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Bowel management is an important part of care provided for individuals with spina bifida. It is necessary to understand the functioning of the bowel and factors that contribute to a successful continence program. Almost all children with spina bifida, even those who can walk, have trouble with bowel control. Bowel management can help the child to learn to prevent accidents and to have regular formed bowel movements. It takes patience, time and hard work. The rewards are worth the effort.
Understanding the digestive system and how the bowel works is important. Digestion is the change food undergoes, breaking it down into smaller parts to be used by the body. The mouth is the first structure of the system. Chewing and saliva begins the process. Swallowing results in the movement of food into the esophagus, on to the stomach and the small intestine where it proceeds to be broken down into nutrients and waste products. Water, electrolytes, and nutrients are absorbed. As the food moves through the small intestine to the large intestine waste products are stored until they are ready to be eliminated (expelled).
Food and waste material move along the small and large intestines by a wave-like motion called peristalsis. This motion propels food forward causing waste material to leave the large intestine and enter the rectum. As the rectum stretches, the internal anal sphincter (valve) relaxes and allows stool to pass. This is an involuntary reflex (no control over action) that sends a message to the brain the elimination is about to occur. The external anal sphincter (valve) is the voluntary reflex (control over action) stimulated by the stretched rectum. The body responds to this reflex by keeping the sphincter closed until a proper place to empty is available.
Both sphincters (valves) internal anal sphincter (IAS) and external anal sphincter (EAS) are affected in individuals with spina bifida. Nerves that control these sphincters are the lowest on the spinal cord. Therefore an opening anywhere along the spinal cord can cause these nerves to not work.
The IAS, internal anal sphincter, may not be able to detect the presence of stool and send the message to the brain. The EAS, external anal sphincter, does not get a message from the brain to hold or release stool. Therefore individuals with spina bifida need a regular elimination program to prevent accidents.
Constipation is the passing of hard ball shaped stools which are difficult to expel. Constipation occurs because the movement of stool through the colon has slowed. Slowing of movement occurs due to:
- Diet low in fiber;
- Inadequate fluid intake;
- Irregular and incomplete emptying;
- Anesthesia-surgery; or
- Pain medications.
Fecal impaction is the accumulation of unexpelled stool. Large clumps of stool collect in the colon making elimination more difficult. As the colon enlarges muscle tone is lost and the urge to empty decreases. Diarrhea like stool occurs because there is seepage of liquid around clumps of stool. This requires a complete clean out of the colon with enemas before a regular emptying program can be started.
Children with spina bifida have episodes of diarrhea like other children. They may have diarrhea because of illnesses, certain foods or “anxiety”. The weak outside sphincter allows stool to “leak” anytime there is stool in the rectum.
Bowel management is important and beings early in the infant’s life and continues in a series of steps. A successful program depends on:
- Good stool consistency;
- Regular emptying times; and
Prevention of constipation is taught from infancy. Keeping the stool soft and easy to push out prevents problems for the infant. Drinking enough fluids and eating the right foods to help to keep the stool soft.
The toddler learns about using the potty chair for bowel movements and is helped to establish a regular emptying time. The older child’s body becomes used to this and fewer accidents occur. Over time the child is able to manage without assistance.
The information in this page is intended to provide general information about bowel training. A specific program is set up according to the child’s age, abilities and needs. You will be given much guidance and instruction from step to step. It is very important to remember that bowel training does not occur overnight but represents months and sometimes years of patient hard work. There ups and down, days that are discouraging and incidents (i.e. illness, surgery) that cause interruptions in the process. However the final goal of continence (no accidents), independence and good stool consistency is attainable and provides the child opportunities to be more involved and accepted by his/her peers.
|Author:||Daniel Jackson, MD - 9/2009|
|Content Last Updated:||5/2011|