Pelvic floor function in patients with clinically complete spinal cord injury and its relation to constipation

Recommendations for evaluation of neurogenic bladder and bowel dysfunction after spinal cord injury and/or disease

Objective: To provide an overview of clinical assessments and diagnostic tools, self-report measures (SRMs) and data sets used in neurogenic bladder and bowel (NBB) dysfunction and recommendations for their use with persons with spinal cord injury /disease (SCI/D).Methods: Experts in SCI/D conducted literature reviews, compiled a list of NBB related assessments and measures, reviewed their psychometric properties, discussed their use in SCI/D and issued recommendations for the National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements (CDEs) guidelines.Results: Clinical assessments included 15 objective tests and diagnostic tools for neurogenic bladder and 12 for neurogenic bowel. Following a two-phase evaluation, eight SRMs were selected for final review with the Qualiveen and Short-Form (SF) Qualiveen and the Neurogenic Bowel Dysfunction Score (NBDS) being recommended as supplemental, highly-recommended due to their strong psychometrics and extensive use in SCI/D. Two datasets and other SRM measures were recommended as supplemental.Conclusion: There is no one single measure that can be used to assess NBB dysfunction across all clinical research studies. Clinical and diagnostic tools are here recommended based on specific medical needs of the person with SCI/D. Following the CDE for SCI studies guidelines, we recommend both the SF-Qualiveen for bladder and the NBDS for bowel as relatively short measures with strong psychometrics. Other measures are also recommended. A combination of assessment tools (objective and subjective) to be used jointly across the spectrum of care seems critical to best capture changes related to NBB and develop better treatments.

Improvements in bladder, bowel and sexual outcomes following task-specific locomotor training in human spinal cord injury

OBJECTIVE

Locomotor training (LT) as a therapeutic intervention following spinal cord injury (SCI) is an effective rehabilitation strategy for improving motor outcomes, but its impact on non-locomotor functions is unknown. Given recent results of our labs' pre-clinical animal SCI LT studies and existing overlap of lumbosacral spinal circuitries controlling pelvic-visceral and locomotor functions, we addressed whether LT can improve bladder, bowel and sexual function in humans at chronic SCI time-points (> two years post-injury).

STUDY DESIGN

Prospective cohort study; pilot trial with small sample size.

METHODS

Eight SCI research participants who were undergoing 80 daily one-hour sessions of LT on a treadmill using body-weight support, or one-hour of LT and stand training on alternate days, as part of another research study conducted at the Kentucky Spinal Cord Injury Research Center, University of Louisville, were enrolled in this pilot trial. Urodynamic assessments were performed and International Data Set questionnaire forms completed for bladder, bowel and sexual functions at pre-and post-training time points. Four usual care (non-trained; regular at-home routine) research participants were also enrolled in this study and had the same assessments collected twice, at least 3 months apart.

RESULTS

Filling cystometry documented significant increases in bladder capacity, voiding efficiency and detrusor contraction time as well as significant decreases in voiding pressure post-training relative to baseline. Questionnaires revealed a decrease in the frequency of nocturia and urinary incontinence for several research participants as well as a significant decrease in time required for defecation and a significant increase in sexual desire post-training. No significant differences were found for usual care research participants.

CONCLUSIONS

These results suggest that an appropriate level of sensory information provided to the spinal cord, generated through task-specific stepping and/or loading, can positively benefit the neural circuitries controlling urogenital and bowel functions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03036527.

Altered Colorectal Compliance and Anorectal Physiology in Upper and Lower Motor Neurone Spinal Injury May Explain Bowel Symptom Pattern

OBJECTIVES

Supraconal spinal cord injury (SCI) and lower motor neurone spinal cord injury (LMN-SCI) cause bowel dysfunction; colorectal compliance may further define its pathophysiology. The aim of this study was to investigate rectal (RC) and sigmoid (SC) compliance and anorectal physiology parameters, in these subjects.

METHODS

Twenty-four SCI subjects with gut symptoms (14 RC, 10 SC) and 13 LMN-SCI subjects (9 RC, 4 SC) were compared with 20 spinal intact controls (10 RC, 10 SC). Staircase distensions were performed using a barostat. Anorectal manometry, including rectoanal inhibitory reflex (RAIR) measurement, was performed in all. Data presented as mean±standard error (SCI/LMN-SCI vs. controls).

