Anorectal stimulation causes increased colonic motor activity in subjects with spinal cord injury

Complications in spinal cord injury persons with "traditional" colostomy: a case series

INTRODUCTION

Neurogenic bowel dysfunction is a frequent consequence of spinal cord injury/disease (SCI/D). A colostomy is considered when conservative treatments fail [1, 2]. In the last year we observed several SCI/D persons with colostomy, admitted to our institution with multiple complications.

CASE PRESENTATION

We present four cases of SCI/D persons treated with Hartmann's procedure and admitted to our institution for pressure ulcer (PU) treatment. All patients underwent PU surgery with good results. All patients reported a subjective good evacuation setting. No one assumed laxative therapies at home. At admission, all patients underwent abdominal radiography that showed an important constipation, with cases of sub-occlusion or complete occlusion with gastroparesis. One person presented a parastomal, strangulated hernia and underwent hernia reduction and patch positioning around the stoma. During hospital stay, bowel management required an important administration of laxatives and frequent, almost daily, stoma washes.

DISCUSSION

Some considerations must be made regarding the use of traditional techniques in SCI/D people, such as Hartmann's, leaving a large part of the colon and the anatomical position of the stoma itself represent limitations to fecal progression and may cause constipation. A specific approach, tailored on the SCI/D patients' characteristics, such as the one described by our group, should be considered. Even if colostomy has been performed, appropriate therapies and health education on how to manage the stoma are fundamental to prevent complications.

The urologist's role in bowel management of adult spina bifida: a narrative review

Background and Objective

Urologists are central to the coordinated care of patients with spina bifida (SB), and efforts to optimize bladder management and protection of the upper tracts are well established. However, the urologist's role in treating this population often extends to the management of bowel dysfunction which may be less defined. The methods available to the urologist for bowel management range from lifestyle modifications to medical and surgical therapy, with many patients requiring combinations of multiple strategies to combat conflicting symptoms of constipation and fecal incontinence (FI). This narrative review aims to compile a detailed algorithm of management options, for the practicing urologist to more confidently address this important facet of care.

Methods

A detailed review was conducted using PubMed and Google Scholar databases to assess the contemporary literature surrounding neurogenic bowel dysfunction in adult SB. Articles published in English between 1990 and 2023 were considered.

Key Content and Findings

This review presents and investigates a schema of increasingly definitive and invasive treatments for bowel dysfunction including lifestyle adaptations, pharmacological treatment, transanal irrigation (TAI), sacral neuromodulation (SNM), antegrade continence procedures, and bowel diversion. TAI and medical bowel care are beneficial in postponing or avoiding more invasive surgical interventions. Should conservative measures prove ineffective, surgical management provides the most definitive bowel control.

Conclusions

Symptoms of constipation and FI that result from neurogenic bowel are best managed with an individualized approach guided by the general treatment algorithm presented in this review. Educated on the numerous appropriate options, patients will often trial methods before proceeding with more invasive treatments. Additional work is required to further evaluate management options specific to the SB populations, especially in more contemporary and largely experimental treatment modalities such as SNM.

Minimally invasive electrical rectal stimulation promotes bowel emptying in an individual with spinal cord injury

CONTEXT

Individuals with SCI typically live with neurogenic bowel dysfunction and impaired colonic motility that may significantly impact health and quality of life. Bowel management often includes digital rectal stimulation (DRS) to modulate the recto-colic reflex to promote bowel emptying. This procedure can be time-consuming, caregiver-intensive, and lead to rectal trauma. This study presents a description of using electrical rectal stimulation as an alternative to DRS to help manage bowel emptying in a person with SCI.

METHODS

We conducted an exploratory case study with a 65-year-old male with a T4 AIS B SCI who normally relies on DRS as the main component of his regular bowel management strategy. In randomly selected bowel emptying sessions during a 6-week period, the participant received burst-pattern electrical rectal stimulation (ERS) (50 mA, 20 pulses/s at 100 Hz), via a rectal probe electrode until bowel emptying was achieved. The primary outcome measure was number of cycles of stimulation required to complete the bowel routine.

RESULTS

17 sessions were performed using ERS. In 16 sessions, a bowel movement was produced after only 1 cycle of ERS. In 13 sessions, complete bowel emptying was achieved with 2 cycles of ERS.

