Medical Disclaimer: The information in this article is meant for educational purposes only. It is not intended to be personalized medical or nutrition advice. For a plan tailored to your needs, please consult with a Registered Dietitian or qualified healthcare professional.
Are you living with paralysis? Do you struggle with having regular bowel movements? Do you spend hours on the toilet everyday? Do you get frequent UTIs? Know that you’re not alone. If you answered “yes” to any of these questions, then this nutrition guide for neurogenic bowel and bladder is for YOU.
Neurogenic bowel and bladder can negatively impact mental health and quality of life. It is frustrating to spend over an hour each day on the toilet trying to make a bowel movement, having a bowel or bladder accident when out in public, or having to cancel social plans because your bowels are acting up.
The good news is nutrition plays a key part of your bowel and bladder management routine that can improve quality of life and independence. Keep reading to learn practical tips and tricks for making dietary changes to help manage your neurogenic bowel and bladder.
What is a Neurogenic Bowel and Bladder?
Before we delve into the nutrition aspect, let’s gain a better understanding of neurogenic bowel and bladder.
For people with neurological conditions, such as spinal cord injury, communication between the brain and the spinal cord nerves that control bowel and bladder function is disrupted. As a result, folks may have decreased sensation of their bowel and bladder.
In the neurogenic bowel, there is loss of motor and sensory control of the gastrointestinal tract, anus, and rectum. Transit time of stool through the intestines is slow, and sensory and motor control of the ano-rectum is lost which means one may not be able to feel the need to make a bowel movement (BM) or lose the ability to use the muscles that control the passage of stool.
In the neurogenic bladder, there is decreased or absent sensation and muscle control of the bladder which impacts urination. In people without a neurogenic bladder, the urinary system’s muscles and nerves work together to hold and excrete urine when appropriate. The nerves carry messages between the brain, spinal cord, and bladder telling the bladder muscles to release or tighten.
With the neurogenic bladder, the nerves that control the bladder don’t function properly and the bladder may be overactive or underactive. Individuals will experience urinary incontinence, which is a difficulty controlling the flow of urine.
The bladder may not empty fully or it may start emptying before the person reaches the toilet. UTIs are very common in people with paralysis; it is estimated that those with SCI have about 2 UTIs per year.
Signs of neurogenic bowel include:
- Fecal impaction
- Fecal incontinence (difficulty holding in stool or bowel leakage)
- Bowel accidents and loss of bowel control
- Slow movement of stool through the gastrointestinal tract
- Pebble-like stool
- Abdominal pain
- Hard or swollen lower abdomen
- Poor appetite
- Spending a long time on the toilet
Signs of neurogenic bladder include:
- Loss of bladder control (urinary incontinence)
- Difficulty emptying bladder
- Urinary tract infections (UTIs)
- Frequent urination
- A feeling or need to urinate urgently
What Populations are Impacted by Neurogenic Bowel and Bladder?
- Spinal Cord Injury
- Spina Bifida
- Multiple Sclerosis
- Cerebral Palsy
- Parkinson’s Disease
- Central Nervous System tumors
- Spinal surgeries
Reflexic vs Areflexic Bowel
There are two types of neurogenic bowel; reflexic and areflexic bowel or also referred to as upper motor neurogenic bowel and lower motor neurogenic bowel or spastic and flaccid bowel.
In the reflexic bowel, the spinal cord injury or lesion is typically above L1/L2 vertebrae. Although each individual is different, folks with reflexic bowel may have slow transit time of stool through the intestines, constipation, fecal retention, impaction, and sometimes fecal incontinence.
In the areflexic bowel, the spinal cord injury or lesion tends to be at or below L1/L2 vertebrae, resulting in increased transit time, fecal incontinence, and constipation.
In both types of neurogenic bowel, there is loss of or impaired sensation of the need to make a bowel movement. There is also loss of or impaired ability to control the external anal sphincter (muscle that helps keep stool in the rectum).
