A systematic review on bowel management and the success rate of the various treatment modalities in spina bifida patients

Transanal irrigation in children with functional constipation: A systematic review and meta-analysis

OBJECTIVES

Refractory functional constipation is a challenging condition to manage in children. The use of transanal irrigation (TAI) is well reported in children with neurological disorders as well as anorectal malformations but less so in children with functional disorders of defecation. The objective of our study was to evaluate the effectiveness, safety and outcomes of TAI in children with functional constipation.

METHODS

PubMed, Scopus and Google Scholar were searched for publications related to the use of TAI in functional constipation. Data regarding the study design, sample size, patient characteristics, investigator-reported response to TAI and adverse effects were extracted from studies that met the selection criteria. The inverse variance heterogeneity model was used for ascertaining the summary effect in this meta-analysis.

RESULTS

The search strategy yielded 279 articles of which five studies were included in the final review. The studies were from the United Kingdom (n = 2), Netherlands (n = 2) and Denmark (n = 1). These studies included 192 children with a median age ranging from 7 to 12.2 years old. The TAI systems used in these studies were: Peristeen (n = 2), Peristeen or Qufora (n = 1), Alterna (n = 1) and Navina (n = 1). The follow-up duration ranged from 5.5 months to 3 years. Eleven (5.7%) children did not tolerate TAI and withdrew from treatment soon after initiation. The pooled investigator-reported success of TAI was 62% (95% CI: 52%-71%). The most common adverse event was pain which was experienced by 21.7% of children. A total of 27 (14%) were successfully weaned off TAI at the last follow-up.

CONCLUSIONS

TAI is reported to be successful in 62% of children with refractory functional constipation. There is a need for well-designed prospective trials to evaluate this treatment option in children with refractory functional constipation.

Association Between Quality of Life and Neurogenic Bowel Symptoms by Bowel Management Program in Spina Bifida

OBJECTIVE

To compare differences in bowel-specific quality of life (QOL), overall qQOL, and neurogenic bowel dysfunction (NBD) severity by bowel management program in patients with spina bifida (SB).

METHODS

We performed a retrospective cross-sectional study of patients ≥12 years old at our multidisciplinary SB center who completed both a modified Peristeen NBD questionnaire (assessing bowel symptom severity and bowel-specific QOL) and the Patient-Reported Outcomes Measurement Information System Pediatric Global Health questionnaire (assessing overall QOL). Nested, multivariable models were fit for associations between outcomes and bowel management program (enemas, conservative management, and none).

RESULTS

A total of 173 patients, 56.1% female and 64.6% with myelomeningocele, were included in our analysis. Median age was 18.2 years old. Patients reported using enemas (n = 42), conservative management (n = 63), and no bowel program (n = 68). When adjusting for covariates, there was no significant association between bowel-specific QOL nor overall QOL across bowel management programs. However, the use of conservative management compared to enemas was associated with worse bowel symptoms severity (adjusted beta=2.58, 95%CI=[0.09,5.06]). Additionally, greater bowel symptom severity was significantly associated with lower overall QOL (adjusted beta=-0.33, 95%CI=[-0.57,-0.10]).

CONCLUSION

NBD symptom severity in SB is more strongly associated with QOL than the individual bowel program being utilized. Our findings suggest that different degrees of NBD require different invasiveness of bowel programs, but it is the outcome of the bowel management program and not the specific program itself that is most associated with QOL.

Transitioning care for adolescents with spina bifida in the US: challenges for management

Open spina bifida (OSB) is a common neural tube defect. Medical and surgical care involves addressing the baseline orthopedic, urologic, and neurological dysfunction as well as the changes or declines that may occur as the patient ages. Given the complexity of this disease, coordinated, multidisciplinary care involving specialists in neurosurgery, orthopedics, urology, rehabilitation and physical medicine, pediatrics, and psychology is necessary to establish and optimize baseline function. Traditionally in the US, pediatric multispecialty spina bifida clinics have provided the patient with a coordinated medical support system. Unfortunately, this coordinated, medical home has been difficult to establish during the transition from pediatric to adult care. Medical professionals must have a strong understanding of OSB to properly manage the disease and detect and prevent associated complications. In this manuscript, we (1) describe the changing needs and challenges of people living with OSB over a lifespan, (2) delineate current practices in the transition of care for people with OSB from childhood to adulthood, and (3) provide recommendations for best practices in navigating the transition process for clinicians who provide care for those afflicted with this most complex congenital abnormality of the nervous system compatible with long term survival.

State of the Art Bowel Management for Pediatric Colorectal Problems: Spinal Anomalies

BACKGROUND

Patients with spinal abnormalities often struggle with fecal and/or urinary incontinence (up to 87 and 92%, respectively) and require a collaborative approach to bowel management in conjunction.