CONCLUSIONS

ERS was associated with effective bowel emptying. This work represents the first time ERS has been used to affect bowel emptying in someone with SCI. This approach could be investigated as a tool to evaluate bowel dysfunction, and it could be further refined as a tool for improving bowel emptying.

Cancer management from a chronic gastrointestinal function perspective

Bowel dysfunction in cancer is a significant and challenging issue for both clinicians and patients. As cancer survival improves, the impact of gastrointestinal symptoms on quality of life is of ever-increasing relevance. This review aims to provide an overview of the common gastrointestinal complaints seen in cancer sufferers and discuss the principles of management and up to date treatment options available.

Lack of improvement in anorectal manometry parameters after implementation of a pelvic floor/anal sphincter biofeedback in persons with motor-incomplete spinal cord injury

BACKGROUND

Effect of biofeedback on improving anorectal manometric parameters in incomplete spinal cord injury is unknown. A short-term biofeedback program investigated any effect on anorectal manometric parameters without correlation to bowel symptoms.

METHODS

This prospective uncontrolled interventional study comprised three study subject groups, Group 1: sensory/motor-complete American Spinal Injury Association Impairment Scale (AIS) A SCI (n = 13); Group 2 (biofeedback group): sensory incomplete AIS B SCI (n = 17) (n = 3), and motor-incomplete AIS C SCI (n = 8), and AIS D SCI (n = 6); and Group 3: able-bodied (AB) controls (n = 12). High-resolution anorectal manometry (HR-ARM) was applied to establish baseline characteristics in all subjects for anorectal pressure, volume, length of pressure zones, and duration of sphincter squeeze pressure. SCI participants with motor-incomplete SCI were enrolled in pelvic floor/anal sphincter bowel biofeedback training (2 × 6-week training periods comprised of two training sessions per week for 30-45 min per session). HR-ARM was also performed after each of the 6-week periods of biofeedback training.

RESULTS

Compared to motor-complete or motor-incomplete SCI participants, AB subjects had higher mean intra-rectal pressure, maximal sphincteric pressure, residual anal pressure, recto-anal pressure gradient, and duration of squeeze (p < 0.05 for each of the endpoints). No significant difference was evident at baseline between the motor-complete and motor-incomplete SCI groups. In motor-incomplete SCI subjects, the pelvic floor/anal sphincter biofeedback protocol failed to improve HR-ARM parameters.

CONCLUSION

Biofeedback training program did not improve anal manometric parameters in subjects with motor-incomplete or sensory-incomplete SCI. Biofeedback did not change physiology, and its effects on symptoms are unknown.

INFERENCES

Utility of biofeedback is limited in patients with incomplete spinal cord injury in terms of improving HR-ARM parameters.

Nursing Interventions for Patients With Neurogenic Bowel Dysfunction Arising From Complete Spinal Cord Injury: A Scoping Review

PURPOSE

We mapped key concepts and identified 4 fundamental nursing interventions for patients with neurogenic bowel dysfunction due to complete spinal cord injury (SCI).

METHODS

A scoping review was conducted according to the recommendations of the Joanna Briggs Institute.

SEARCH STRATEGY

Searches were performed in PubMed, LILACS, CINAHL, COCHRANE, and SCOPUS electronic databases. We use searched the gray literature using the Google Scholar search engine. We formulated a question to guide the search, based on the participants, concept, and context format: "What are the key manual nursing interventions performed in patients with neurogenic bowel dysfunction resulting from complete spinal cord injury?" We included nursing intervention strategies that may be performed by health professionals, patients, or caregivers. Two reviewers independently participated in the selection; disagreements were resolved by a third reviewer and 5 experts.

FINDINGS

Thirteen studies conducted between 1998 and 2019 were selected; 5 were randomized clinical trials. Four main interventions were identified for conservative management of neurogenic bowel dysfunction in patients with complete SCI. They were digital-anal stimulation, manual extraction of feces, abdominal massage, and strategies used to stimulate the gastrocolic reflex.

CONCLUSIONS

Research suggests that each of these interventions, administered alone or in combination, supports bowel evacuation in patients with a complete SCI. Each of these interventions may be performed by a nurse, and taught to the patient and/or lay caregiver.

