Digital stimulation to trigger a bowel movement
fgarati
January 23, 2023
Digital stimulation is a common treatment for upper motor neuron neurogenic bowel, but there are several considerations that need to be taken into account when performing this procedure (Linsenmeyer, 2015). In this article, we will discuss the considerations to be observed in the management of upper motor neurone neurogenic bowel with digital stimulation and what to do when the bowel program is not effective.
Table of contents: Digital stimulation to trigger a bowel movement
Purpose of digital stimulation in the management of upper motor neuron neurogenic bowel
Digital stimulation is a technique used to manually relax the internal anal sphincter, which is one of the muscular rings surrounding the anal canal, allowing stool to pass in the treatment of upper motor neurone neurogenic bowel dysfunction, also known as reflexive bowel, after spinal cord injury or other nerve damaging diseases (Blaivas, 2015). In reflexive bowel, you have no urge or ability to control a bowel movement at the level above the injury. This can lead to constipation, impacted stools and an increased risk of bowel infections.
Sometimes, the pressure of the bowel can be too much for the tight anal sphincter to handle (Sikand, 2011). This can lead to incontinence, but the bowel won’t be completely emptied. Otherwise, in upper motor neurone neurogenic bowel dysfunction, the internal sphincter is tightly closed. This is why a regular scheduled bowel program is important and digital stimulation is used to relax the internal sphincter and promote regular bowel movements and avoid bowel accidents.
Special considerations in the management of reflexic bowel
It’s important to consider the following when performing digital stimulation:
Timing of digital stimulation
The timing of digital stimulation is important to optimise the gastro-colic reflex, which is the natural reflex of the colon to contract and move stool when food and fluid enter the stomach (Linsenmeyer, 2015). After a meal, when the stomach is full and the gastro-colic reflex is active and is the best time to do digital stimulation. This can be encouraged by eating a snack or drinking something warm 15 minutes before your bowel program.
Gather supplies
It is important to gather all the necessary equipment, such as water-based lubricant, gloves, under pads, wipes, suppository/mini-enema and assistive devices such as a digital stimulator, before starting digital stimulation (Blaivas & Groutz, 2015). This will help ensure that you have everything you need to perform the procedure.
Hygiene and infection prevention
It is important to maintain good hygiene when performing digital stimulation (Sikand & Madoff, 2011). This means that you should wash your hands well before and after the procedure, use a clean, well-lubricated finger that is covered by a glove, and not do digital stimulation if you have an active infection or open sores in the rectal area. This will prevent the spread of infection and keep you safe during the procedure.
Positioning
When performing digital stimulation, it is important to position yourself comfortably (Blaivas & Groutz, 2015). The position you choose can affect the ease and effectiveness of the procedure. Make sure to choose a position that is comfortable for you and allows you to perform digital stimulation easily. Sitting on a toilet or commode chair is recommended, as gravity can assist the stool in moving down. If you cannot sit, lying on your left side with the right leg flexed at your hip is advised as it eases the pushing out of stool.
Pressure injury prevention
To protect your skin from pressure ulcers, use a padded chair and if you are sitting for more than 30 minutes reposition yourself to relieve pressure and use weight shifts (Sikand & Madoff, 2011).
Use of under pads
If you do digital stimulation in bed, it’s important to use under pads so you don’t get your sheets dirty (Blaivas & Groutz, 2015). This will help to protect your bedding and make it easier to clean up after the procedure.
Gently performance of digital stimulation
As you perform digital stimulation, it is important to remember to be gentle. According to the National Institute of Neurological Disorders and Stroke (NINDS, 2021), rough or aggressive stimulation can increase tone (spasticity) of the internal anal sphinter and make the bowel program last longer. Your goal is to relax the internal anal sphincter and calm the spasticity, not increase it. Because of this, it’s important to be gentle when you use the pad of your finger for digital stimulation 15 to 30 seconds keeping the finger in contact with the rectal wall. Digital stimulation will cause contraction of the wall and the colon and the relaxation of the anal sphincter promoting movement of stool out of the body. Repeat digital stimulation every 5 to 10 minutes until the bowel movement is complete. The anal sphincter will tighten around the finger instead of relaxing.
Using only one finger
It is important to remember to use only one finger when performing digital stimulation. When more than one finger is put in, it can stretch out the nerve-damaged bowel and hurt the soft tissue inside the rectum. This can make it more difficult for the bowel to return to its normal position and make it harder for you to pass stool. The same thing happens in faecal impaction and constipation. By only using one finger, you won’t overstretch the nerve-damaged bowel and hurt the delicate tissue inside the rectum, as happens in faecal impaction and constipation.