METHODS

To define existing approaches and propose state-of-the-art bowel management, a literature search was performed using Medline/PubMed, Google Scholar, Cochrane, and EMBASE databases and focusing on the manuscripts published July 2013 and July 2023.

RESULTS

Patients with spinal anomalies have impaired innervation of the rectum and anal canal, decreasing the success rate from laxatives and rectal enemas. Thus, transanal irrigations and antegrade flushes are widely utilized in this group of patients. Based on spinal MRI, the potential for bowel control in these children depends on age, type, and lesion level. On referral for bowel management, a contrast study is performed to assess colonic motility and evacuation of stool, followed by a series of abdominal X-rays to define colonic emptying and adjust the regimen. The options for management include laxatives, rectal enemas, transanal irrigations, antegrade flushes, and the creation of a stoma. Approximately 22-71% of patients achieve social continence dependent on the type and level of the lesion.

CONCLUSION

Patients with spinal anomalies require a thorough assessment for continence potential and stool burden prior to initiation of bowel management. The optimal treatment option is defined according to the patient's age, anatomy, and mobility. The likelihood of independent bowel regimen administration should be discussed with the patients and their caregivers.

Transanal irrigation to manage neurogenic bowel in the pediatric population with spina bifida: a scoping review

OBJECTIVE

To map available scientific evidence about the pediatric population with spina bifida submitted to transanal irrigation to manage signs and symptoms of neurogenic bowel.

SOURCE OF DATA

This research was developed according to recommendations from the Joanna Briggs Institute Reviewers' Manual and the PRISMA Extension for Scoping Reviews. Searches were carried out in the databases: CINAHL, Medline/Pubmed, Scielo, Scopus, Web of Science, Embase, LILACS, Proquest, and the CAPES catalog of theses and dissertations. Quantitative and qualitative studies on the topic were included, as long as they dealt with this population. There was no predetermined time frame.

SUMMARY OF THE FINDINGS

The authors found 1.020 studies, selected 130 for close reading, and included 23 in the review, all of which had been published from 1989 to 2021. The authors mapped the characteristics of the studies, including their definitions of concepts and use of scales, criteria for the indication of transanal irrigation, training to carry out the procedure, devices and solutions used, number and frequency of transanal irrigations, health care actions, time spent, associated complications, complementary exams, adherence rate, follow-up, and outcomes, focusing on the benefits for bowel management.

CONCLUSIONS

Despite the variability of evaluation parameters and term definitions, evidence suggests that transanal irrigation is a safe and effective method to manage fecal incontinence. Studies in the field are likely to grow, using standardized scales and longitudinal follow-ups. The authors suggest further research on transanal irrigation in the pediatric population with spina bifida in the Latin American context.

Outcomes of autologous bone marrow mononuclear cell administration in the treatment of neurologic sequelae in children with spina bifida

BACKGROUND

To evaluate the safety and efficacy of autologous bone marrow mononuclear cell (BMMNC) infusion in the management of neurological sequelae in children with spina bifida (SB).

METHODS

BMMNCs were harvested from bilateral anterior iliac crests. Two intrathecal BMMNC administrations were performed with an interval of 6 months. The measurements of outcomes included clinical assessments, cystomanometry and rectomanometry.

RESULTS

Eleven children with SB underwent autologous BMMNC infusions from 2016 to 2020. There were no severe adverse events during the study period. The number of patients requiring assistance to expel stools decreased from 11 before cell infusion to 3 after the second cell infusion. The number of patients who had urine leakage decreased from 9 patients at baseline to 3 patients after the second BMMNC infusion. The mean bladder capacity increased from 127.7 ± 59.2 ml at baseline to 136.3 ± 54.8 ml at six months and to 158.3 ± 56.2 ml at 12 months after BMMNC infusions. Detrusor pressure (pdet) decreased from 32.4 ± 22.0 cm H₂O at baseline to 21.9 ± 11.8 cm H₂O after 12 months of follow-up. At baseline, six patients could walk independently. After the 2nd infusion, eight patients could walk independently.

CONCLUSION

Intrathecal infusions of autologous bone marrow mononuclear cells are safe and may improve bowel, bladder, and motor function in children with SB.

TRIAL REGISTRATION

NCT, NCT05472428. Registered July 25, 2022- Retrospectively registered, https://www.

CLINICALTRIALS

gov/ct2/show/NCT05472428 .

Fetal Repair of Neural Tube Defects

Myelomeningocele is the most common congenital neurologic defect, and the only nonlethal disease addressed by fetal surgery. A randomized control trial has established amelioration of the Arnold-Chiari II malformation, reduced ventriculoperitoneal shunt rate, and improvement in distal neurologic function in patients that receive in utero repair. Long-term follow-up of these school-age children demonstrates the persistence of these effects. The use of stem cells in fetal repair is being investigated to further improve distal motor function.