IMPLICATIONS FOR PRACTICE

An individualized bowel management program for patients with neurogenic bowel dysfunction due to SCI is necessary to ensure regular bowel evacuation, preserve fecal continence, and support dignity and health-related quality of life. The conservative interventions identified in this scoping review should be incorporated in protocols or guidelines for management of neurogenic bowel dysfunction in this vulnerable population.

Neurogenic Bowel and Management after Spinal Cord Injury: A Narrative Review

People with spinal cord injury (SCI) suffer from the sequela of neurogenic bowel and its disabling complications primarily constipation, fecal incontinence, and gastrointestinal (GI) symptoms. Neurogenic bowel is a functional bowel disorder with a spectrum of defecatory disorders as well as colonic and gastrointestinal motility dysfunction. This manuscript will review the anatomy and physiology of gastrointestinal innervation, as well as the pathophysiology associated with SCI. It will provide essential information on the recent guidelines for neurogenic bowel assessment and medical management. This will allow medical providers to partner with their patients to develop an individualized bowel plan utilizing a combination of various pharmacological, mechanical and surgical interventions that prevent complications and ensure successful management and compliance. For people with SCI and neurogenic bowel dysfunction, the fundamental goal is to maintain health and well-being, promote a good quality of life and support active, fulfilled lives in their homes and communities.

Neurogenic Bowel Dysfunction: The Impact of the Central Nervous System in Constipation and Fecal Incontinence

Spinal cord injury and neurogenic bowel dysfunction (NBD) are life-changing events for affected patients. The clinical manifestations of NBD vary depending on the level and severity of the spinal cord lesion. Managing patients with NBD can be complicated by comorbidities, such as immobility, bladder dysfunction, progressive neurologic decline, psychological factors, loss of independence, and social withdrawal, and ideally involves a multimodal, multidisciplinary approach. Evaluation and management should be individualized, depending on the residual neurologic capabilities of the patient and their predominant gastrointestinal symptoms, and commonly involves lifestyle modifications, physical therapy, laxative medications, and surgical interventions.

Digital rectal stimulation as an intervention in persons with spinal cord injury and upper motor neuron neurogenic bowel. An evidenced-based systematic review of the literature

Context: Need for evidential support of practice guideline recommendations for management of neurogenic bowel management in adults with spinal cord injury.Objective: To determine evidence for digital rectal stimulation (DRS) as an intervention in the management of upper motor neuron neurogenic bowels (UMN-NB) in persons with spinal cord injury (SCI).Methods: A systematic review of the literature including research articles and practice guidelines evaluating upper motor neuron neurogenic bowel treatments and the use of digital rectal stimulation was performed using OvidMedline, PubMed and the Cochrane database and included research articles and practice guidelines. Limitations were made related to English language, patient age and focus on spinal cord injured patients. Strength of evidence was assessed using the Johns Hopkins Nursing evidence-based practice model.Results: Eleven articles were included in the systematic review. Only one used DRS as a primary intervention. There was moderate evidence for DRS in persons with SCI and UMN-NB. There was evidence of the physiologic effect of DRS and support for combining DRS with other treatment regimens.Conclusion: There is insufficient evidence to promote any one intervention for the management of UMN-NB. The promotion of DRS, and education as to the proper technique for DRS should remain an emphasis of education of home management of UMN-NB in persons with SCI. Future research should focus on the use of standardized, validated tools to evaluate management techniques for UMN-NB.

How to improve image quality of DWI of the prostate-enema or catheter preparation?

OBJECTIVES

To compare the impact of laxative enema preparation versus air/gas suction through a small catheter on image quality of prostate DWI.

METHODS

In this single-center study, 200 consecutive patients (100 in each arm) with either enema or catheter preparation were retrospectively included. Two blinded readers independently assessed aspects of image quality on 5-point Likert scales. Scores were compared between groups and the influence of confounding factors evaluated using multivariable logistic regression. Prostate diameters were compared on DWI and T₂-weighted imaging using intraclass correlation coefficients.