Reflexic vs Areflexic Bladder
The two types of neurogenic bladder, reflexic and areflexic bladder, are also known as spastic and flaccid bladder, respectively. Reflexic bladder typically occurs above the T12 vertebrae while areflexic bladder occurs below T12 – L1 vertebrae (the region of the spinal cord known as the cauda equina).
In an areflexic bladder, there is a decrease or loss of bladder muscle and sphincter tone. The bladder will continue to fill and may leak urine when too full. People may have difficulty emptying their bladder voluntarily and may accidentally leak urine when coughing or sneezing.
The main goal of bladder management in people with neurogenic bladder is to find a bladder emptying program specific to the person’s unique needs. Management will differ for each person and may change over time.
Other clinical goals of bladder management include regular bladder emptying, maintaining bladder continence, preventing and treating complications such as UTI, kidney stones, and autonomic dysreflexia (which typically occurs in injuries or lesions at or above T6).
The Neurogenic Bowel and Bladder Management Puzzle
I like to describe neurogenic bowel and bladder management as a puzzle because there are many pieces to it and you need all the pieces to come together to have a working bowel and bladder management program.
Neurogenic bowel and bladder management is complex, multifaceted, and unique for each individual depending on their specific needs. It’s important to focus on all the factors, or “puzzle pieces”, together instead of in isolation.
Some pieces of the puzzle include oral and/or rectal medications to promote bowel regularity, scheduled toilet time, physical activity (gentle exercise, especially in older adults, may help with constipation), nutrition, catheterization, botox injections into the bladder or urinary sphincters, and possible surgeries.
Nutrition is just one piece of this puzzle; focusing on diet alone will not suffice. It is key to continue all the other parts of your neurogenic bowel and bladder management routine.
Role of Nutrition in Management of Neurogenic Bowel and Bladder
You may be wondering what the connection between nutrition and neurogenic bowel and bladder is. Keep reading to find out. It’s important to first note that there isn’t much good quality research on this topic, so much of the information available is based on best practice and clinical experience.
Since every person with a neurogenic bowel and bladder is different and has unique needs, trial and error are often needed to discover what works best for you.
Role of Nutrition in Neurogenic Bowel
Alongside your typical bowel management program (note: the information in this article is not meant to substitute your current routine), making dietary changes has the potential to:
- Shorten your bowel program. (People with neurogenic bowel can spend anywhere from 1 to 5 hours per day on their bowel programs and still have incomplete bowel emptying. Fear and anxiety of having a bowel accident can accompany these challenges which can prevent people from socializing, working, and traveling. Quality of life is greatly improved when proper bowel management reduces time spent on the toilet down to roughly 30-60 minutes.)
- Lessen bloating
- Reduce abdominal pain
- Lessen bowel leakage and constipation
- Reduce risk of hemorrhoids and diverticulitis
- Regulate bowel movements
- Improve stool consistency to prevent bowel accidents
- Keep stool moving through the intestines easily (improved bowel transit time)
- Improve quality of life
Role of Nutrition in Neurogenic Bladder
- Keep urine light in colour
- Maintain blood pressure
- Prevent kidney and bladder stones
- Maintain kidney function
- Flush out the bladder
- Prevent urinary tract infections (UTIs)
Fiber for Neurogenic Bowel
Now that you know the potential beneficial impact nutrition can have on managing neurogenic bowel and bladder, let’s jump into the specifics. We’re going to chat about the health benefits of fiber, the different types of fiber, how they can support neurogenic bowel, and much more.
Gut Health Benefits of Fiber
Appropriate dietary fiber intake has many wonderful health benefits for our digestive system, such as improving constipation by softening stool and reducing diarrhea by solidifying and bulking up the stool.
Fiber also supports bowel regularity, can reduce your risk of hemorrhoids, diverticular disease and colorectal cancer, and promotes a healthy, diverse array of gut bacteria living in our GI (gastrointestinal) tracts.
Additional Health Benefits of Fiber
Adequate fiber intake has many health benefits outside of the gut as well. Soluble fiber (we’ll learn more about this in the next section) may help lower LDL cholesterol (the “bad” kind of cholesterol) by binding it in the small intestine. Once it is in the small intestine, fiber traps the LDL-cholesterol particles, which prevents them from entering the bloodstream and liver, and excretes it through your feces.