Reduction of transverse rectal diameter and its effect on bladder dynamics in children with spinal dysraphism

INTRODUCTION

To examine the reduction of transverse rectal diameter and its effect on bladder dynamics in children with spinal dysraphism.

METHODS

We prospectively evaluated 61 consecutive children with spinal dysraphism, 25 (41%) boys and 36 (59%) girls, aged 4 to 16 years; mean age 9.3 ± 3.8 years, who received bowel management. All children underwent echosonographic measurement of transverse rectal diameter before and after starting bowel management. Also, all the patients had undergone urodynamic studies before and after starting bowel management, with no changes in their urological treatment.

RESULTS

Bowel management caused an decrease in transverse rectal diameter by 56 ± 7.2% (p < 0.001). In addition, a decrease was observed for maximal detrusor pressure by 27.8 ± 7.8% (p < 0.001), leak point pressure by 37.2 ± 4.4% (p < 0.001), and PVR by 36.7 ± 8.0 (p < 0.001). Maximum bladder capacity was significantly increased after bowel management in both non-adjusted (36.4 ± 14.8%; p < 0.001) and adjusted analysis for age (39.4 ± 14.3%, p < 0.001). Detrusor compliance was also increased by 89.2 ± 24.8% (p < 0.001). Female gender and % change of maximal detrusor pressure were significant predictors of transversal rectal diameter change in univariate as well as in multivariate analysis (OR = 10.548, 95% CI 2.309-48.180; p = 0.002 and OR = 1.121, 95% CI 1.009-1.245; p = 0.034).

CONCLUSIONS

Decrease in transverse rectal diameter may be useful for bladder function and urodynamic findings in children with spinal dysraphism. Therefore, decrease in transverse rectal diameter should be a supplement to standard urotherapy.

External kinesiology tape for improvement in fecal incontinence symptom bother in women: a pilot study

INTRODUCTION AND HYPOTHESIS

Fecal incontinence is a debilitating condition with a devastating impact on quality of life. Using a commercially available kinesiology band we developed an anal tape to be applied to the anus with the aim to determine its impact on symptom bother and quality of life.

METHODS

Four-week prospective, self-controlled, pilot study of patients with FI. The primary outcome was improvement in any of the four domains (lifestyle, coping/behavior, depression/self-perception, embarrassment) evaluated by the "Fecal Incontinence Quality of Life Scale." Secondary outcomes included improvement in frequency of incontinence events and safety. Days 0-14 served as control period and days 15-28 as study period. Patients were asked to rate their satisfaction and willingness to use the device in the future using a 10-cm continuous visual analog scale.

RESULTS

Twenty patients completed the study. Median age was 64 years; all patients were females. Significant improvements were observed in all domains of the Fecal Incontinence Quality of Life Scale from baseline to day 28 (p < 0.001 for all) and in three of four domains between day 15 and 28 (p < 0.04) but not between days 1 and 14. Five patients (25%) had a ≥ 50% improvement in incontinence events. Patients reported satisfaction and willingness to use the anal tape in the future. Other than mild difficulty to remove the anal tape, no adverse events were reported.

CONCLUSIONS

In this small pilot study, the use of the anal tape was safe and effective. The primary outcome of significant improvement in quality of life was achieved ( ClinicalTrials.gov ID:NCT02989545).

PUBLIC TRIAL REGISTRY

ClinicalTrials.gov identifier NCT02989545. https://clinicaltrials.gov/ct2/show/NCT02989545.

Neurogenic bowel treatments and continence outcomes in children and adults with myelomeningocele

PURPOSE

Neurogenic bowel dysfunction (NBD) is a common comorbidity of myelomeningocele (MMC), the most common and severe form of spina bifida. The National Spina Bifida Patient Registry (NSBPR) is a research collaboration between the CDC and Spina Bifida Clinics. Fecal continence (continence) outcomes for common treatment modalities for NBD have not been described in a large sample of individuals with MMC. NSBPR patients with MMC and NBD were studied to determine variation in continence status and their ability to perform their treatment independently according to treatment modality and individual characteristics.

METHODS

Continence was defined as < 1 episode of incontinence per month. Eleven common treatments were evaluated. Inclusion criteria were established diagnoses of both MMC and NBD, as well as age ⩾ 5 years (n= 3670). Chi-square or exact statistical tests were used for bivariate analyses. Logistic regression models were used to estimate the odds of continence outcomes by age, sex, race/ethnicity, level of motor function, and insurance status.

RESULTS

At total of 3670 members of the NSBPR met inclusion criteria between November 2013 and December 2017. Overall prevalence of continence was 45%. Prevalence ranged from 40-69% across different treatments. Among continent individuals, 60% achieved continence without surgery. Antegrade enemas were the most commonly used treatment and had the highest associated continence rate. Ability to carry out a treatment independently increased with age. Multivariable logistic regression showed significantly higher odds of continence among individuals aged ⩾ 12 years, female, non-Hispanic white, and with private insurance.

