M - BOWEL
M.1.1
The aims of bowel management after SCI are to promote continence, achieve bowel emptying in a regularly scheduled timely manner, in a socially convenient way, and avoid complications. (Adapted from BOWEL 2012, p.452; Level C)
M.2.1
Define the level and completeness of SCI according to the current International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) scale. (PVA-NBD 2020, p.452; Level C)
M.2.2
A systematic comprehensive evaluation of bowel function, impairment, and possible problems should be completed at the onset of SCI and at least annually throughout the continuum of care. (PVA-NBD 2020, p.452; Level C)
M.2.3
A comprehensive, detailed gastrointestinal history should be completed at the onset of SCI, annually, and as needed when any significant gastrointestinal changes occur. (PVA-NBD 2020, p.452; Level C)
M.2.4
A physical examination should be done at the onset of SCI, annually, and upon any significant change in bowel function or health. This should include thorough abdominal and rectal examinations. (PVA-NBD 2020, p.452; Level C)
M.2.5
An abdominal x-ray/computed tomography scan can be used to evaluate the extent of fecal loading, fecal incontinence due to stool overflow, and other bowel problems such as fecal impaction, bowel obstruction, megacolon, and megarectum. (PVA-NBD 2020, p.452; Level B)
M.2.6
Colonic transit time testing with radiopaque markers or scintigraphy can be used to provide more information on neurogenic bowel dysfunction. (PVA-NBD 2020, p.452; Level B)
M.2.7
A wireless motility capsule can be used to evaluate gastric emptying time, small intestinal transit time, and colonic transit time. (PVA-NBD 2020, p.452; Level B)
M.2.8
Anorectal manometry can be used for a detailed assessment of pelvic floor dysfunction in individuals with motor incomplete SCI (AIS C and D). (PVA-NBD 2020, p.452; Level B)
M.3.1
A BBM program should be used in individuals with both reflexic and areflexic neurogenic bowel dysfunction. (PVA-NBD 2020, p.452; Level B)
M.3.2
The optimal frequency of bowel movements per week should account for an individual’s lifestyle and premorbid bowel history. (PVA-NBD 2020, p.452; Level C)
M.3.3
Mechanical rectal stimulation may be used for individuals with reflexic neurogenic bowel dysfunction. (Adapted from PVA-NBD 2020, p.452; Level B)
M.3.4
Manual evacuation of stool may be used for individuals with areflexic neurogenic bowel dysfunction. (Adapted from PVA-NBD 2020, p.452; Level B)
M.3.5
Abdominal massage should not be used for neurogenic bowel dysfunction emptying. (PVA-NBD 2020, p.452; Level B)
M.3.6
The Valsalva maneuver should not be used for neurogenic bowel dysfunction emptying. (PVA-NBD 2020, p.452; Level C)
M.4.1
Use of adaptive equipment, including a suppository inserter and adaptive digital stimulator, should be considered for individuals with limited hand function or difficulty with reach. (PVA-NBD 2020, p.453; Level C)
M.4.2
A clinical evaluation of a pressure distributing commode/shower chair should be performed with a focus on the individual’s current bowel care routine and transfer ability, goals of the individual and caregiver, and individual functionality, including postural stability, reach, and skin integrity. (Adapted from PVA-NBD 2020, p.453; Level B)
M.5.1
Providers should inquire about and document diet history, including all dietary supplements that an individual with SCI is taking. (PVA-NBD 2020, p.453; Level C)
M.5.2
Providers should refer to a registered dietitian if the individual has a poor appetite, poor oral intake, or significant weight changes. (PVA-NBD 2020, p.453; Level C)
M.5.3
Individuals with SCI should not be uniformly placed on high-fibre diets. Increases in fibre intake from food or a supplement should be done gradually to assess tolerance. (PVA-NBD 2020, p.453; Level B)
M.5.4
Foods that cause an individual with SCI to experience excessive flatulence, bloating, abdominal distension, and/or altered bowel movements should be identified and either limited or avoided. (PVA-NBD 2020, p.453; Level C)
M.5.5
Providers should recommend that an individual with SCI maintain euhydration (state of optimal total body water content) and avoid dehydration to reduce the tendency to experience constipation. The amount of fluid needed to promote optimal stool consistency must be balanced with the amount needed for bladder management. (PVA-NBD 2020, p.453; Level C)
M.5.6
Providers should not routinely recommend probiotics to an individual with SCI. (PVA-NBD 2020, p.453; Level C)
M.5.7
Probiotics may be advantageous to an individual with SCI who is taking antibiotics by reducing antibiotic-associated diarrhea and Clostridium difficile-associated diarrhea. (PVA-NBD 2020, p.453; Level A)
M.6.1
Providers can use oral medications for bowel management; however, the evidence for their use is limited, and there is no data to suggest the use of one medication over another. (PVA-NBD 2020, p.453; Level C)