RESULTS

SCI subjects had a higher RC (17.0±1.9 vs. 10.7±0.5 ml/mm Hg, P<0.05) and SC (8.5±0.6 vs. 5.2±0.5 ml/mm Hg, P=0.002). LMN-SCI subjects had a lower RC (7.3±0.7 ml/mm Hg, P=0.0021) while SC was unchanged (8.3±2.2 ml/mm Hg, P>0.05). Anal resting pressure was decreased in SCI (55±5 vs. 79±7 cmH2O, P=0.0102). Anal squeeze pressure was decreased in LMN-SCI (76±13 vs. 154±21 cmH2O, P=0.0158). In SCI and LMN-SCI, the amplitude reduction of the RAIR was greater (62±4% and 70±6% vs. 44±3%, P=0.0007).

CONCLUSIONS

Colorectal compliance abnormalities may explain gut symptoms: increased RC and SC contributing to constipation in SCI, reduced rectal compliance contributing to fecal incontinence (FI) in LMN-SCI. Reduced resting anal pressure in SCI and reduced anal squeeze pressure in LMN-SCI along with a greater RAIR amplitude reduction may be factors in FI. These co-existing abnormalities may explain symptom overlap, and represent future therapeutic targets to ameliorate neurogenic bowel dysfunction.

Plain abdominal radiograph as an evaluation method of bowel dysfunction in patients with spinal cord injury

Objective

To evaluate the usefulness of plain abdominal radiography as an evaluation method for bowel dysfunction in patients with spinal cord injury (SCI).

Methods

Forty-four patients with SCI were recruited. Patients were interviewed about their clinical symptoms, and the constipation score and Bristol stool form scale were assessed. The colon transit time (CTT) was measured by using radio-opaque markers (Kolomark). The degree of stool retention and the presence of megacolon or megarectum were evaluated using plain abdominal radiographs. We examined the relationship between clinical aspects and CTT and plain abdominal radiography.

Results

The constipation scores ranged from 1 to 13, and the average was 4.19±3.11, and the Bristol stool form scale ranged from 1 to 6, with an average of 4.13±1.45. CTTs were 19.3±16.17, 19.3±13.45, 15.32±13.15, and 52.42±19.14 in the right, left, rectosigmoid, and total colon. Starreveld scores were 3.4±0.7, 1.8±0.86, 2.83±0.82, 2.14±1, and 10.19±2.45 in the ascending, transverse, descending, rectosigmoid, and total colon. Leech scores were 3.28±0.7, 2.8±0.8, 2.35±0.85, and 8.45±1.83 in the right, left, rectosigmoid, and total colon. The number of patients with megacolon and megarectum was 14 (31.8%) and 11 (25%). There were statistically significant correlations between the total CTT and constipation score (p<0.05), and Starreveld and Leech scores (p<0.05). Significant correlations were observed between each segmental CTT and the segmental stool retention score (p<0.05).

Conclusion

Plain abdominal radiography is useful as a convenient and simple method of evaluation of bowel dysfunction in patients with SCI.

Sigmoid compliance and visceral perception in spinal cord injury patients

Intestinal motor and sensory dysfunctions in traumatic complete or incomplete spinal cord injury (SCI) are frequent and result in altered mechanisms of defecation. The aim of this study is to investigate sigmoid compliance and perception in chronic SCI patients. Sigmoid responses to fixed-tension distentions were assessed using a tensostat in six patients (six men, 42 ± 4 years) with chronic complete transection of the spinal cord (high-SCI; five tetraplegic C5-C7 and one paraplegic T4-T6) and impaired evacuation (i.e. constipation). A group of 10 healthy individuals (six men, 25 ± 1 years) served as controls. SCI patients had higher sigmoid compliance at the highest distention level than the controls (10.3 ± 2.4 vs. 5.1 ± 0.8 ml/mmHg; P<0.05). Perception scores at first sensation were higher in SCI patients (2.3 ± 0.7 vs. 1.1 ± 0.1; P<0.05), but were not different at the highest distention levels (3.7 ± 0.8 vs. 3 ± 1; NS). The most commonly reported sensation by patients was distention/bloating and was referred less commonly to the hypogastrium compared with distention/bloating in controls. An increased sigmoid compliance can be detected in constipated SCI patients. The preservation of some degree of visceral sensations, although abnormally referred, could imply the occurrence of sensory input remodeling at the spinal level.