Transanal irrigation (TAI) in the paediatric population: Literature review and consensus of an Italian multicentre working group

Constipation and fecal incontinence in pediatric patients are conditions due to either functional or organic bowel dysfunction and may represent a challenging situation both for parents, pediatricians, and pediatric surgeons. Different treatments have been proposed throughout the past decades with partial and alternant results and, among all proposed techniques, in the adult population the Transanal Irrigation (TAI) has become popular. However, little is known about its efficacy in children. Therefore, a group of Italian pediatric surgeons from different centers, all experts in bowel management, performed a literature review and discussed the best-practice for the use of TAI in the pediatric population. This article suggests some tips, such as the careful patients' selection, a structured training with expert in pediatric colorectal diseases, and a continuous follow-up, that are considered crucial for the full success of treatment.

Neurogenic Bowel Dysfunction in Children and Adolescents

Neurogenic/neuropathic bowel dysfunction (NBD) is common in children who are affected by congenital and acquired neurological disease, and negatively impacts quality of life. In the past, NBD received less attention than neurogenic bladder, generally being considered only in spina bifida (the most common cause of pediatric NBD). Many methods of conservative and medical management of NBD are reported, including relatively recently Transanal Irrigation (TAI). Based on the literature and personal experience, an expert group (pediatric urologists/surgeons/gastroenterologists with specific experience in NBD) focused on NBD in children and adolescents. A statement document was created using a modified Delphi method. The range of causes of pediatric NBD are discussed in this paper. The various therapeutic approaches are presented to improve clinical management. The population of children and adolescents with NBD is increasing, due both to the higher survival rate and better diagnosis. While NBD is relatively predictable in producing either constipation or fecal incontinence, or both, its various effects on each patient will depend on a wide range of underlying causes and accompanying comorbidities. For this reason, management of NBD should be tailored individually with a combined multidisciplinary therapy appropriate for the status of the affected child and caregivers.

Bowel Emptying Methods Used by German Residents Living With Spina Bifida

PURPOSE

The purpose of this study was to describe and analyze methods of bowel emptying among Germans living with spina bifida. We also analyzed relationships between age, sex, level of spinal bifida anomaly, and methods of bowel elimination.

DESIGN

A quantitative, descriptive study.

SUBJECTS AND SETTING

The sample comprised 88 persons (56 women and 32 men) residing anywhere in the Federal Republic of Germany. Their mean age was 17.5 years (SD 13.64 years), range 0 to 55 years.

METHODS

Data were collected through an online survey questionnaire developed for the urological follow-up protocol for patients with spina bifida. Parents completed the questionnaire for participants younger than 18 years.

RESULTS

Twenty participants (22.7%) reported normal defecation and 68 (77.3%) reported neurogenic bowel dysfunction requiring regular bowel management. Participants requiring bowel management predominately used rectal irrigation (40.9%) and digital rectal stimulation (27.3%) to enhance bowel evacuation. Age emerged as the only factor related to the bowel management techniques. Younger participants (≤20 years) were more likely to use rectal irrigation for bowel evacuation (P = .001, Fisher's exact test), whereas older respondents (≥21 years) were more likely to use digital rectal stimulation (P = .015, Fisher's exact test). Analysis revealed no differences in methods of bowel evacuation based on sex or level of spina bifida anomaly (cervical, thoracic, lumbar, or sacral).

CONCLUSIONS

Rectal irrigation was the most common method for bowel evacuation. Participants were less likely to employ potentially effective and more conservative measures for intestinal emptying, such as toilet training/timed evacuation associated with Valsalva maneuvers, abdominal press, abdominal massage, and digital rectal stimulation. Additional comparative studies with more participants and other countries with intestinal emptying methods are needed to better understand the needs of individuals with spina bifida and their families and to improve the health-related quality of life of these people.

The influence of bowel management on urodynamic findings in spina bifida children with detrusor overactivity and detrusor sphincter dyssynergia

OBJECTIVE

To examine the effects of bowel management on urodynamic findings in spina bifida children with detrusor overactivity (DO) and detrusor sphincter dyssynergia (DSD).

MATERIAL AND METHODS

Between 2014 and 2019 we prospectively evaluated 39 consecutive spina bifida children with DO and DSD (18 (46.2%) boys and 21 (53.8%) girls, aged 4-16 years; mean age 9.5 ± 3.7 years) who received bowel management and we treated their bowel dysfunction with an aim of alleviating the symptoms of constipation, preventing constant overdistension of the rectosigmoid, providing regular emptying of the colon and faecal continence. Bowel management included daily enema, laxative application and a special diet who was performed during 12 months. All children had undergone urodynamic studies before and after starting bowel management, with no changes in their urological treatment.