M.7.1
Providers can use rectal medications for bowel management. (PVA-NBD 2020, p.453; Level B)
M.7.2
A polyethylene glycol (PEG)-based bisacodyl suppository is recommended over a hydrogenated vegetable oil-based bisacodyl suppository. (PVA-NBD 2020, p.453; Level B)
M.7.3
Docusate mini enemas are recommended over glycerin, mineral oil, or vegetable oil-based bisacodyl suppositories. (PVA-NBD 2020, p.453; Level B)
M.7.4
The routine use of enema formulations such as sodium phosphate (Phospho-Soda), soapsuds, or milk and molasses are not recommended; however, in select individuals, intermittent use for constipation may be helpful. (PVA-NBD 2020, p.453; Level C)
M.7.5
Transanal irrigation is recommended in individuals with neurogenic bowel dysfunction who have insufficient results with BBM. (PVA-NBD 2020, p.454; Level A)
M.7.6
Pulsed irrigation evacuation (PIE) in a hospital/clinic setting can be used to relieve fecal impaction. (PVA-NBD 2020, p.454; Level B)
M.8.1
Regular physical activity should be encouraged as part of a healthy lifestyle. (PVA-NBD 2020, p.454; Level B)
M.8.2
For some individuals, a standing program may be beneficial for bowel function but should be weighed against other means of physical activity, as well as against precautions to undertake the activity safely. (PVA-NBD 2020, p.454; Level B)
M.9.1
Routine use of FMS for neurogenic bowel dysfunction is not recommended. (PVA-NBD 2020; Level B)
M.10.1
Malone antegrade continence enema (MACE) procedures can be used for individuals with SCI with severe neurogenic bowel dysfunction for whom other treatment modalities have failed. (PVA-NBD 2020, p.454; Level B)
M.10.2
The MACE procedure can be a choice for individuals with neurogenic bowel dysfunction who prefer the option after thorough education regarding risks, benefits, and complications and after shared decision making with their providers. (PVA-NBD 2020, p.454; Level B)
M.10.3
Colostomy is recommended for individuals with severe neurogenic bowel dysfunction for whom other treatment modalities have failed or who have had significant complications. (PVA-NBD 2020, p.454; Level B)
M.10.4
Colostomy can be a choice for individuals with neurogenic bowel dysfunction who prefer the option after thorough education regarding risks, benefits, and complications and after shared decision making with their providers. (PVA-NBD 2020, p.454; Level B)
M.11.1
Providers must assess and monitor for the unique clinical presentation of gastrointestinal and intra-abdominal complications related to neurogenic bowel dysfunction in individuals with SCI. (PVA-NBD 2020, p.454; Level C)
M.11.2
Providers must assess and monitor for complications that primarily affect areas outside the abdomen but that are related to neurogenic bowel dysfunction, such as AD and skin breakdown. (PVA-NBD 2020, p.454; Level C)
M.11.3
Treatment for hemorrhoids is conservative; if bleeding is refractory, non-excisional techniques are warranted. Excisional hemorrhoidectomy should be avoided. (PVA-NBD 2020, p.454; Level B)
M.12.1
Risk to skin integrity: all individuals with diminished/absent sensation and prolonged toileting should use a pressure-distributing seat, whether using the toilet or a shower chair. This will reduce the risk of pressure damage to the skin, but not eliminate it. Individuals with a history of skin damage and resultant scarring may not tolerate even a short sitting time safely. Minimizing the duration of bowel care through an effective and timely bowel management program is essential. (Adapted from BOWEL 2012; Level C)
M.13.1
Education for individuals with SCI, caregivers, and health care providers should be provided and comprehensive to all levels of learners. (PVA-NBD 2020, p.454; Level C)
M.13.2
The components of the bowel program should be taught to individuals with an SCI as well as to caregivers. (PVA-NBD 2020, p.455; Level C)
M.13.3
Education on potential complications should be completed. (PVA-NBD 2020, p. 455; Level C)
M.13.4
Education and support for the caregiver should be considered and completed when appropriate. (PVA-NBD 2020, p.455; Level C)
M.13.5
Sexual intimacy and considerations related to bowel program management should be discussed. (PVA-NBD 2020, p.455; Level C)
M.14.1
Assessments of neurogenic bowel disease should include psychosocial aspects that are barriers to learning the bowel program, such as cognition (ability to learn and direct others), depression, anxiety, pain, literacy, language, and ethnic or cultural issues. (PVA-NBD 2020, p.455; Level C)
M.14.2
If an individual with SCI is having multiple problems with neurogenic bowel disease or is noncompliant with the bowel program, a formal screening tool should be used to assess depression, anxiety and quality of life. (PVA-NBD 2020, p.455; Level C)