Effect of age on bowel management in traumatic central cord syndrome

STUDY DESIGN

A retrospective multicenter study.

OBJECTIVES

To investigate the characteristics of bowel dysfunction in elderly people with traumatic central cord syndrome (TCCS).

SETTING

A total of 28 Rosai hospitals in Japan.

METHODS

The Rosai Hospital registry included 3006 persons with spinal cord injury during 1997-2007. The study subjects were 186 patients with TCCS (160 men, 26 women; mean age, 61.7±11.6 years, ±s.d.). Patients were divided according to age into the young group (<50 years, n=30), the middle-age group (50-69 years, n=112) and the elderly group (≥70 years, n=44). We assessed the differences in bowel management techniques (spontaneous, rectal medications and manual emptying) and activity of daily living (ADL) with respect to bowel care at discharge among the three groups.

RESULTS

Continent spontaneous defecation was the most common bowel management method (50%, 93/186). The percentage of elderly subjects on continent spontaneous defecation (36.4%) was significantly less than that of the young group (66.7%; P<0.05). Furthermore, the percentage of elderly patients who required no bowel care (18.2%) was significantly less than those of the young (53.3%) and middle-age groups (41.1%; P<0.01). However, few differences in bowel care-related ADL were recognized among the three groups in patients who required manual emptying.

CONCLUSION

The results identified significantly fewer patients aged ≥70 years with 'continent spontaneous defecation' or 'independent for bowel care' compared with younger patients. The results also highlighted the clinical importance of bowel dysfunction associated with TCCS especially in elderly people.

Bowel function in acute stroke patients

Objective

To investigate factors related to bowel function and colon motility in acute stroke patients.

Method

Fifty-one stroke patients (29 males, mean age 63.4±13.6 years, onset 13.4±4.8 days) were recruited and divided into two groups: constipation (n=25) and non-constipation (n=26) groups. We evaluated the amount of intake, voiding function, concomitant swallowing problem and colon transit time (CTT) using radio-opaque markers for ascending, descending and rectosigmoid colons. The Adapted Patient Evaluation Conference System (APEC), Korean version of Modified Bathel Index (K-MBI) and Motricity Index (MI) were evaluated.

Results

The constipation group showed significantly prolonged CTT of ascending, descending and entire colon (p<0.05) and more severe swallowing problems (p=0.048). The APEC scale (2.65±1.44 vs 1.52±0.92, p=0.001), K-MBI scores (59.4±14.4 vs 28.0±24.3, p<0.001) and MI scores (69.1±22.3 vs 46.8±25.9, p=0.001) of the constipation group were significantly lower compared to the non-constipation group.

Conclusion

Our study demonstrated that bowel function in acute stroke patients was associated with functional status and swallowing function, indicating the need for intensive functional training in post-stroke constipation patients.

Rectal evacuation and antegrade colonic luminal transport by sacral anterior root stimulation in pigs

PURPOSE

Electrical sacral anterior root stimulation with a selective anodal block may relieve difficulties with bowel evacuation by selective colorectal activation and anal sphincter suppression. This study compares rectal evacuation induced by anodal block with that induced by unselective stimulation.

METHODS

The sacral anterior roots were stimulated with cuff electrodes in seven chloralose-anesthetized minipigs. Anodal block and unselective stimulation were applied in random order and compared by anorectal manometry and by the obtained colorectal evacuation. Evacuation was quantified scintigraphically after retrograde radioactive paste installation.

RESULTS

Unselective stimulation evoked sphincter activation which obstructed rectal evacuation during the 30-second stimulation period, after which poststimulation evacuation occurred (mean, 13%; P < 0.05). Anodal block reduced the anal canal pressure by median 83% compared with unselective stimulation. With unrestrained evacuation, a different evacuation pattern (mean, 18%; P < 0.05) occurred within the first ten seconds of the stimulation period and evacuated volume was higher (P = 0.08). Colonic evacuation reached a mean of 17% with unselective stimulation and 11% with anodal block.

CONCLUSION

Anodal block and unselective sacral root stimulation induce rectal evacuation and colonic luminal transport in pigs. However, anodal block may improve stimulation-induced defecation by enabling a near-physiologic defecation pattern.

