Neurogenic bowel vs. constipation

Neurogenic bowel vs. constipation

Posted by AskNurseLinda on Aug 6, 2018 9:55 am

Often, I hear people talking about the working condition of their bowel after spinal cord injury. People might discuss their bowel function as constipation as opposed to neurogenic bowel. In fact, these are two separate issues. If you think about the old saying, a poodle is a dog but not all dogs are poodles, the same can be said for the bowel. A constipation can appear in a neurogenic bowel, but all neurogenic bowels are not constipated. Let’s break it down a bit.

A spinal cord injury affects the nerves that cause the bowel to function. The bowel is controlled by a variety of nerves that function automatically. The bowel will function to propel material through it after any level of spinal cord injury because it is under the influence of the autonomic (automatic) nervous system although it might be slower than prior to injury or disease. The bowel even has nerves within it that function when material is in the bowel. Your body will propel material through the bowel on its own without your thinking about it. Just like your heart beating, the bowel works. You cannot speed it or slow it through thinking.

Food, broken down in the form of a thick sludge called chyme, will work its way along the entire length of the really long bowel.  The purpose of the small intestine is to extract nutrients from food and water at the molecular level, pass them through the bowel into the blood stream to power and hydrate the body. The large intestines also extract nutrients and water but will also mold the chyme into the stool that is expelled from the body.

The farthest end of the bowel is controlled by specific nerves. Sacral nerves S2, S3 and S4 causes your internal rectal sphincter to relax and the rectum and anus to contract to evacuate your lower bowel. If the message from the brain is not interrupted from injury or disease, these sacral spinal cord segments can contract the external rectal sphincter to expel or hold stool.

Spinal nerves T11-L2 (Thoracic 11- Lumbar 2) will contract your internal sphincter and tighten your rectum and anus to hold in stool until you find the appropriate time and place to evacuate your bowel unless interrupted by spinal cord injury. This is a marvelous process when messages are able to be transmitted. We don’t really think too much about the process until it is disrupted.

Neurogenic bowel is a disruption of the nerves that transmit the messages from the bowel to the brain and back again. Because nerve function to the bowel is complex due to the length of this huge organ, the type of spinal cord bowel injury is classified in two ways. Upper motor neuron (UMN) bowel is diagnosed in individuals with an injury or disease at the cervical or thoracic levels. The injury can be anywhere long this part of the spinal cord. This type of bowel function is typically spastic. The bowel will empty spontaneously whenever any amount of stool is formed in the rectum. This can lead to embarrassment if not in a socially acceptable venue for toileting. Typically, the body will be spastic below the level of injury as well.

The other bowel classification is lower motor neuron (LMN) bowel. In this case, the injury is typically in the lumbar or sacral area. This bowel is flaccid or ‘areflexic’ meaning that stool will collect in the rectum without spontaneous evacuation (no reflex release). The bowel just gets more and more dilated as it fills with stool. If left without evacuation, the stool will expand stretching the bowel so that it is difficult to snap back to its regular shape over time.  Some stool might be evacuated as overflow, but the bowel does not empty. The stool remains in the rectum with constant water removed so it becomes very dry and very hard. In a lower motor neuron bowel, stool is manually removed during the bowel program.

Either diagnosis of upper motor neuron bowel or lower motor neuron bowel is treated with a bowel program to safely and effectively remove stool, to avoid social embarrassment, skin break down and to keep stool from bowel backing up into the bowel leading to impaction or nausea and vomiting of stool.

There are some diseases that affect the bowels. Almost any disease that affects the nerves will affect the bowels. This includes multiple sclerosis, ALS, Parkinson’s Disease and others. Diabetes affects nerve function commonly known in the feet and hands. However, diabetes actually affects nerve function throughout the body. This can include the bowel. You might not feel the tingling sensation that is felt in the feet and hands as nerves are affected with diabetes, but there is a change in bowel content and function. When sugar or carbohydrate hits the bowel from foods eaten, you will notice immediate need to evacuate your bowel. Diabetes has a higher incidence in individuals with spinal cord injury, so SCI and diabetes is a double risk for bowel problems.

Constipation is a different problem. Constipation is not necessarily a problem that has its origins in spinal cord injury. In fact, anyone can become constipated with or without a spinal cord injury. Constipation is stool that is too dry. The cause can be from too slow of transit of chyme through the bowel or not enough hydration in the body or both. Slow transit through the bowel or lack of fluid will dry stool as the entire time the chyme is in the bowel, water is being extracted. Constipation can also be caused by a stricture or narrowing of the bowel, colon cancer or other structural problem in the bowel.

