Life on Wheels (27 page)

Diet plays an important role in managing stool softness. Before relying on drugs such as stool softeners to manage your bowels, start with food. Foods that prevent or cure constipation include fluids, wheat bran, rice bran, vegetables, and fruits—especially prunes, figs, and dates.

The advice you have heard for years is true: include fiber and bulk in your diet. Fibrous food absorbs and retains water, keeping your stool at an appropriate softness. Fiber remains in the intestines because it is not digested. Humans are not equipped with the enzymes capable of breaking down cellulose and absorbing it into the body (only termites have that ability!). Fiber helps stimulate the nerve reflexes in the colon wall that trigger bowel movement. Fiber also reduces your chances of developing hemorrhoids, varicose veins, or diverticulitis, which results from the formation of small pockets in the intestines where stool becomes trapped, allowing bacteria to grow.

Fiber can be overdone. Add fiber gradually, making note of how it affects your stool, and work your way up to a consistent level, allowing your body to adapt. Because fiber absorbs water, you must increase fluid intake as you increase bulk in your diet. Too much fiber without enough fluid can cause hard stools—and eventually impaction. Diuretic medicines, designed to remove fluid from the body, will also affect the amount of fiber you can accommodate, as do the diuretic effects of coffee and alcohol.

The modern, highly processed diet in general is much lower in fiber than in the past. To add fiber to your diet, choose whole grain or coarse breads or use a bread machine to make high-fiber breads. Miller’s bran and rice bran are available in powdered form to sprinkle on cereals, salads, and other creative alternatives. Whole fresh fruits and vegetables provide bulk and fiber.

The age-old belief in prunes is true. Prunes are high in fiber and vitamin A, have no cholesterol or fat, and have a laxative effect. A glass of prune juice each day can help manage your bowels. Or keep a supply of pitted prunes around so you can pop one in your mouth now and then during the day.

Don’t use coffee as a tool to manage your bowels or health. For some people, a cup of coffee has a laxative effect, but not because of the caffeine, which can be a cause of constipation. If you have chronic problems, either with constipation or diarrhea, look at your coffee habits. Too much coffee also amplifies stress.

Dairy foods, by virtue of their calcium content, contribute to constipation. Milk should not be too large a part of your diet.

Medications influence your diet and how you process foods. Ask your physician how drugs she prescribes for you will affect your stool consistency and bowel program.

Most of you will have received guidance in a rehabilitation program or been advised by your physician on what bowel and bladder management program will work best for you. However, sometimes a doctor or program will simply apply a given model that doesn’t take individual abilities and needs into account. Your own personal experience will show what your individual capabilities are and guide you in determining the best management program. Many brain or spinal cord traumas—whether from injury, infection, birth defect, or disease—are not complete, so some messages from the nerves might be getting through, giving you access to some degree of use of your bladder or bowel sphincter muscles. Your ability to tighten or relax these muscles can determine whether the process requires manual support or how much of your day you must devote to elimination. Although you might be diagnosed as having no control or sensation, you might retain some manual control of the sphincter muscles or have some capacity to sense when your bowel or bladder is full.

A neurogenic bladder has a difficult time emptying itself completely. Urine left behind in the bladder—known as “residual”—will stagnate and allow growth of bacteria, which causes infection. A very full bladder can eventually back up into the kidneys, disrupting the important filtration task they perform and leading to infection and disease.

You must drink plenty of water, as much as three quarts per day or a glass every hour. All of this fresh fluid keeps flushing you out and reduces the risk of bacteria remaining in place long enough to cause trouble. But chair users face a contradiction in drinking extra fluids. For many chair riders, using the bathroom is time consuming and involves a lot of mechanical or physical effort or the time involved in cleaning an intermittent catheter. You must find a balance for yourself, putting a priority on your safety and health while reducing inconvenience.

With a flaccid bladder, some ability to know when it is time to empty is lost. There is already a disruption in the automated system of your brain getting the signal that it is time to empty and sending back the message for the sphincter muscle to release. The bladder cannot develop enough pressure to overcome the resistance of the sphincter muscle, so urine is held in. If the bladder fills too much, it begins to stretch, known as “overdistention,” and urine begins to back into the kidneys. Remaining muscle tone will be damaged, and what bladder function you have can be lost. Since your body is not giving you the sensations to know when these events are happening, you must practice a regular bladder program and be very conscious of how much fluid you take into your body and how your body determines when you need to void.

It might be possible to empty a flaccid bladder if you use the Credé technique—pressing against your bladder with your fist to overcome the resistance of the sphincter. Discuss this method with your doctor to ensure that it is safe for you. This technique is likely to leave behind residual urine, but, depending on your fluid intake, this could be a manageable approach. It might be necessary on occasion to catheterize yourself.

A spastic bladder might try to empty itself at any time; the amount can be small, leaving behind residual urine. The reflex is most likely to occur when the bladder is full, but it can also be triggered by contractions from muscle spasticity in your legs, if that is an issue for you. Spasms in the bladder will increase with the presence of an infection or stones. The spastic bladder can be triggered by massaging the abdomen, by leaning forward or doing pushups from the sitting position, or by stimulating the rectum with a gloved finger. Once the reflex begins, it will continue, so you need either to be sitting on a toilet or commode or have an appropriate collection system in place. Women rely on medication, urine-absorbing pads or, as a last resort, bladder augmentation surgery.