Bowel dysfunction in patients with motor complete spinal cord injury: clinical, neurological, and pathophysiological associations

BACKGROUND

Abnormal bowel function is a key problem in patients with spinal cord injury (SCI). Previous works provided only partial information on colonic transit time (CTT) or anal dysfunction but did not identified a comprehensive neurogenic bowel pattern.

AIM

To evaluate clinical, neurological, and pathophysiological counterparts of neurogenic bowel in patients with motor complete SCI.

METHODS

Fifty-four patients (56% men, mean age 35 yr) with chronic motor complete SCI (mean evolution time 6 yr) were evaluated: 41% with injuries above T7 (> T7) and 59% with injuries below T7 (< T7); patients were also classified according to the presence or not of sacral spinal reflexes. Clinical assessment, total and segmental CTT quantification, anorectal function evaluation by manometry, intrarectal balloon distension, and surface electromyography were performed.

RESULTS

Three different neuropathophysiological patterns were observed: Pattern A, present in > T7 injuries, characterized by very frequent constipation (86%) with significant defecatory difficulty and not very severe incontinence (Mean Wexner score 4.5); it was related to moderate delay in CTT (mainly in the left colon and recto-sigma), incapacity to increase the intra-abdominal pressure, and the absence of anal relaxation during the defecatory maneuvre; Pattern B, present in < T7 injuries with preserved sacral reflexes, characterized by not so frequent constipation (50%) but very significant defecatory difficulty and not very severe incontinence (Wexner 4.8); the pathophysiological counterpart was a moderate delay in CTT, capacity to increase intra-abdominal pressure, increased anal resistance during the defecatory maneuver, and presence of external anal sphincter (EAS) contraction when intra-abdominal pressure increased and during rectal distension; Pattern C, present in < T7 injuries without sacral reflexes, characterized by not very frequent constipation (56%) with less defecatory difficulty and greater severity of incontinence (Wexner 7.2); this was associated with severe delay in CTT (mainly in the left colon), capacity to increase intra-abdominal pressure, absence of anal resistance during the defecatory maneuver, and absence of EAS contraction when intra-abdominal pressure increased and during rectal distension.

CONCLUSION

In patients with motor complete SCI, we were able to define three different neuropathophysiological patterns that are associated with bowel function abnormalities and clinical complaints; this might be of help when designing therapeutic strategies.

Upper and lower gastrointestinal motor and sensory dysfunction after human spinal cord injury

This chapter describes the results of investigations of the upper and lower gastrointestinal tract in subjects with complete and incomplete spinal cord injury. In one study, gastric emptying was investigated and found delayed. The delay was tentatively attributed to a colo-gastric inhibitory reflex triggered by inappropriate colonic emptying. In another study, anorectal motor and sensory functions were measured. Decreased tone of the internal anal sphincter, exaggerated recto-anal reflexes following rectal distension and spontaneous high-amplitude rectal contractions at low distension volumes were among the findings of the study. Some of the subjects, classified as having a complete injury according to usual clinical criteria (American Spinal Injury Association, ASIA), reported sensation of distension of the rectum. This raises the issue of the need for better methods for the clinical assessment of sensory transmission in the spinal cord. Promising results obtained with functional magnetic resonance imaging of the brain during rectal stimulation in a small group of paraplegics, with complete injuries by ASIA criteria, showed evidence of activation of several brain regions.

Gastrointestinal symptoms in spinal cord injury: relationships with level of injury and psychologic factors

INTRODUCTION

Previous surveys of gastrointestinal symptoms after spinal cord injury have not used validated questionnaires and have not focused on the full spectrum of such symptoms and their relationship to factors, such as level of spinal cord injury and psychologic dysfunction. This study was designed to detail the spectrum and prevalence of gastrointestinal symptoms in spinal cord injury and to determine clinical and psychologic factors associated with such symptoms.

METHODS

Established spinal cord injury patients (>12 months) randomly selected from a spinal cord injury database completed the following three questionnaires: 1) Rome II Integrative Questionnaire, 2) Hospital Anxiety and Depression Scale, and 3) Burwood Bowel Dysfunction after spinal cord injury.