Soluble fiber also helps stabilize blood sugar levels, particularly for those with diabetes. Soluble fiber can slow down the absorption of sugar in the intestinal tract, stabilizing the release of sugar into the bloodstream and avoiding a rapid blood sugar spike from low-fiber carbohydrate sources. Further, fiber can also help reduce one’s risk of developing type II diabetes.
What is Fiber?
Fiber is the parts of plant foods that the body can’t digest or absorb. It passes through your stomach, small intestine, large intestine, and out of your body intact (unlike protein, fats, and carbohydrates which the body breaks down and absorbs). There are two kinds of fiber: soluble and insoluble.
Soluble fiber helps with constipation and diarrhea by adding bulk to dry/hard stools and loose/runny stools. It dissolves in water to form a gel-like substance.
Insoluble fiber helps with constipation by absorbing water into your stool which softens it and makes it easier to pass through your GI tract. This type of fiber does not dissolve in water, but instead, it traps and holds onto water pulled from your intestines which adds bulk and moisture to stool.
Note that many high-fiber foods contain both kinds of fiber, so it’s important to consume fiber from a wide variety of sources.
Food Sources of Soluble Fiber
Note that this is not an exhaustive list.
- Oats and oatmeal
- Legumes (beans, lentils, peas, chickpeas, soybeans)
- Chia seeds
- Apples and applesauce
- Brussels sprouts
- Sweet potato
- Psyllium husk
- Fiber supplement, such as Metamucil
Food Sources of Insoluble Fiber
- Ground flax seeds (flaxmeal)
- Wheat bran
- Green beans
- Leafy greens (spinach, kale, collard)
- Potatoes with skin
- Fruits and vegetables with skin
- Whole grains (eg. whole wheat or whole grain pasta, bread, and crackers)
- Brown rice
How Much Fiber Do I Need?
Aim for roughly 25-40g of fiber each day. It is recommended that women aim for about 25g and men aim for 38g of fiber per day, but please don’t worry about the numbers. As long as you include fiber-rich foods at most of your meals and snacks, you should be able to hit that target.
I recommend beginning with 15g and then slowly building up from there while assessing tolerance to these changes.
Assess how you feel a few days after introducing fiber to your diet. If you experience some digestive discomfort, then hold back on increasing fiber intake for another few days or until your symptoms subside. You may want to experiment with another high-fiber food instead.
If, however, you feel fine after the first few days, then it means your GI system can tolerate that amount of fiber and you can further increase intake.
Tips for Increasing Fiber Intake
- Aim to include fiber in most of your meals and snacks throughout the day
- Switch to high fiber cereals such as bran buds
- Add 1-2 tbsp flaxmeal, chia seeds, hemp hearts or psyllium to yogurt, smoothies, oatmeal, and cereal
- Switch to whole grain pasta, bread, crackers, and brown rice
- Bake with whole wheat flour
- Make lentil curry, vegetarian chili, soups
- Add beans/legumes to salads
- Add spinach to smoothies, lasagna, soups, chili, and stir-fries
- Include a fruit or vegetable at meals and snacks
- Make high-fiber smoothies with fruit, spinach, nut butter, avocado, oats, chia, psyllium, or flaxmeal
- Add nuts or nut butter to yogurt or oatmeal
- Add fruit to yogurt, cereal, oatmeal
- Add oats, flaxmeal, chia seeds or psyllium to muffins, cookies, banana bread, or energy bites
- Add beans or legumes to soups (either whole or blended)
- Make guacamole or add avocado to salads
- Keep the skins on sweet potatoes and potatoes
- Make oatmeal for breakfast
Fluids for Neurogenic Bowel and Bladder
Fluids are crucial for neurogenic bowel and bladder management; with your bowel, fiber needs fluid to help fiber and food move through your GI tract.
If you don’t have enough fluid intake, or if you struggle with dehydration, you’re more likely to be constipated and your stools will be hard and difficult to pass through your GI tract.
