Key facts about managing bowel incontinence

This section covers bowel continence management, including constipation and other bowel problems.

You have probably discovered that achieving bowel continence has been one of your most difficult challenges.

The goal of effective bowel management is a routine that enables you to:

• avoid bowel accidents
• maintain stool consistency, and avoid constipation and diarrhoea
• achieve social continence at work and at play.

What is the cause of bowel incontinence?

As with the neurogenic bladder, bowel incontinence is caused by spina bifida related nerve damage. The nerves between the spinal cord and the bowel system have been damaged.

What are the main things that require management?
The nerve damage has caused the following:

• reduced sensation to know that your bowel is full and needs emptying, leading to bowel accidents
• reduced sensation to know when an accident has occurred
• weaker anal muscles making it more difficult for the anus to hold stools in
• bowel functioning which makes you much more prone to constipation, and if this occurs for a long time, the lower bowel becomes very stretched and even less sensitive.

The above problems will range from mild to severe in people with spina bifida. Your particular symptoms hopefully will be very mild.

What are the keys to effective bowel management?
The introduction of clean intermittent catheterisation (CIC) has made it so much easier to manage bladder incontinence in a way that supported an independent lifestyle. Nothing similar has been found for the bowel.

There is no bowel management technique which stands out like CIC does for the bladder.

How to manage bowel incontinence
The keys to effective bowel continence management are:

• understanding exactly how your bowel works and how it reacts to different food types
• how mobile you are - walker or in a wheelchair - makes a big difference. The more you exercise, the better your bowels will function. Maintaining your mobility will protect you from constipation.
• keeping your stool at the right consistency (ie. too hard = constipation; too soft = diarrhoea) through careful diet and exercise so that your bowel is able to be managed
• effectively ‘training your bowel’ so that it is full at set times, thus making an emptying routine possible
• using the right aid to help empty the bowel - microenemas, large volume washouts, etc.
• great diet and plenty of exercise. These will keep your weight down and prevent obesity.

With a positive attitude, good organisational skills and making sure you regularly get advice from experts, you can effectively manage bowel incontinence.

If your bowel management is not ‘bomb proof’ by early adulthood, get specialist assistance from an expert. It can be difficult to talk about and really confronting, but you simply must.

Why is it so important to avoid becoming constipated?
Constipation can occur very quickly in spina bifida and makes effective continence management impossible.
Constipation increases the risk of urinary tract infections.

Many people with spina bifida have a natural tendency toward having firm stools. This is good, as firmer stools are easier to manage than loose stools. However, constipation where the stool is too hard is not good.

Constipation is often associated with bouts of diarrhoea, which is very confusing. The ‘too hard’ stools block the bowel; very soft and runny stools stuck above the constipation cannot be processed by the bowel properly, and will flow around the hard material causing a bout of diarrhoea.

Chronic constipation also stretches the bowel and leads to weakened sensation. This stretching can take years to get back to normal.

What causes constipation and diarrhoea?
The primary causes are:

• poor diet and lack of exercise
• medications, especially some used for bladder incontinence. Antibiotics - often for urinary tract infections - may cause temporary diarrhoea.

What other factors can cause a change in bowel habits?

Lifestyle factors and life events such as:

• holidays
• disruption in usual daily routines
• a change in water, such as when travelling
• illness, especially involving fever
• anxiety especially at work or school
• hospital procedures
• changes to family structure such as a new birth, separation, death of a relative or friend
• starting a new school or job.

A good diet: The key to good health and happy bowels
What diet will help achieve the right stool consistency for good bowel management?
While a healthy diet for people of all ages is a general health principle, diet can be used effectively by some people to alter stool consistency and support bowel control.
It is important to know which foods cause loose stools (diarrhoea) and which foods will promote a good firm stool.

As you can see, it is not a mater of limiting your food intake to alter stool consistency. It is a matter of selecting the right foods to suit your purpose. There is plenty of variety to choose from. You won’t go hungry!

Medical treatment of constipation and diarrhoea

Are there any drugs that can be used to control stool consistency?
Yes. Drugs can sometimes be used to control stool consistency, but should only be used for a limited period of time. Long term use of drugs may have a damaging effect on bowel functions.

There are four types of drugs prescribed:

• laxatives (to deal with constipation)
• bulk forming agents (making your stools bigger)
• stool softeners (softening your stools)
• stool hardeners (hardening your stools).

What are the best techniques to assist with bowel emptying?
There are many techniques and methods for emptying bowels ranging from normal toileting to sophisticated surgical techniques. Most of you will have had extensive toileting experience.