Sometimes, people have a temporary constipation. You could be out of your routine and not take in enough fluid one day, over drink alcohol which will dehydrate the body or exercise or work with an overproduction of sweat. People become dehydrated for a variety of reasons, even illness such as fever. The result is seen in your stool which becomes very dry.

It is important to keep up with your fluid intake to keep your bowels moving efficiently and effectively. If you are sweating, you may need to take in a bit more fluid such as on a hot day. Don’t forget humidity can dry your body as well even if the temperature is not high. In the winter, you can dehydrate from being in a room with dry heat.

In addition to fluid intake, the bowel is affected by movement and diet. Those with slower moving digestive systems might become constipated more frequently. Your bowel might function more slowly if you are not using your abdominal muscles in movement or have a diet that lacks roughage.  Movement can include walking but also, just moving your extremities actively or passively. People who are sedentary through work, choice or, disability might have slower bowel movement. Roughage can help the bowel work by eating foods with increased fiber or use of fiber adding products.

Medication is a common culprit in constipation. Certain medications have constipation as a side effect. Medications known as constipation culprits are narcotics, calcium channel blockers used to treat high blood pressure, antiseizure medications and antispasmodic medications. You might develop constipation soon after starting these medications or constipation may develop after being on them for awhile so don’t overlook them in your constipation assessment. You can check with your healthcare professional about changing to another, less constipating medication or add fluid and fiber to your daily routine. Whichever you decide, it is critical that you do not stop these medications without consulting with your health care professional.

Chronic constipation can be found in anyone. Chronic constipation is defined as having less than three bowel movements per week. You will note that in a typical bowel program after spinal cord injury, a bowel movement occurs every other day so chronic constipation is avoided. Chronic constipation is also considered when the stool is dry or very hard. Straining is another factor. Sitting on the commode or toilet to lengthy periods of time can put a similar effect as straining on the anatomy of the lower bowel.

Because of a slower, neurogenic bowel, limitations with fluids, some medications and lack of mobility, individuals with spinal cord injury can become constipated. Because you have a neurogenic bowel, it does not mean that you will have constipation. A neurogenic bowel is a risk factor but not a criterion.

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Re: Neurogenic bowel vs. constipation

Posted by Virginia girl on Sep 28, 2018 2:04 pm

First Nurse Linda I so appreciate all the information you supply on your webinars and incorporate into your blogs. Can’t tell you how much I have benefited from your discussions, especially including information about physiology. When you live in a rural area, access to knowledgeable professionals is so limited.

I am a 61-year-old female, C5-6 quad for 46 years. Have a suprapubic indwelling Foley catheter. Bowel regimen has always been 1 (or 2 if needed) Peri-Colace & digital evacuation every morning. Gallbladder removed in the 90s and was dx with stones in my common bile duct in 2012 and required 3 ERCPS to clear out stones. Take Ursodiol to prevent stones, 5 mg oxybutynin 2 x day and 10 mg baclofen at night. Also take 1 g of sodium, hx hyponatremia because of drinking too much fluid. I eat a well-balanced diet which includes fruits and vegetables daily.

As of July of this year quite suddenly, began having significant trouble with constipation. Increased my Peri-Colace, supplemented with Dulcolax pills or Milk of Magnesia as needed per recommendation of my PCP. Had to have an enema in the ER early in July to get some bowel results. Began working with a gastroenterologist in July, he recommended daily use of MiraLAX. Bowel results had been and continued to be a mud consistency even after a trial of adding Benefiber(used for around a week, probably not long enough). Scheduled a colonoscopy the end of July, was not cleaned out enough to complete the study. Over the summer, used various products to avoid impaction (magnesium citrate, MiraLAX). Began reading bowel resource materials available through your website and other SCI resources. Also talked to nurse at Craig Hospital for guidance related to functioning of the neurogenic bowel. Bloodwork WNL.

Completed a colonoscopy the end of August with significant difficulties with getting colon clean enough for the study even after 2.5 days of prep (1 bottle of magnesium citrate, 4 Dulcolax pills & 2  32 oz of Gatorade with MiraLAX). Thankfully, all was WNL with no signs of polyps, inflammation or cancer. Gastroenterologist thinks all trouble related to neurogenic bowel. I guess my peristalsis has really been reduced. Began to show a rash when taking MiraLAX so gastroenterologist prescribed one 145 mcg of Linzess daily. Have been using this medication for 2 weeks along with 1/2 packet of Benefiber over the last week. Bowel results are inconsistent while bowel consistency is still like mud which is EXTREMELY difficult to evacuate for a caregiver using digital evacuation.