Fluids are also crucial for the neurogenic bladder; they help flush out bacteria in the bladder, keep urine light in color, help maintain blood pressure, prevent kidney and bladder stones, and support kidney function. Fluids also help prevent UTIs, which are highly prevalent in people with neurogenic bladder.
How Much Fluid Should I Drink?
There is no hard and fast rule for how much fluid you should drink per day, and the answer is different for each individual depending on factors such as age, medical conditions, or activity levels. You need more fluids when you exercise and in hot weather.
The general recommendation is 2-3 liters per day (equivalent to 8-12 cups or 64oz). Spread your fluid intake evenly throughout the day to keep intake balanced and to avoid drinking too much at once.
If you want a more specific guide, it is recommended that women 19 years and older consume about 9 cups of fluids per day, and men 19 years and older should have 12 cups. Note that 1 cup is 250 ml.
If you’re unsure if you’re staying hydrated and drinking enough, check your thirst, urine, and mood. If you’re thirsty, your urine is dark yellow in color and you’re not producing much, you’re light-headed or having trouble staying focussed, and you’re likely dehydrated. Urine should be light yellow or clear. Being more constipated than usual is also a sign you may not be drinking enough fluids.
People with paralysis may intentionally avoid drinking too much water in order to avoid having to empty their catheters frequently. I encourage you to do your best to drink adequate fluids for your bowel and bladder health, even if it means having to go to the washroom more often. No one enjoys having a UTI!
What Beverages Count as Fluid?
Water is not the only beverage that counts as fluid. That would be boring!
- Flavored seltzer
- Milk or nondairy substitutes
- Coffee (limit caffeine to 3 cups per day)*
*Note that caffeinated beverages, alcohol, carbonated drinks, and some other foods (such as tomato-based products, chocolate, certain acidic fruits, spicy foods) may irritate the bladder. If you think they may be impacting you, try cutting them out for about a week to see if your symptoms improve and then you can gradually (every 1-2 days) add one item at a time back into your diet. While you re-introduce these foods, make note of any changes in urinary frequency, urgency, or incontinence.
Tips for Increasing Fluid Intake
Many individuals struggle with drinking enough fluids each day. Here are some practical tips:
- Add frozen or fresh fruit, vegetables or herbs to your water to enhance the taste. Some suggestions include: lemon or lime wedges, fresh mint, cucumber slices, cinnamon sticks, strawberries, mangos, watermelon, oranges, or pineapple
- Keep a reusable water bottle with you throughout the day as a reminder to drink – keep it at your work desk, at school, when you exercise, or when you’re out. Refill it when you run out
- Take sips of water while eating meals and snacks
- Make soups more often as the liquid in them can also count towards your fluid intake
- Pair it with another habit. For example, drink a glass of water with your afternoon snack, after you brush your teeth, or after a workout
What About Supplements?
You may have read online about certain supplements for neurogenic bowel and bladder, such as cranberry tablets for UTIs or probiotics for gut health. Read on to learn evidence-based information about supplements to support neurogenic bowel and bladder.
“Probiotics” has been a popular buzzword in the wellness world for a number of years now. Probiotics are supplements or foods that contain live micro-organisms or “good” bacteria in sufficient numbers that positively alter the consumer’s gut microbiome (amount of good bacteria living in your intestines) and thus have a health benefit.
The amount of research studies on the benefits of probiotics for neurogenic bowel and bladder is lacking, unfortunately. It’s also a complicated subject as there are many different types, or strains, of probiotics that have various functions (ie. there are some probiotics for those with IBS, some for antibiotic-associated diarrhea, general health, and much more).
Probiotics and Neurogenic Bladder
You may have heard of taking probiotics to prevent UTIs; in fact, studies have shown specific strains of probiotics to be effective in preventing recurring UTIs in women. Researchers in Australia wanted to see if probiotics could have the same effect in preventing UTIs in people with SCI.
They conducted a study with 207 participants and divided them into placebo groups and groups with different probiotic strains over a 6-month period, but the results didn’t show any benefit in probiotics preventing UTIs. The sample size was likely too small and they didn’t follow up with participants after the 6-month period, so further research is needed and it’s unclear if probiotics help.