RESULTS

Image quality was significantly higher in the enema group regarding the severity of susceptibility-related artifacts (reader 1: 0.34 ± 0.77 vs. 1.73 ± 1.34, reader 2: 0.38 ± 0.86 vs. 1.76 ± 1.39), the differentiability of the anatomy (reader 1: 3.36 ± 1.05 vs. 2.08 ± 1.31, reader 2: 3.37 ± 1.05 vs. 2.09 ± 1.35), and the overall image quality (reader 1: 3.66 ± 0.77 vs. 2.26 ± 1.33, Reader 2: 3.59 ± 0.87 vs. 2.23 ± 1.38) with almost perfect inter-observer agreement (κ = 0.92-0.95). In the enema group, rectal distention was significantly lower and strongly correlated with the severity of artifacts (reader 1: ρ = 0.79, reader 2: ρ = 0.73). Furthermore, there were significantly fewer substantial image distortions, with odds ratios of 0.051 and 0.084 for the two readers which coincided with a higher agreement of the prostate diameters in the phase-encoding direction (0.96 vs. 0.89).

CONCLUSIONS

Enema preparation is superior to catheter preparation and yields substantial improvements in image quality.

KEY POINTS

• Enema preparation is superior to decompression of the rectum using air/gas suction through a small catheter. • Enema preparation markedly improves the image quality of prostate DWI regarding the severity of susceptibility-related artifacts, the differentiability of the anatomy, and the overall image quality and considerably reduces substantial artifacts that may impair a reliable diagnosis.

The effect of the therapy of "combination 3 methods progression" in patients with neurogenic bowel dysfunction (constipated type): Study protocol for a randomized controlled trial

BACKGROUND

As one of the important manifestations of neurogenic bowel dysfunction, constipation is characterized by high incidence and harmful effects. It has a negative impact on both physical and psychological health of patients. And there are no effective treatment options for this type of disease clinically. Therefore, this study is designed to examine the effect of the therapy of "combination 3 methods progression" in patients with neurogenic bowel dysfunction (constipated type).

METHODS

This is a randomized, controlled, parallel-design clinical trial. A total of 60 patients with neurogenic bowel dysfunction (constipated type) will be randomly assigned to intervention group and control group. The control group will receive 4 weeks of usual rehabilitation care, the intervention group will receive 4 weeks of the therapy of "combination 3 methods progression" in addition to usual rehabilitation care. The primary outcome is the number of spontaneous bowel movement per week. Secondary outcomes are stool characteristics, degree of difficulty in defecation, level of anxiety, level of depression, and level of self-efficacy.

DISCUSSION

The interventions of this protocol have been programmed to alleviate constipation in patients with neurogenic bowel dysfunction. Findings may provide preliminary evidence for clinical efficacy of the therapy of "combination 3 methods progression."

TRIAL REGISTRATION

Chinese Clinical Trial Registry, IDF: ChiCTR2000041463. Registered on December 26, 2020.

Current State of Knowledge on Digital Rectal Stimulation in Individuals With Traumatic and Nontraumatic Spinal Cord Injury: A Scoping Review

OBJECTIVES

To map and characterize the nature of the evidence on the use of digital rectal stimulation for bowel management in individuals with spinal cord injury (SCI).

DATA SOURCES

Five electronic databases were searched (ie, MEDLINE, EMBASE, CINAHL, Cochrane CENTRAL, and Cochrane Incontinence Group) from 1990 to November 2019.

STUDY SELECTION

Articles that provided information on the use of digital rectal stimulation either alone or in combination with treatments were included. Title and abstract screening was split between 2 reviewers after reaching consensus on the first 100 studies screened. Full-texts were reviewed independently by 2 reviewers. Discrepancies were resolved by a third reviewer.

DATA EXTRACTION

The data extraction form was developed by 2 reviewers and piloted. Data were extracted by one reviewer and checked for accuracy by a second reviewer.

DATA SYNTHESIS

A total of 4841 studies were screened, including 425 full text articles; 33 articles were identified. Thirty-two studies focused solely on individuals with SCI and 1 study explored the experiences of caregivers of individuals with SCI. The majority of participants were aged between 30 and 59 years old. Most studies used quantitative methods (n=30, 91%). Fourteen of the studies (42%) were cross-sectional. Within experimental or quasiexperimental designs, digital rectal stimulation was commonly studied as an adjunct to other methods such as suppositories or enemas. Incontinence and defecation time were the most commonly examined outcomes.

CONCLUSION

There were few studies found that focus on digital rectal stimulation. Further studies examining experience, effectiveness, complications, and long-term outcomes are warranted.