RESULTS

Bowel management caused an increase in maximum bladder capacity from 183.0 (112.0-234.0) to 237.0 (165.0-298.0) (p < 0.001). When maximal bladder capacity adjusted for age there was also significant increment (adjusted before 0.54 (0.47-0.64), adjusted after 0.75 (0.70-0.82), p < 0.001). In addition, we observed a decrease in maximal detrusor pressure from 64.3 (49.0-77.0) to 46.4 (32.0-59.0) cm H2O (p < 0.001) and an increase in bladder compliance from 3.0 (2.0-3.3) to 5.6 (3.9-6.6) ml/cm H2O (p < 0.001). There was also significant reductions in leak point pressure from 62.0 (48.0-69.0) to 39.0 (30.0-43.0) cm H2O (p = 0.001), and significant reductions in post-void residual volume (PVR) from 165.0 (128.0-187.0) to 98.0 (68.0-136.0) ml in our 13 patients who could achieve spontaneous voiding (p = 0.001).

CONCLUSION

Administering bowel management may be useful for bladder function and urodynamic findings in spina bifida children with DO and DSD. Therefore, bowel management should form an integral part of the treatment in spina bifida children with DO and DSD.

Bowel function and care: Guidelines for the care of people with spina bifida

PURPOSE

Bowel dysfunction, such as constipation and fecal incontinence, has a significant impact on health, activities of daily living, and quality of life among people with spina bifida. Secondary complications may result from bowel dysfunction and include urologic dysfunction, loss of skin integrity, shunt (hydrocephalus) function, as well as loss of social opportunities and employability.

METHODS

Using a consensus building methodology, the guidelines for management of bowel dysfunction in spina bifida were written by experts in the field of spina bifida and bowel function and care.

RESULTS

The evidence-based guidelines are presented in table format and provide age-specific recommendations to achieve fecal continence without constipation. Recommended treatments are presented from least to most invasive options. Literature supporting the recommendations and the interval research published to date is also presented.

CONCLUSION

These guidelines present a standardized approach to management of bowel dysfunction in spina bifida. Bowel management in children and young adults with spina bifida is limited by variability in clinical practice and paucity of robust research in neurogenic bowel. Collaborative multi-institutional efforts are needed to overcome research barriers and provide innovative solutions.

Efficacy of Peristeen® transanal irrigation system for neurogenic bowel in the pediatric population

This study demonstrates significantly improved bowel symptoms and satisfaction with Peristeen® use in pediatric patients with neurogenic bowel. The longer patients used Peristeen®, the greater the reduction in severity of their Neurogenic bowel and the greater the satisfaction with their bowel management.

The impact of bowel management on the quality of life in children with spina bifida with overactive bladder and detrusor sphincter dyssynergia

OBJECTIVE

The aim of the study was to assess the impact of bowel management on the quality of life in children with spina bifida with overactive bladder and detrusor sphincter dyssynergia.

MATERIALS AND METHOD

The research was carried out over the 2014-2017 period, during which 70 patients with spina bifida with overactive bladder and detrusor sphincter dyssynergia were observed. The first group (group 1) consisted of 35 patients who were administered bowel management combined with anticholinergic medication therapy and CIC. The second group (group 2) consisted of 35 patients who were treated only with anticholinergic medication therapy and CIC. Bowel management included daily enema, laxative application, and a special diet, with a view of treating constipation and fecal incontinence that was estimated on the basis of Roma III criteria, the echosonographically determined transversal rectal diameter, and encopresis frequency. The effects of the administered bowel management on urinary incontinence were estimated on the basis of the average dry interval between two CICs. Regarding the quality of life, a KINDL questionnaire was used for children and parents to determine the overall quality of life, but also the various aspects of the quality of children's life (physical well-being, emotional well-being, self-confidence, family, friends, school, disease). The test score ranges from 0 to 100, where 0 is the lowest and 100 denotes the highest quality of life. The follow-up period of every patient was one year.

RESULTS

At baseline, there was no significant difference between the groups regarding demographic and clinical features (p > 0.05). After one year, treatment by bowel management demonstrated significant improvement for both fecal constipation/incontinence and urinary incontinence (p < 0.001). The bowel management group showed improved overall quality of life in contrast to the group without bowel management 88.9 ± 7.1 vs. 55.4 ± 11.4 (p < 0.001, assessed by parents) and 84.5 ± 8.9 vs. 53.4 ± 12.5 (p < 0.001, assessed by children), respectively. Moreover, the positive impact of bowel management on quality of life was confirmed for all domains of the quality of life (physical well-being, emotional well-being, self-confidence, family, friends, school, disease), (p < 0.001 for all), both by the parents' and the children's assessment.

