Losing bowel control with bowel accidents is probably the most embarrassing and frustrating experience that you have faced, as a result of your SCI. Proper bowel management is the answer to your problem. A bowel training program that aims at establishing a routine for emptying your bowels is the safest, most convenient and dependable for you. There is no single unfailing method that would suit everyone. Experimentation is needed in each case to find a method that suits one’s own needs and lifestyle. Over a period of time the bowel can be ‘re-educated’ to empty regularly, adequately and at predictable times.
The baseline for your program will be similar to the bowel pattern that you had before your injury. Even if you had an irregular bowel habit before your injury it is better to establish a more regular habit now as this will enable you to participate in a fuller social life without the fear of embarrassment of accidents.
General Considerations

• Make sure you eat a well balanced diet.:Eat foods that provide roughage like raw vegetables, fruits, whole fruits with skin, green vegetables, whole grain cereals etc. This would increase the bulk that would make bowel movement easier
• Drink plenty of fluids:Most fluids help to soften stools. Drink more if you are constipated.
• Stick to a scheduled bowel program.
• Keep active.

Would the type of food I eat affect my bowels?
Yes. Food and proper fluid intake play a vital role in establishing a good routine. Stool consistency is directly related to food eaten. It determines the success or failure of your program. It is also important to have a right diet to avoid obesity. A person who is overweight may put excessive pressure on a small area of the body, causing a pressure sore and in addition their is the difficulty of having to lift the excess weight, whether the SIP lifts independently or is lifted by others.
What kind of food should I eat?

• Eat a great variety of food
• Eat more fibre rich foods
• Eat plenty of fruit and vegetables
• Cut down on fat and sugar, especially if you are overweight

A daily diet should include servings of:

These are protein foods needed for muscle repairs and maintenance and they also aid the healing of pressure sores. Remember these products do not have any fibre, therefore it is essential to compliment this with items from the other categories

Fresh fruits and vegetables are the sources of vitamins. They help the body to fight infections and also for the formation of various body tissues. It is important in wound healing. e.g. pressures sores.

How can I increase my fibre intake?
Fibre is found in cereals, fruits and vegetables but not in meat and animal products like milk. Your fibre intake will increase by taking:

• Breakfast cereals: Porridge (Daliya), sprouted black gram or pulses, corn flakes.
• Wholemeal flour and brown rice: It is recommended not to sieve the flour before making chapatti, puri etc. Brown rice can be used in place of ordinary rice.
• Vegetables: Have generous helpings, especially, peas, spinach, potatoes in their jackets and eat the skins too if possible. Eat more salads.
• Fruits: Try to eat one portion of fresh fruits each day including skins when possible like apples, guavas, pears etc. Papaya is a highly recommended fruit,
• Pulses and lentils: black channa, rajma, whole dals.

Is there anything I should avoid?
Try avoiding:

• Excess of spices.
• Cold carbonated beverages and alcohol
• Gas forming foods such as onions, Arbi etc.
• Too much fat and sugar
• Excessive amount of oils and Ghee

Establishing a Bowel Programme
A bowel program will work better if you

• Do the program everyday and at the same hour.
• Do it even if you have had an accidental bowel movement shortly before or if you have diarrhoea.
• Try the bowel movement at the same time of the day that you had bowel movements before your injury. But choose a time for your bowel routine that is convenient and which allows you sufficient time so you will not be rushed.
• If possible take advantage of the ‘gastro-colic reflex’. This is the reflex stimulation of the bowels that occurs 20-30 minutes after meals. Moving the bowels is thereby easier immediately following a meal.
• Do the program on a toilet seat or pot. The bowels work better sitting than lying. Keep as physically active as possible even when in bed for long periods. Do exercises to maintain range of motion exercises in paralysed limbs and make frequent position changes. Exercise increases muscle tone and stimulates bowel movement.
• Be patient! The bowels sometimes take days or weeks to change their pattern.

Types Of Bowel
The program that you should follow will depend on your level of injury that in turn will determine whether your bowel is ‘AUTOMATIC’ or ‘FLACCID\LIMP’.
AUTOMATIC BOWEL
If your level of injury is above L1, you will have an Automatic Bowel.

• In this case the sphincter in the anus stays shut until there is stimulation in the bowel to make it open so that the stool can come out.
• An automatic bowel will move in response to a suppository or stimulation by a finger.

FLACCID OR LIMP BOWEL
This occurs if your level of injury is L1 or below.

• In this case sphincter of the anus is limp and the person with this kind of bowel has incontinence.
• A flaccid bowel does not respond to finger stimulation.

Program for an Automatic Bowel

• Start with a suppository.
• Insert the prescribed suppository at your scheduled time.
• If a suppository works quickly for you insert it while sitting on a toilet or commode when this is possible. If it takes over 15 minutes insert it while lying on your left side.

STEPS FOR INSERTING A SUPPOSITORY

• With the gloved finger lubricated with KY jelly push the suppository about 2 cms. Gently push it to the right or left side to make sure it is in direct contact with the bowel wall.
• Drink a cup of tea or coffee or do anything that generally helps to bring on a bowel movement for you, go back to your pre-injury habit.
• If not on a toilet or commode transfer after 15-20 minutes. Sitting time should not exceed 30 minutes.
• After being seated put your feet on the footstool to get into as much of a "squatting" position as possible. Massage the upper abdomen from right to left and down several times.
• If you are unable to sit then lie on your left side. If a bedpan is to be used do so with care
• If on the second day there has still been no bowel movement repeat the suppository. If there are no results within the expected time, do a digital finger stimulation.

How to calculate the time a suppository would take for action
In the beginning it will be helpful to keep a careful record of your bowel pattern. transfer to the toilet seat, insert the suppository and wait. Note the time that it takes for the bowel movement to occur. This time varies from person to person and you have to find out for yourself how much time you need. You should also observe how different kinds of food affect your bowel movements and use them accordingly to influence your bowel movement favorably.

Steps for digital stimulation

• Gently insert a gloved lubricated forefinger beyond the anal sphincter and gently move it in stimulating circular motion several times. If still unsuccessful end the bowel routine for the day.
• Repeat the same routine on the third day. If still unsuccessful:
  • with gloved lubricated forefinger gently remove pieces of stool.
  • resort to an enema as prescribed by your doctor.

Program for a limp\ flaccid bowel
In such cases your bowel will not push the stool and the stool will have to be taken out with a finger at least once a day to begin with. If possible do it sitting on your toilet seat if not on your left side. With a gloved and lubricated finger remove as much stool as you can. Since this type of bowel tends to be incontinent i.e. it leaks, eat food that makes the stool firm.

Other Important Considerations
Do not use enemas or strong laxatives regularly. They stretch the bowel, injuring its muscles and make following a regular program more difficult. A mild laxative may be taken occasionally when needed. HOWEVER, drinking more liquid and eating food high in fibre is usually enough.

• A small amount of liquid stool (diarrhoea) may be a sign of impacted bowel. A ball of hard stool may get stuck in the gut and only liquid leaks around it. This is called ‘SPURIOUS DIARRHOEA’.
• Do not take medicine to stop this diarrhoea as this could make it worse. Try to get the impacted pieces of stools out with a finger.
• If there is bright red blood in the stool, probably a blood vessel was injured in the program. BE MORE GENTLE ! If there is dark blood or if the stools are dark and tar like seek medical advice.

A bowel program may at first seem difficult and messy. But it soon becomes an easy habit. It is very important for both your health and social well being. You should be regular and do it at the same time each.