Most of the research that has been conducted has been with people with SCI and not other conditions where people have neurogenic bowel and bladder. I was only able to find one study done with 5 participants who were children with spina bifida but that was it.
Bottom line: there isn’t enough evidence right now to recommend probiotics to prevent UTIs in people with neurogenic bladder.
Probiotics and Neurogenic Bowel
Studies in people without paralysis have shown probiotics can be helpful in alleviating symptoms of antibiotic-associated diarrhea when taken during a course of antibiotics. They can also help restore your gut’s healthy bacteria after antibiotic treatment. There is not enough research in the paralysis population to make the same recommendation.
I conducted many thorough searches through the research trying to find studies done on the impact of probiotics on neurogenic bowel and could not find anything. Of the little research that has been done in the SCI population, it has been about the impact of probiotics in people on antibiotics, not for constipation or loose stool relating to neurogenic bowel.
More on that note though, there have been some studies with small sample sizes testing whether probiotics can reduce the incidence of antibiotic-associated diarrhea and results are promising, but larger, more robust studies are needed. You can read some of the studies here and here.
Something interesting that came up in these studies was that being undernourished was associated with a greater risk for antibiotic-associated diarrhea, underscoring the importance in being well nourished for your overall health.
- There are currently no clear indications or contraindications to recommend regular usage of probiotics in people with neurogenic bowel.
- Probiotics may be helpful if you are taking antibiotics (for example, for a UTI or other infection) to reduce the incidence of antibiotic-associated diarrhea or Clostridium difficile-associated diarrhea.
- It is unsure if probiotics help with symptoms of neurogenic bowel.
- Unless you are immunocompromised*, there is likely no harm from taking a probiotic supplement or consuming probiotic-containing foods. It may have a positive effect on your general health and your gut microbiome.
- If you wish to include more probiotic-rich foods in your diet to promote overall gut health, try out these fermented foods:
- Miso (you can make miso soup!)
- Probiotic-containing yogurt
*Probiotics / supplements with live bacteria are typically NOT recommended for people on immunosuppressant medications. Please consult with your healthcare provider before starting a new supplement.
Does Cranberry Juice or Tablets Prevent UTIs?
You may have heard of people drinking cranberry juice when they have a UTI or to prevent future UTIs. The evidence is quite conflicting whether cranberry juice or cranberry tablets actually help. In able-bodied populations, cranberry products may help prevent UTIs but don’t help to treat them. Evidence is limited in folks with neurogenic bladder.
The majority of studies have been done in the SCI population and not other conditions where people have neurogenic bladder, and the majority of the research shows cranberry juice or tablets don’t prevent or treat UTIs.
However, there have been a few small studies with promising results. In a small study of 47 participants with SCI, cranberry extract tablets were shown to reduce the incidence of UTI.
Bottom line: Cranberry juice or tablets may or may not help reduce the number of UTIs in people with neurogenic bladder. However, they are likely not harmful so if you want to give them a try, you can*.
*Regular consumption of cranberry products may increase the risk of kidney stones in people with a history of oxalate calculi (a type of kidney stone). Cranberry products may interact with the blood thinner, Warfarin, so be sure to check with your healthcare provider before starting a new supplement.
Note that this is not an exhaustive list of supplements for neurogenic bowel and bladder.
Thank you for reading until the end. I hope you found this article helpful! I’d love to hear about your experiences: has nutrition helped with your neurogenic bowel and bladder? What worked and what didn’t? Leave a comment below.
If you’re looking for high fiber, gut-friendly recipes to get started with, check out these raspberry oatmeal muffins, this chia pudding, feta spinach lentil salad, blueberry pie smoothie, overnight oats, and these oatmeal banana muffins.
Jackie is a Toronto-based Registered Dietitian with a Masters of Health Science (MHSc) in Nutrition Communications, whose mission is to empower and support people with disabilities to manage their condition, prevent complications, and live active lifestyles through nutrition. Jackie runs a virtual private practice and consulting business and runs her blog which has simple recipes and health information for the disability community.