RESULTS

A total of 110 patients participated. The prevalence of abdominal bloating and constipation were 22 and 46 percent, respectively. Bloating was associated with cervical (odds ratio = 9.5) and lumbar (odds ratio = 12.1) level but not with thoracic level of injury. Constipation was associated with a higher level of injury (cervical odds ratio = 5.6 vs. lumbar) but not with psychologic factors. In contrast, abdominal pain (33 percent) and fecal incontinence (41 percent) were associated with higher levels of anxiety (odds ratio = 6.8, and odds ratio = 2.4) but not with the level of injury.

CONCLUSIONS

There is a high prevalence and wide spectrum of gastrointestinal symptoms in spinal cord injury. Abdominal bloating and constipation are primarily related to specific spinal cord levels of injury, whereas abdominal pain and fecal incontinence are primarily associated with higher levels of anxiety. Based on our findings, further physiologic and psychologic research studies in spinal cord injury patients should lead to more rational management strategies for the common gastrointestinal symptoms in spinal cord injury.

The defecation reflex in rats: fundamental properties and the reflex center

While pharmacological and physiological studies in rats are now increasing, physiological properties of their defecation have been scarcely investigated. This study was performed to define the properties of defecation in decerebrate rats, with special reference to the pontine defecation reflex center, which has been postulated in dogs. Intraluminal pressure was recorded from the colon and rectum with balloon-pressure transducer method using balloons of 15-20 mm in length and 0.1-0.3 ml in volume. Distention of a balloon in the descending colon and rectum with an additional injection of 0.03-0.1 ml air induced propulsive contractions on the descending colon and rectum. The mean of threshold pressures to induce propulsive contraction was 17.0 +/- 5.8 mm Hg (mean+/-S.E.) in the proximal part and 18.3 +/- 3.3 mm Hg in the distal part of the descending colon, and 11.8 +/- 1.3 mm Hg in the rectum. The maximum amplitude of propulsive contractions was 55 mm Hg in the rectum, 47 mm Hg in the distal part of the descending colon and 38 mm Hg in the proximal part. Similar colorectal propulsive contractions were produced by gastric distention (5-10 ml, 20-30 mm Hg) and electrical stimulation of the anal canal. Contrarily, spontaneous contractions of the proximal colon were suppressed by rectal distention and anal-canal stimulation. These results suggest that the descending colon and rectum, but not the proximal colon, were innervated by the pelvic afferent and efferent fibers mediating the defecation reflex. Pontine transection at the cerebellar peduncle level abolished colorectal propulsive contractions induced by distention of the stomach, descending colon and rectum, and stimulation of the anal canal, although much smaller contractions were still induced after the pontine transection. These results suggest that the pontine defecation reflex center exists and works in rats, as in dogs.

Descending spinal projections from the rostral gigantocellular reticular nuclei complex

Electrophysiological and physiological studies have suggested that the ventral medullary gigantocellular reticular nuclei (composed of the gigantocellular ventralis and pars alpha nuclei as well as the adjacent lateral paragigantocellular nucleus; abbreviated Gi-LPGi complex) provide descending control of pelvic floor organs (Mackel [1979] J. Physiol. (Lond.) 294:105-122; Hubscher and Johnson [1996] J. Neurophysiol. 76:2474-2482; Hubscher and Johnson [1999] J. Neurophysiol. 82:1381-1389; Johnson and Hubscher [1998] Neuroreport 9:341-345). Specifically, this complex of paramedian reticular nuclei has been implicated in the inhibition of sexual reflexes. In the present study, an anterograde fluorescent tracer was used to investigate direct descending projections from the Gi-LPGi complex to retrogradely labeled pudendal motoneurons (MN) in the male rat. Our results demonstrated that, although a high density of arborizations from Gi-LPGi fibers appears to be in close apposition to pudendal MNs, this relationship also applies to other MNs throughout the entire spinal cord. The Gi-LPGi also projects to spinal autonomic regions, i.e., both the intermediolateral cell column and the sacral parasympathetic nucleus, as well as to regions of the intermediate gray, which contain interneurons involved in the organization of pelvic floor reflexes. Lastly, throughout the length of the spinal cord, numerous neurons located primarily in laminae VII-X, were retrogradely labeled with Fluoro-Ruby after injections into the Gi-LPGi. The diffuse descending projections and arborizations of this pathway throughout the spinal cord suggest that this brainstem area is involved in the direct, descending control of a variety of spinal activities. These results are in contrast with our observations of the discrete projections of the caudal nucleus raphe obscurus, which target the autonomic and somatic MNs involved specifically in sexual and eliminative functions (Hermann et al. [1998] J. Comp. Neurol. 397:458-474).