CONCLUSION

Administering bowel management considerably alleviates the symptoms of fecal and urinary incontinence and considerably improves the quality of life. Bowel management should be considered as an integral part of treatment of children with spina bifida.

Growing up with spina bifida: bridging the gaps in the transition of care from childhood to adulthood

Spina bifida is the most common nonchromosomal birth defect, resulting in permanent disability of multiple organ systems, yet compatible with long-term survival. Important advances across various disciplines have now improved survival among the spina bifida population. Although the majority of individuals living with spina bifida are now adults, there are few publications in the neurosurgical literature regarding the care of adults with spina bifida, associated medical conditions, surgical interventions, and long-term complications. The major goals for transitioning adult patients with spina bifida are preservation of function and promotion of independence as well as general overall health. Nevertheless, many gaps exist in our knowledge and understanding of the complex needs of this aging patient population. The goal of this paper was to provide a comprehensive updated review of the literature regarding the challenges and considerations involved in the transitional care to adulthood for patients with spina bifida. Unique to this review, the authors provide a first-hand personal communication and interview with an adult patient with spina bifida that discusses many of these challenges with transition.

Malone Antegrade Continence Enemas vs. Cecostomy vs. Transanal Irrigation-What Is New and How Do We Counsel Our Patients?

PURPOSE OF REVIEW

No gold standard exists for managing neurogenic bowel dysfunction, specifically in individuals with spina bifida. Since the International Children's Continence Society published its consensus document on neurogenic bowel treatment in 2012, an increased focus on why we must manage bowels and how to improve our management has occurred. This review provides updated information for clinicians.

RECENT FINDINGS

A surge in research, mostly retrospective, has been conducted on the success and satisfaction of three types of management for neurogenic bowel. All three management techniques have relatively high success rates for fecal continence and satisfaction rates. Selection of which treatment to carry out still is debated among clinicians. Transanal irrigation is a safe and effective management option for neurogenic bowel that does not require surgery. Antegrade enemas can be carried out via cecostomy tube or Malone antegrade continence enema with similar fecal continence outcomes.

Bowel management in children with spina bifida

Spina bifida is a birth defect that commonly causes bowel and bladder dysfunction in children with a significant negative impact on quality of life and emotional wellbeing. Fecal continence improves satisfaction and the quality of life of both children and their caretakers. Bowel management in children with spina bifida is hampered by limited controlled studies and variable practice within different institutions and subspecialists. The goals of a successful bowel management program in children with spina bifida consist of predictable bowel movements, social continence, and eventual independence. Treatment options range from conservative interventions such as diets and oral laxatives that modify stool consistency and transit, to trans-anal irrigations and antegrade continence enemas that facilitate predictable recto-sigmoid emptying and provide a greater degree of independence. In children, the treatment approach should be implemented in the context of the child's developmental age in order to allow for optimum social integration with their age-appropriate peers. We present a review of a stepwise approach to bowel management in children with spina bifida and the challenges related to the proposed treatment options.

Reinnervation of the rectum with transfer of the genital branch of the genitofemoral nerve to the pelvic nerve in rats

OBJECTIVE

The purpose of this study was to determine the feasibility of rectum reinnervation with transfer of a primarily genitofemoral nerve to the pelvic nerve in the rat.

METHODS

Thirty-six male rats were randomly divided into 3 groups: rats in the nerve transfer group (n = 12) were subjected to rectal denervation and then bilateral genitofemoral nerve–pelvic nerve transfer; rats in the nerve resection group (n = 12) underwent rectum denervation without nerve transfer; and rats in the control group (n = 12) underwent sham surgery. Rectum denervation was achieved by transection of the L-6 spinal nerves, the spinal nerves below L-6, and the pelvic nerve. Four months postoperatively, retrograde nerve tracing, regenerative nerve morphological examination, and rectal manometry assessment were performed.

RESULTS

Regenerative nerve morphological examination showed good axonal regeneration after genitofemoral nerve transfer. Nerve stimulation induced increased rectal pressures in 10 of 12 rats in the nerve transfer group. The mean rectal pressure in this group was 54.9 ± 7.1 mm Hg, which is higher than the mean value in the nerve resection group (5.5 ± 2.0 mm Hg) but lower than that in the control group (70.6 ± 8.5 mm Hg) (p < 0.05). The appearance of FluoroGold-labeled neurons in the L-1 and L-2 spinal cord segments in the nerve transfer group confirmed the formation of new neural pathways.

CONCLUSIONS

The results have demonstrated that genitofemoral nerve–pelvic nerve transfer can achieve nerve regeneration. In this animal model, the authors were able to reinnervate the rectum by nerve transfer.