With either a flaccid or spastic bladder, you will want to limit your fluid intake in the evening to reduce your need for emptying during the night.

A catheter is a narrow tube inserted through the urethra, beyond the sphincter muscle, and into the bladder, allowing it to drain. There are two kinds of catheterization, indwelling and intermittent. Which kind you use depends on the bladder condition you have and other considerations such as convenience, lifestyle, and cost. An indwelling catheter remains in the bladder for up to several days and is usually attached to a drainage bag that straps onto the leg and collects urine. With intermittent catheterization, urine is emptied into a plastic urinal or container or directly into a standard urinal.

A flaccid bladder typically must be emptied with an indwelling catheter, since the sphincter muscle is frozen and cannot be consciously relaxed. A spastic bladder might not be capable of emptying itself completely, so occasional use of a catheter might be necessary to remove residual urine. Males with spastic bladders or some control of the urinary sphincter can often manage well with male urinary condoms.

This woman who uses intermittent catheterization describes her routine:

Catheters come in various sizes, identified in French units, which indicate the outside circumference—16 and 18 Fr. are common sizes. The overall size does not indicate the size of the inside channel, so it is important to learn more about the design of the product you choose. You might want to cut open a used catheter to become familiar with its design. The size of the inside channel will determine how quickly the catheter might become clogged. A larger catheter is not always a good solution, as it can still plug up and cause complications in the urethra.

Catheters are made of latex or silicone. Some latex catheters are coated with Teflon to ease their passage. However, latex catheters will generally be smaller inside because of the extra surface layer. Some people develop latex sensitivity and so must use the more costly silicone type.

Either intermittent or indwelling catheters entail a risk of chronic infection because you are necessarily introducing a foreign object into your urinary tract. Again, religiously keeping the catheter clean, using a fresh one as often as possible, and drinking plenty of water will go a long way toward protecting you from infection.

An indwelling or Foley catheter remains in place for days at a time, allowing the bladder to empty continuously into a leg or bedside drainage bag. Indwelling catheters include a small balloon at the internal end that is filled with water to keep the catheter from pulling out. The “Foley kit” used for sterile insertion includes the water-filled syringe for this purpose. An indwelling catheter is also the solution for quadriplegics who cannot perform intermittent catheterization for lack of hand dexterity.

A suprapubic catheter is a type of indwelling catheter inserted surgically through the abdomen into the bladder because of conditions that prevent entry through the urethra. Some people experience leakage around the opening where the catheter enters. There is a chance of having to relocate a suprapubic catheter after some years; the previous opening could take a while to close, requiring you to deal with leaking from the opening until it heals.

With indwelling and suprapubic catheters, there is an increased risk of infection from the continuous presence of a foreign object in the body. Catheters can become clogged in time if the urine contains sediment or is cloudy from a persistent infection. It is very important to pay attention to whether you are voiding as much fluid as you are taking in.

Indwelling and suprapubic catheters empty the bladder continuously. As a result, the bladder shrinks and loses muscle tone. Eventually, bladder walls can become firm. Carefully consider whether to go ahead with either of these two options, since they can result in a change to your bladder that might not be reversible. Consult with your physician on the reasons to use them. Despite these permanent changes, one of these options might be the right thing for you to do. In particular, those without the hand dexterity for self-catheterization benefit from continuous drainage. The logistics of getting assistance or the difficulty of trying to do it alone when it challenges your ability might not be worth the effort to avoid the possible complications. If you will continue to use an indwelling approach, a smaller bladder might not matter to you.

Spasms can cause leakage around a catheter, since the strength of the muscle contraction may force more urine into the tube than it can accommodate. The excess will flow around the tube instead. Some spasms can be powerful enough to force out an indwelling catheter even with its balloon inflated, which can stretch the bladder and cause damage to the urethra. This is more of an issue for women, whose urethras are shorter than men’s. There are two commonly recommended anticholinergic medications for this problem, Probanthine and Ditropan, which relax the bladder to minimize spasms.

If you are having to change your catheter more often than usual, take time to find out why. Not drinking enough fluid is the most common reason for a catheter to become prematurely clogged. Water is the best fluid to drink. Tea, lemonade, and fruit juices are also good. Cranberry juice has long been thought to be healthy for the bladder and even part of a treatment program for infections, although there is no hard research to support it. Do not choose products that rely heavily on sugar, corn syrup, or artificial flavors and sweeteners.

A clogged catheter might also be an indication that you are developing stones. Stones do not develop when your urine, rather than becoming too alkaline, maintains a sufficient acid level. Carbonated drinks and certain foods make the urine more alkaline, noticeable by a stronger odor. The best way to get your urine back to an acid level is simply to drink more water. You can test this yourself with pH paper found at any pharmacy. A good pH level is from 5 to 6.5.