Establishing a bowel emptying routine
Effective bowel management involves a system for bowel emptying at regular intervals, at least every 24 hours. For example, you could associate the timing of bowel emptying with meals, baths, and physical activities. A particular time of day can help establish predictable continence patterns.

Anal/rectal stimulation
Sometimes anal/rectal stimulation to promote bowel emptying can be achieved by wiping the anus firmly with toilet paper as soon as you sit. If the stool is not being expelled, slight pressure can be applied with the fingers to each side of the anus.
Digital stimulation involves inserting a gloved finger into the anus and massaging to stimulate a contraction to eliminate a stool.

Suppositories and microenemas
Most enemas and suppositories are special fluids squirted or placed into the anus. They assist to irrigate the bowel and wash out the stools. They assist particularly where you have reduced ability to push out the stools.

Large volume wash outs
If other methods do not work, large volume enemas also called ‘colonic washouts’ may be required to wash out the bowel. The amount and type of fluid is determined by the specialist clinic, and may include solutions of salty water; soap and water; or other solutions. The enema is administered by using a bowel washout kit. Make sure you get assistance from your continence nurse, and regularly review your technique at regular check-up visits.

A large volume washout will clear the bowel for up to three days. The main problem is that you will probably need help to administer it. This of course means you are not as independent as you would like to be.

Are there any other procedures that may help with bowel incontinence?
Yes. Buttock strapping is a possibility. This provides a bit of extra assistance to your anus to hold in stools. However, this technique will not work when the stools are soft, or when there is diarrhoea. Strapping can be used when swimming, on special outings or even most of the time.
Try different types of tapes to ensure that they are waterproof or that no adverse reactions will occur. Typically used tapes include elastic adhesive tapes, nonallergenic tapes, waterproof adhesive and even electrician’s tape.

Buttock strapping procedure

• The tape is applied low on the buttocks so that it is under you when you sit down.
• Cut the appropriate length of tape.
• Look for the position of the anus.
• Attach tape to one buttock. While holding buttocks together, attach the other end of the tape to the other buttock, ensuring that the tape passes over the anus.
• If the skin is sensitive, place some nonallergenic tape on each buttock. Stronger tape can then be applied on top of this.
• If the anus is very lax, a small piece of paper, such as half a piece of toilet paper, can be folded and placed over the anus. Females should check that the tape has not slipped down into the vagina.

What is an anal plug?
Anal plugs are an important continence management tool, and can offer real independence for some. The anal plug, made from foam, is lubricated with Vaseline and inserted into the anus. After coming into contact with the moisture of the bowel, the plug expands in about 30 seconds to form a bowl-like shape that prevents leakage. The anal plug is made from slightly porous material so that air can pass though it. The plug is removed with an attached string and is changed after each toilet visit.
The anal plug can be worn safely for up to 12 hours. Combined with diet and bowel emptying procedures, anal plugs have significantly changed the lives of many.

What surgical procedures may assist?
There are some options available for you to consider. Of course, you will consult a specialist in order to be advised as to the most suitable procedure for your needs. The most promising development is the Malone procedure which makes it much easier to administer the bowel wash out.

Malone procedure for ante grade (downward) bowel wash out

• The Malone stoma is a new surgical procedure that greatly improves the management of bowel incontinence for people with spina bifida.
• The procedure allows bowel wash outs or enemas to be done in an antegrade manner (flushing downwards) rather than in the traditional retrograde manner (flushing upwards from the anus).
• This works much more effectively and is much easier to self-administer. It supports greater self management, and therefore independence.
• In a very simple procedure, the appendix is brought to the surface of the skin and a stoma (opening on the skin) is created around the bikini line. The stoma allows access to the bowel through the appendix. The stoma has a little plastic trapdoor inserted in it that opens and closes.
• A catheter is placed into the stoma and into the bowel. A solution is injected through the catheter into the bowel. The fluid irrigates and flushes out stools in the bowel through the anus in approximately 20 minutes.
• A variety of fluids can be used (treacle and milk; saline; liquorice).
• This is much easier to do, especially for persons with limited mobility, than inserting a tube up the anus and firing a solution upwards against the force of gravity.
• Sometimes the stoma is created directly into the bowel. It has even been done through the belly button.
• The procedure is reversible, ie. if it doesn’t work, the trapdoor is removed and the stoma grows over.
• Quality of life is improved. You can swim and do most other things with the device.
• The procedure is just starting to be used in spina bifida (at a range of different ages) and the results are positive.
• Be aware that it is not a magic bullet (it doesn’t cure incontinence) and it won’t work for everyone.
• Talk to spina bifida associations and doctors/continence nurses at spina bifida clinics for more advice and referral.

MALONE PROCEDURE