Medical and surgical management of neurogenic bowel

PURPOSE OF REVIEW

Neurogenic bowel dysfunction (NBoD) commonly affects patients with spina bifida, cerebral palsy, and spinal cord injury among other neurologic insults. NBoD is a significant source of physical and psychosocial morbidity. Treating NBoD requires a diligent relationship between patient, caretaker, and provider in establishing and maintaining a successful bowel program. A well designed bowel program allows for regular, predictable bowel movements and prevents episodes of fecal incontinence.

RECENT FINDINGS

Treatment options for NBoD span conservative lifestyle changes to fecal diversion depending on the nature of the dysfunction. Lifestyle changes and oral laxatives are effective for many patients. Patients requiring more advanced therapy progress to transanal irrigation devices and retrograde enemas. Those receiving enemas may opt for antegrade enema administration via a Malone antegrade continence enema or Chait cecostomy button, which are increasingly performed in a minimally invasive fashion. Select patients benefit from fecal diversion, which simplifies care in more severe cases.

SUMMARY

Many medical and surgical options are available for patients with NBoD. Selecting the appropriate medical or surgical treatment involves a careful evaluation of each patient's physical, psychosocial, financial, and geographic variables in an effort to optimize bowel function.

Bowel management in children with spina bifida

Spina bifida is a birth defect that commonly causes bowel and bladder dysfunction in children with a significant negative impact on quality of life and emotional wellbeing. Fecal continence improves satisfaction and the quality of life of both children and their caretakers. Bowel management in children with spina bifida is hampered by limited controlled studies and variable practice within different institutions and subspecialists. The goals of a successful bowel management program in children with spina bifida consist of predictable bowel movements, social continence, and eventual independence. Treatment options range from conservative interventions such as diets and oral laxatives that modify stool consistency and transit, to trans-anal irrigations and antegrade continence enemas that facilitate predictable recto-sigmoid emptying and provide a greater degree of independence. In children, the treatment approach should be implemented in the context of the child's developmental age in order to allow for optimum social integration with their age-appropriate peers. We present a review of a stepwise approach to bowel management in children with spina bifida and the challenges related to the proposed treatment options.

Predictors of permanent disability among adults with spinal dysraphism

OBJECTIVE Predictors of permanent disability among individuals with spinal dysraphism are not well established. In this study, the authors examined potential risk factors for self-reported permanent disability among adults with spinal dysraphism. METHODS A total of 188 consecutive individuals undergoing follow-up in an adult spinal dysraphism clinic completed a standardized National Spina Bifida Patient Registry survey. Chi-square tests and logistic regression were used to assess bivariate relationships, while multivariate logistic regression was used to identify factors independently associated with self-identification as "permanently disabled." RESULTS A total of 106 (56.4%) adults with spina bifida identified themselves as permanently disabled. On multivariate analysis, relative to completion of primary and/or secondary school, completion of technical school (OR 0.01, 95% CI 0-0.40; p = 0.021), some college (OR 0.22, 95% CI 0.08-0.53; p < 0.001), college degree (OR 0.06, 95% CI 0.003-0.66; p = 0.019), and holding an advanced degree (OR 0.12, 95% CI 0.03-0.45; p = 0.002) were negatively associated with permanent disability. Relative to open myelomeningocele, diagnosis of closed spinal dysraphism was also negatively associated with permanent disability (OR 0.20, 95% CI 0.04-0.90; p = 0.036). Additionally, relative to no stool incontinence, stool incontinence occurring at least daily (OR 6.41, 95% CI 1.56-32.90; p = 0.009) or more than weekly (OR 3.43, 95% CI 1.10-11.89; p = 0.033) were both positively associated with permanent disability. There was a suggestion of a dose-response relationship with respect to the influence of educational achievement and frequency of stool incontinence on the likelihood of permanent disability. CONCLUSIONS The authors' findings suggest that level of education and degree of stool incontinence are the strongest predictors of permanent disability among adults with spinal dysraphism. These findings will be the basis of efforts to improve community engagement and to improve readiness for transition to adult care in a multidisciplinary pediatric spina bifida clinic.

Retrograde continence enema in children with spina bifida: Not as effective as first thought

AIM

The aim of the study is to investigate the effectiveness of Peristeen retrograde continence enema (RCE) in the management of faecal incontinence in children with spina bifida.

METHODS

We identified a homogenous group of spina bifida patients in whom RCE was initiated (Jan 2006-July 2013). Confidential assessments included (i) Fecal Incontinence Quality Of Life (FIQOL), (ii) St Marks Faecal Incontinence score, (iii) Cleveland Clinic Constipation score and (iv) Neurogenic Bowel Dysfunction score.

RESULTS

Of 20 patients, 11 (mean age 14.5 ± 5.3 years) were male. Of 20 patients, nine were still using RCE (mean follow-up 4.1 years). Three patients ceased RCE within 10 days, six after 4-12 months and two after 36-48 months. Reasons for cessation included balloon difficulties (n = 4), procedure deemed too difficult (n = 4) and pain (n = 3). There were no differences between the groups in length of training time for technique, instillate fluid/volume used and time taken to perform RCE. There were no differences between the groups for quality of life, faecal incontinence or constipation scores.

