant may notice bright red blood or swollen tissues protruding from around the anal sphincter. Some of the things you can do about hemorrhoids are pretty obvious:

  • When using the digital stimulation technique, be as gentle and brief as possible to still get the desired results
  • If you use laxatives, use them moderately since excessive laxative use can actually worsen your hemorrhoids
  • Control your weight, since obesity is a risk factor for hemorrhoids

If you already have problems with hemorrhoids, your physician might suggest some diet changes and use of an over-the-counter preparation to reduce the swelling. Some of these preparations can be mixed with the lubricant you use for your bowel program. If that doesn’t work, next in line might be a procedure known as banding, where the swollen hemorrhoidal tissues are tied off to restrict blood flow and later cut off by your physician. A more extreme solution would be a surgical removal of the hemorrhoid tissues.

While it’s important to deal with problem hemorrhoids, they aren’t the worst things you can have, and they aren’t a major risk to your health.

The good news is that most bowel problems can be handled with only minor changes to your life. If you’re careful, monitor yourself, keep healthy habits, and talk to your doctor or nurse about your bowel problems as they occur, things will likely work out just fine. Your life shouldn’t have to center around a commode chair.

This is part of a library of educational brochures developed by Craig Hospital with a federal grant titled, "Marketing Health Promotion, Wellness, and Risk Information for Spinal Cord Injury Survivors in the Community. The opinions expressed here are not necessarily those of the funding agency, the National Institute on Disability and Rehabilitation Research of the US Department of Education.

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