Decreased colonic motility in persons with chronic spinal cord injury

OBJECTIVES

In persons with spinal cord injury (SCI), several studies have shown that large bowel transit is decreased at the level of the left colon and rectum, and that postprandial colonic response to food is absent. To define these parameters further, the effects of food on colonic motility in persons with SCI were studied and compared to those of spinally intact (SI) individuals.

METHODS

The study was conducted in eight subjects with SCI (four paraplegic and four quadriplegic) and six age-matched SI subjects. After routine bowel preparation, colonoscopy was performed with the proximal end of a solid state pressure transducer catheter (four sensors each separated by 10 cm) tethered to the splenic flexure using endoclips (Olympus). The subjects were then allowed to carry out their usual daily activities. Two phases were compared: 1 h before breakfast, designated as the "resting phase," and 1 h during breakfast, designated as the "food-ingestion phase."

RESULTS

Baseline colonic activity of the SCI group was significantly less than in SI subjects. During meals, the motility index, mean amplitude of the waves, percent activity, and number of waves was significantly less in the SCI group. In both the SI and SCI groups, a postprandial colonic response was observed. However, in the SCI group, the response was seen only in the descending colon and not in the rectosigmoid region.

CONCLUSIONS

SCI decreases colonic motility, and this alteration may relate to difficulty with evacuation. The postprandial colonic response in SCI is present but is suboptimal and confined to the descending colon.

Spinal cord injury medicine. 5. Preserving wellness and independence of the aging patient with spinal cord injury: a primary care approach for the rehabilitation medicine specialist

This self-directed learning module highlights consideration and treatment of individuals with long-term spinal cord injury (SCI). It is part of the chapter on SCI medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the challenges of chronic disease prevention, diagnosis, therapeutic options, and the resultant impact on the person with long-term SCI. With cardiovascular disease becoming a leading cause of mortality in this population, risk factor modification through weight, lipid, and glucose control becomes more important. Likewise, bowel dysfunction increases with duration and severity of SCI. Conservative and surgical management options are discussed. Musculoskeletal repetitive trauma injuries occur commonly in long-term SCI but can be prevented with appropriate lifestyle or equipment modifications. These and other conditions occurring in the person with long-term SCI are closely related to psychosocial function with resultant social isolation, depression, and substance abuse. Thus, identification and surveillance of these comorbidities are addressed, with an emphasis on prevention.

OVERALL ARTICLE OBJECTIVE

To summarize the unique medical, psychosocial, and functional needs of the individual with long-term SCI.

Anorectal physiologic testing for bowel dysfunction in patients with spinal cord lesions

PURPOSE

Bowel dysfunction is common in patients with spinal cord lesions. This study aims to determine whether there are any discriminatory findings at anorectal physiologic testing in patients with spinal cord lesions.

METHODS

Twelve consecutive patients (6 females) with significant spinal cord lesions who had mixed symptoms of constipation, fecal impaction, and fecal incontinence were evaluated by perfusion manometry and pudendal nerve terminal motor latency. None of the patients had a sphincter defect as evaluated by endoanal ultrasonography.

RESULTS

The median age was 54 (range, 40-87) years. Eight (67 percent) of them had had traumatic spinal cord injuries. Other spinal cord lesions included spina bifida, syringomyelia, arachnoid cyst, and spinal cord ischemia after abdominal aortic aneurysm repair. In patients with spinal cord lesions, the mean (range) resting anal canal pressure and maximum squeeze anal canal pressure were 46 (10-100) mmHg and 76 (30-120) mmHg respectively compared with 62 (50-70) mmHg, and 138 (100-180) mmHg, respectively, in healthy controls. Eleven (92 percent) patients had prolonged pudendal nerve terminal motor latency (9 bilateral and 2 unilateral) whereas rectoanal inhibitory reflex was abolished in all 9 patients tested.

CONCLUSIONS

Spinal patients with severe bowel symptoms tended to have lower anal canal pressures than healthy controls. Pudendal netropathy and impaired rectoanal inhibitory reflex are common and may be important in the pathogenesis of bowel dysfunction in patients with spinal cord lesions.