CONCLUSIONS

We demonstrated a high rate of cessation with RCE in patients with spina bifida. This could not be explained by associated conditions, or by enema-related parameters. One possible explanation is the lack of ongoing outpatient support for the children and their families.

Consensus Review of Best Practice of Transanal Irrigation in Children

Pediatric patients with either functional or organic bowel dysfunction may suffer from constipation and fecal incontinence and represent a complex group in whom management is often difficult. Many noninvasive and invasive treatments have been proposed, with variable efficacy and adverse effects. Transanal irrigation (TAI) is now an accepted alternative, in both children and adults, for bowel dysfunction that has not responded to conservative and medical therapies. There is, however, still some uncertainty about the use of TAI in pediatric populations. Hence, a group of specialists from different nations and pediatric disciplines, all with long-standing experience of bowel management in children, performed a literature search and had round table discussions to determine the best-practice use of TAI in the pediatric patient population. Based on these findings, this article provides best-practice recommendations on indications, patient selection, important considerations before treatment, patient and family training, treatment regimens, troubleshooting, and practical aspects of TAI. We conclude that careful patient selection, a tailored approach, directly supervised training, and sustained follow-up are key to optimize outcomes with TAI in children with functional or organic bowel dysfunction.

Evidence-Based Continence Care: An Integrative Review

PURPOSE

The purpose of this integrative review is to identify the best nurse-managed continence care strategies among rehabilitation patients from the current body of evidence.

DESIGN

The newly designed 2015 Competency Model for Professional Rehabilitation Nursing serves as a conceptual framework to categorize evidence-based recommendations for continence care into the four domains of the model.

METHODS

A search of the evidence was completed in December 2015. Literature reviewed was limited to articles published from 2005-2015 in the English language. Search priority was given to systematic reviews and randomized controlled trials.

FINDINGS

Nurse-led interventions include evidence-based clinical assessments with use of validated instruments following step-wise algorithms derived from clinical practice guidelines. The interprofessional team emphasizes role-based continence interventions with shared work to reach goals. Leadership recommendations call for administrative support and allocation of resources for continence care and also empower select bedside nurses to become continence champions. Finally, nurse-patient education and caregiver training target the promotion of successful living. System-based continence recommendations are identified to include rehab-oriented electronic documentation systems, written continence policies and procedures, and ongoing nursing education emphasizing accountability to high performance standards.

CONCLUSIONS

Rehabilitation nurses are the team leaders in promoting continence in the rehabilitation setting. They are the cultivators of hope and foster resilience among patients to move forward despite acute or chronic illness and disability. This article is intended to support rehabilitation nurses in their review of clinical evidence in effort to move toward a more uniform approach to bowel and bladder management.

CLINICAL RELEVANCE

This review equips rehabilitation nurses who seek to improve their practice by identifying the best evidence-based approaches to continence care.

Cross-Sectional Study of Bowel Symptoms in Adults With Cerebral Palsy: Prevalence and Impact on Quality of Life

OBJECTIVES

To determine the prevalence and type of bowel symptoms, and their impact on health-related quality of life (HRQOL) in adults with cerebral palsy (CP).

DESIGN

Prospective cross-sectional study.

SETTING

Urban, outpatient rehabilitation facility.

PARTICIPANTS

Adults with CP (N=91; 46 men, 45 women; mean age, 36y; age range, 18-79y).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Participants were interviewed using standardized instruments to assess the frequency and types of bowel dysfunction. The International Consultation of Incontinence Questionnaire-Bowel was used to assess bowel incontinence and impact on quality of life, and constipation presence was determined using the Rome III criteria for constipation. Constipation symptoms were rated by the Patient Assessment of Constipation-Symptom Scale. Participants' mobility status was classified using the Gross Motor Function Classification System (GMFCS). Interactions between mobility measures, anthropometric measures, and bowel symptoms were assessed.

RESULTS

Of the 91 participants enrolled, 62.6% were GMFCS IV or V. Twenty-eight participants (30.8%) reported severe difficulty with control of liquid stool (rating never or rarely); these participants were more likely to have a greater GMFCS level (P=.0004). Twenty-six participants (28.6%) reported that bowel function caused embarrassment some/most/all of the time. Fifty-nine participants (64.8%) met criteria for chronic constipation, which did not differ by GMFCS levels. Overall, 57.1% of participants reported that bowel symptoms interfered with life; 40.7% reported moderate to severe interference.

CONCLUSIONS

Bowel symptoms were frequent, a source of embarrassment, and impacted HRQOL in these adults with CP. Addressing bowel-related symptoms has the potential to improve HRQOL in these adults.