Never had much success with Dulcolax suppositories but ordered Magic Bullet suppositories which have not arrived. Also ordered Enemeez mini enemas, used one 4 days ago with success. After 46 years of success using Peri-Colace and digital evacuation, using a mini enema or suppository on a routine basis would be a difficult change to incorporate into my routine. This ordeal has been SO STRESSFUL, and very much limited my activities. Have had some episodes of bowel incontinence but thankfully no symptomatic UTIs and want to keep it that way! Also I definitely want to prevent impaction. Suggestions? Thank you so much.

Virginia girl

Re: Neurogenic bowel vs. constipation

Posted by AskNurseLinda on Sep 30, 2018 3:34 pm

Hi, Virginia Girl, what a tale of classical bowel problems. You have been through it. Yes, the bowel can slow down for any number of reasons from long term spinal cord injury to just getting a little older or a combination of factors. You have received excellent advice from people with great experience in treating the sluggish bowel.
Here are some ideas that you might want to discuss with your healthcare provider. Be sure someone who is directing your care knows what you are doing. Since I don't know you, I might suggest something that is not in your best interest so be sure an ask before moving forward. Also, don't make more than one change at a time. Wait a few weeks before trying something else. It can take a while for bowels to adjust.
Stool that is too wet is difficult to remove. It needs form to be able to be propelled out, which you have experienced. It could be too much water intake but I will assume you do that for your bladder function and lack of UTIs indicate that is working. Sometimes after the bowel cleanses that you have completed, the flora of the bowel is wiped out. The bowel flora consists of good bacteria that naturally live in the bowel. This bacteria breaks down food for easier digestion. Your flora is probably gone from the bowel cleanse. Normally, after a bout of regular diarrhea, the good bacteria replaces itself but with extreme bowel preps, the replacement cannot keep up with the need. Probiotics are sometimes used for a short term to replace that bacteria. A one month supply is enough. Long term probiotic use has been getting some bad press but check to see if a short term course will be o.k. for you. This often works wonders, even with continued bowel programs.
Since the stool is already too wet, a suppository might be too strong for you as it will lead to leakage and the stool that does appear will be even wetter as it is not getting time for the water to be absorbed (lack of flora). When the stool is wet, it is usually recommended to bulk it up with fiber. Fiber comes in various forms. You can drink it in water or eat it as a cookie or a chewable pill. Once the stool is bulked up, you might then need a suppository.
If you find you need something to flush out the lower colon, the enemeez is a good choice. It does not take long to work. I understand your not wanting to use a product since you did not use one before. You could try this temporarily until you rebuild the stool either with probiotics for one month only or using fiber. They are different actions but both tend to result in a bulkier stool
So, first ask if probiotics for one month is ok for you. Use the enemeez temporarily to evacuate your bowel. Check on the consistency of your stool. You might find you do not need to use it for the entire month but you bowel might return to its typical consistency sooner than the entire month of probiotic.
If a couple of weeks go by and the stool is not forming up, try adding the fiber.
I think this might work for you and that you will return to your usual function. It does take time so do not get discouraged. Nurse Linda

Re: Neurogenic bowel vs. constipation

Posted by Virginia girl on Oct 13, 2018 4:00 pm

Thank you for your helpful information. I did take a high powered probiotic(recommended recommended by my G.I. doc) daily for around a month without noticeable change. I’m sure it did help after the bowel cleanses-just not enough to resolve wet stool. I have added half doses of Benefiber, wanted to start slowly, and will increase to a full dose daily. Do you have any knowledge/thoughts on use of Linzess? I used to take 1 Peri-Colace daily (and a second one if needed) but have switched over to Linzess 145 mcg daily. I also take a sodium tablet daily because a history of hyponatremia (NA typically 135) from excess fluid intake to prevent UTIs. I try to be sure I don’t overdo the fluid.
recommended by my G.I. doc) daily for around a month without noticeable change. I’m sure it did help after the bowel cleanses-just not enough to resolve wet stool. I have added half doses of Benefiber, wanted to start slowly, and will increase to a full dose daily. Do you have any knowledge/thoughts on use of Linzess? I used to take 1 Peri-Colace daily (and a second one if needed) but have switched over to Linzess 145 mcg daily. I also take a sodium tablet daily because a history of hyponatremia (NA typically 135) from excess fluid intake to prevent UTIs. I try to be sure I don’t overdo the fluid.
recommended by my G.I. doc) daily for around a month without noticeable change. I’m sure it did help after the bowel cleanses-just not enough to resolve wet stool. I have added half doses of Benefiber, wanted to start slowly, and will increase to a full dose daily. Do you have any knowledge/thoughts on use of Linzess? I used to take 1 Peri-Colace daily (and a second one if needed) but have switched over to Linzess 145 mcg daily. I also take a sodium tablet daily because a history of hyponatremia (NA typically 135) from excess fluid intake to prevent UTIs. I try to be sure I don’t overdo the fluid. So appreciate your input