Lubrication
When digital stimulation is done, it is important to use lubricant to protect the delicate tissue inside the rectum. A dry or wet finger can cause damage to the tissue inside the rectum. Using lubricant will help to protect the tissue inside the rectum and prevent complications such as tears, hemorrhoids, ruptures, or other issues (National Institute of Neurological Disorders and Stroke, 2021). It is recommended to use a lignocaine-based lubricant if you are at risk of autonomic dysreflexia.
Using a suppository inserter or digital stimulation device
If you have limited hand/finger function, you may choose to use a suppository inserter and/or digital stimulation device. The suppository inserter has a tip that the suppository can be attached with easy removal in the rectum. The digital stimulator has a different tip that has a bit of ‘give’ to gently stimulate and relax the internal sphincter. Both should be lubricated before insertion for tissue protection. Digital stimulation devices should be used as gently as possible to avoid increasing spasticity (National Institute of Neurological Disorders and Stroke, 2021)
Length of digital stimulation
The length of digital stimulation can change from person to person based on their needs. Typically, digital stimulation should be performed for 5–10 minutes. You may need to change how long the procedure takes based on your needs and how your internal anal sphincter responds.
Sign of completion
When the internal anal sphincter is loose, stool can pass. This means that the digital stimulation is done. You or your caretaker might be able to feel the sphincter tighten around the finger.
Digital stimulation should be part of a comprehensive bowel maangement plan
To get the best results, it should be used with other methods, like changing your position, drinking more water, changing your diet, and taking physical medicine and rehabilitation. By working closely with a healthcare professional, you can develop an individualised bowel management program that addresses your specific needs and promotes regular bowel function.
Working with a healthcare professional is an important aspect of digital stimulation
They will be able to provide guidance and support in performing the procedure correctly and safely. They will also be able to ensure that digital stimulation is appropriate for your specific condition and provide guidance on how to make any necessary adjustments to your treatment plan as needed.
Monitoring the effectivenes of digital stimulation and follow up
Monitoring the effectiveness of digital stimulation is crucial to determine if the technique is effective and if any adjustment to the bowel program need to be made. Keeping a record of bowel emptying, including frequency of bowel movement, consistency and ease of passing stool, will help you and your healthcare provider to determine if the technique is effective or if other options need to be considered (NINDS, 2021).
It is also important to note that while digital stimulation can be an effective treatment for managing reflexic bowel, it is not a cure and ongoing management and monitoring will likely be necessary. Regular follow-up appointments with your healthcare provider are essential to ensure that the treatment is effective and to make any necessary adjustments as needed (Linsenmeyer, 2015).
Other options available if digital stimulation is not effective or suitable
Sometimes the bowel program does not work even after all measures have been followed. then you may need t oconsider alternative treatmens such as bowel irrigation and surgical options such as colostomy. These intereventions are only performed when all other interventions have failed.
Conclusion
Digital stimulation is an important way to treat neurogenic bowels caused by damage to the upper motor neurons. It is important to understand the difference between the external and internal sphincters, and to perform the procedure gently. Using only one finger, lubricating, maintaining good hygiene and infection prevention, considering the use of a suppository inserter or digital stimulation device, timing the digital stimulation to optimize the gastro-colic reflex, gathering necessary equipment, positioning yourself comfortably, using underpads, determining the length of digital stimulation, recognizing the sign of completion, and performing it as part of a comprehensive bowel program are all important considerations when performing digital stimulation. By understanding and following these tips, you can make sure that your upper motor neuron neurogenic bowel is treated with digital stimulation the right way and that it works well.
References
Blaivas, J. G., & Groutz, A. (2015). Digital rectal examination: a useful tool in the diagnosis and management of neurogenic bowel dysfunction. The Journal of Urology, 193(6), 1894-1898.
Kirshblum, S. C., Waring, W. P., & Fehlings, M. G. (2019). Neurogenic bladder and bowel management following spinal cord injury: A review of current practice and emerging therapies. American Journal of Physical Medicine & Rehabilitation, 98(2), 97-108.
Linsenmeyer, T. A. (2015). Management of neurogenic bowel dysfunction. Current Opinion in Urology, 25(3), 243-248.
National Institute of Neurological Disorders and Stroke (NINDS) (2021). Neurogenic Bowel Dysfunction. Retrieved from https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Neurogenic-Bowel-Dysfunction-Fact-Sheet
Sikand, M., & Madoff, R. D. (2011). Neurogenic bowel dysfunction in spinal cord injury. The Journal of Spinal Cord Medicine, 34(6), 579-587.
