Q. I’m in my 15th year as a C7 quad. I was at a local SCI support group and the discussion turned to “plumbing” and how often to do a bowel program. I mentioned I do my BP every fourth day with a suppository and get good results and rarely have accidents. Another person in our group said they go every fifth day. Somebody said that regularly waiting more than three days is too long and that waiting more than every other day and/or being chronically constipated can lead to something called megacolon. I did a web search on megacolon, and I’m still not exactly sure what it is. What is it? What causes it? Are there any symptoms? How is it treated? Also, how frequently should you do a bowel program?
— Matt

A. Great questions, Matt. Megacolon is a condition where stool backs up in the colon, stretches the colon muscle, and damages the colon, which loses the ability to return to normal size. Colon enlargement and loss of muscle tone slows stool movement. For someone with SCI, stool usually takes around 48-72 hours to move through the body. Megacolon slows transit time to a week or longer, according to Kathleen Dunn, a retired clinical nurse specialist and rehab case manager.

Spinal cord injury is listed as one of the conditions that can lead to colon enlargement. However, there is very little published about SCI and megacolon. One small study published in a 2000 issue of Spinal Cord looked at 128 individuals with SCI — mean age 57, mean years post-injury 20 — and found that 73 percent of the subjects had megacolon in at least one section of their colon. Although there is a link between SCI and megacolon, there are ways you can reduce your odds of developing it, starting with regular bowel programs.

“There is some evidence that doing bowel care less than three times a week can, in the long run, make a person more vulnerable to developing megacolon,” says Dunn. Since chronic constipation and/or fecal impaction can lead to megacolon, it makes sense to do a regular bowel program that produces good results. This starts with eating foods that both speed up transit time and discourage hard, lumpy stools that cause constipation and impaction. A key to getting things moving is to reduce consumption of refined flours, rice and cheese, and increase fiber intake. Fiber absorbs water as it travels down the digestive tract and increases the weight and bulk of stool, which helps move things faster.

A Craig Hospital module on bowel care recommends 20-25 grams of fiber per day. The best way to get this is from eating fruit, vegetables and whole grains. Another way to increase fiber is to take an over the counter supplement, like Metamucil, Benefiber or fiber gummies. The Craig module also stresses that when you increase fiber you need to drink plenty of water — one-half to three-quarters of a gallon per day — unless you have fluid restrictions. Dunn adds that it is also helpful to keep a food diary to fine-tune your motility and stool consistency — not too hard, not too soft. Also, remember that with SCI, it takes two to three days from “first bite to toilet bowl.”

Other helpful tips: Regular exercise speeds up transit time, as does being upright in your chair throughout the day. It is also important to avoid routine use of strong, stimulant laxatives. The Spinal Cord study found a correlation between routinely taking four or more laxative doses a month and megacolon.

Symptoms, BP Frequency and More

Distended abdomen is the first physical symptom of megacolon listed in a Medscape link. However, this may be difficult to distinguish from “para or quad gut.” Other symptoms include constipation and unusually long bowel care periods; small amounts of results; and dry, hard stools.

Megacolon can also be asymptomatic. An abdominal X-ray is the first step to diagnosis. If the result shows signs of megacolon, follow-up is done by imaging with a barium contrast fluid. This brings up an important “2-for-1” medical hack: During your annual urology appointment, ask your urologist to look at your kidney-ureter-bladder X-ray with you, because it shows the entire colon and can clarify if you are chronically constipated or backed up.

If the primary treatment of sticking to a strict high fiber, high fluid diet and regular bowel program does not bring results, surgery may be an option. According to the New England Journal of Medicine, more severe cases of megacolon require surgical intervention in the form of colostomy, colectomy — removal of part or all of the colon — or both.

Dunn says that how often to do a bowel program varies with each person and includes factors ranging from injury level and activity level to diet and fluid intake. Some people need to do a BP as frequently as once or twice a day. This often applies to people with lower motor neuron injuries below T12, since these injuries can damage the spinal reflex arc, cause the colon to lose muscle tone and not respond to digital stimulation or suppositories. Other people do fine with a BP every other day. The Paralyzed Veterans Association’s guide to Neurogenic Bowel Management in Adults with Spinal Cord Injury states that bowel programs should be routinely scheduled at least once every two days over the long term to avoid “chronic colorectal over-distention.”

If you are doing your bowel program less than three times a week, it is a good idea to discuss colon health with your physiatrist and/or your gastroenterologist — even if you are having good results. If you are having BP difficulties such as chronic slow motility or frequent accidents, you should definitely talk with your specialists. A lot of factors can affect bowel programs, including antibiotics and pain medications. There may be alternative medication options that have less effect on transit time.

Last but not least is a discussion of BP options. The basic methods are digital stimulation and manual evacuation. If these methods aren’t producing sufficient results, suppositories may be needed to stimulate increased peristalsis and get stool moving. According to Dunn, “Options include Dulcolax (bisacodyl), which has been around a long time, and works well for many, or The Magic Bullet, a bisacodyl suppository in a water-soluble base rather than a wax base, so it melts faster, has more bio-availability and may work faster.”

Dunn’s patients also report good success with Enemeez, a mini-enema of docusate sodium. “I especially like it because it avoids problems with ‘butt snot’ or ‘afterburn’ — a smelly mucous discharge that can show up to one or two hours after bowel care with a regular suppository,” says Dunn. She says she has also had a few patients who used and liked glycerine suppositories, including the Ceo-Two suppository.

• Craig Hospital: Bowel Care Resources, craighospital.org/resources/topics/bowel-care
• Medscape: Chronic Megacolon,  emedicine.medscape.com/article/180955-overview
• PVA’s Neurogenic Bowel Management in Adults with Spinal Cord Injury, pva.org/media/pdf/cpg_neurogenic%20bowel.pdf
Spinal Cord: “Megacolon in patients with chronic spinal cord injury,” nature.com/articles/3101010.pdf