Re: Neurogenic bowel vs. constipation

Posted by AskNurseLinda on Oct 13, 2018 8:30 pm

Hello, Virginia Girl. It is so nice to hear from you. It is never a quick fix to bowel issues. It takes time to adjust as you are so well aware.

I was excited about Linzess when it was introduced so I phoned the company to see about use with SCI. It is not on their list of intended issues. That is to say, they did not apply for treatment of SCI neurogenic bowel when the application for FDA approval was requested. Therefore, it is not recommended for treatment of neurogenic bowel mostly because it is a treatment for constipation. Constipation or hard or difficulty passing stool is different physiologically than neurogenic bowel as a result of SCI. You seem to have more loose or diarrhea type stools.

All of that being said, Linzess stimulates the nerves in the bowel to work. Many people, including myself, thought this could be a treatment for neurogenic bowel. However, it is a different mechanism of treatment which stimulates the brain to stimulate those nerves in the bowel. With SCI, the message do not get through.

All this being said, I know there are individuals who take Linzess off label, meaning for reasons not issued by the company. Some people like it. Many don’t. The main side effect of the drug is diarrhea which is not desired. The diarrhea arrives about two weeks after starting the medication. You will want to notice if you have diarrhea in particular because of your sodium issue in addition to the fact that diarrhea can upset all of your electrolyte balances.

Since your physician prescribed the medication, they might have some information about your condition. So, follow their recommendations but be aware of the threat of diarrhea so you can notify them of this complication. It might be difficult to distinguish a new case of diarrhea from your watery stool. The individuals that I have spoken with who have had this complication indicate it is a significant diarrhea, not a small change so I think you will know if you have it.

If it is ok with your physician, keep up with the benefiber to the full dose. That should help bulk up your stool. You need to continue your water intake routine for your sodium so don’t worry about taking in less. The bulk former will help absorb your water intake. 

Have your care provider review all of your medications to see if something could be overstimulating your bowel. Most individuals with SCI have a slow bowel. You seem to be just the opposite with a quickly moving bowel. On the one hand, that is an advantage, on the other, the complications you have been having. Be sure you have been checked for an impaction or blockage as sometimes this is present with only watery stool going around the blockage. I recall you have a colonoscopy, so a blockage would have been noted but one can form later.
The replacement of the flora in your bowel with the probiotics is a step in the right direction. That should help but might still take some additional time to work.

You are very lucky to have healthcare professionals that are working with you. Keep them informed of your prescribed and over the counter medications. Track number and consistency of stool. I hope you will see a reduction in number until the situation is resolved. Sometimes regulation can take up to six weeks or even a little longer. It is a challenge, but your efforts will pay off. Nurse Linda

Re: Neurogenic bowel vs. constipation

Posted by Virginia girl on Nov 6, 2018 3:30 pm

I want to give a favorable update. Since my last post the consistency and frequency of my bowel routine has greatly improved. I have been able to return to my regular bowel routine. I now use one dose of Benefiber every morning and take one tablet of Linzess (72 mcg) every 2-3 days. I no longer use Peri-Colace or any other stimulant or softener. One of the greatest lessons I have learned over my 3.5 month journey is that any changes that you start with the digestive system take time to improve. When your bowels are out of whack you can become so anxious and frustrated that you consciously or unconsciously want improvements quickly. The other important point I learned was when making alterations to your bowel routine be sure and make one change at a time so that you can accurately determine what works and what doesn’t. I am so grateful for Nurse Linda and the Christopher Reeves Foundation for all the wonderful information and the chance to connect with other folks with SCI.

Re: Neurogenic bowel vs. constipation

Posted by AskNurseLinda on Nov 6, 2018 8:24 pm

Hi, Virginia Girl, thank you for the follow up. I am glad you found success. I think it is keenly important that fellow readers hear about your improvement. It does take a lot of time but bowels can be conquered.
I am especially happy for you. Nurse Linda

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