Japanese Practice Guidelines for Fecal Incontinence Part 3 -Surgical Treatment for Fecal Incontinence, Fecal Incontinence in a Special Conditions- English Version

In Japan, the surgical treatment for fecal incontinence (FI) can be performed using minimally invasive surgery, such as anal sphincteroplasty and sacral neuromodulation (SNM), as well as antegrade continence enema (ACE), graciloplasty, and stoma construction. In addition, currently, several other procedures, including biomaterial injection therapy, artificial bowel sphincter (ABS), and magnetic anal sphincter (MAS), are unavailable in Japan but are performed in Western countries. The evidence level of surgical treatment for FI is generally low, except for novel procedures, such as SNM, which was covered by health insurance in Japan since 2014. Although the surgical treatment algorithm for FI has been chronologically modified, it should be sequentially selected, starting from the most minimally invasive procedure, as FI is a benign condition. Injuries to the neural system or spinal cord often cause disorders of the sensory and motor nerves that innervate the anus, rectum, and pelvic floor, leading to the difficulty in controlling bowel movement or FI and/or constipation. FI and constipation are closely associated; when one improves, the other tends to deteriorate. Patients with severe cognitive impairment may present with active soiling, referred to as "incontinence" episodes that occur as a consequence of abnormal behavior, and may also experience passive soiling.

Rehabilitation of neurogenic bladder and bowel after spinal cord injury

Neurogenic bladder and bowel refers to the dysfunction of bladder and bowel caused by neurogenic etiology. Spinal cord injury is a major cause of this dysfunction, which seriously affects the injured person’s quality of life. The injury causes not only motor weakness of abdominal and perineal muscles, but also sensory changes and autonomic dysfunction of bladder and bowel. Spinal cord injuries involve multiple systems, and thus affect the normal functioning of the bowel and bladder in several ways: difficulty in urination and defecation, frequent or infrequent voiding, decrease of the sensation of fullness, incontinence, autonomic dysreflexia, perineal hygiene, deterioration of renal function, fecal impaction, psychological burden, etc. Thus, this review aims to provide updated practical guidance for the evaluation and management of neurogenic bowel and bladder by the clinicians who want to provide better care for their patients. Management of neurogenic bowel and bladder starts with carefully recording the patient’s history, including their bowel habits prior to the spinal injury. In general, evaluation of the neurogenic bladder requires more clinical tests than for the neurogenic bowel. The patients’ problems can be alleviated by adopting various measures: proper daily water and food intake, simultaneous pharmacologic treatments for the bowel and bladder, physiologic reflexes, bladder catheterization, rectal irrigation, surgical measures, etc. Priority should be given to the management of the neurogenic bladder with clean intermittent catheterization and decompression of the bladder pressure, and management of the neurogenic bowel by pharmacological treatment.

"Imola-Montecatone" subtotal colectomy to improve bowel management in spinal cord injury patients. Retrospective analysis in 19 cases

STUDY DESIGN

Retrospective single-center study.

OBJECTIVES

Persons with spinal cord injury live with neurogenic bowel dysfunction. Difficulties with management of neurogenic bowel can increase over time with age and time post injury, with a negative impact on autonomy and quality of life. Many conservative treatments are available to improve bowel management; however, in case of failure, a colostomy may be considered.

SETTING

Specialized Care Unit, Montecatone Rehabilitation Institute and General Surgery Division, Imola Hospital, Imola, Italy.

METHODS

From 2016 to 2019, selected patients affected by SCI and bowel dysfunction failing conservative care were treated with subtotal colectomy associated with placement of a bioabsorbable prosthesis, to prevent parastomal hernia. The surgical procedure is presented along with results.

RESULTS

Overall, 19 individuals underwent the described procedure; after 1 year of follow-up, we observed four minor complications: two cases of dehiscence of the abdominal incision, easily treated during hospital stay, and two cases of leakage of mucorrhoea.

CONCLUSION

Our results demonstrate the efficacy of the procedure to improve bowel management in persons with spinal cord injury.

Predictors of urinary or fecal incontinence in dogs with thoracolumbar acute non-compressive nucleus pulposus extrusion

Background

Urinary (UI) and fecal (FI) incontinence occur in up to 7.5% and 32% of dogs, respectively, after thoracolumbar acute noncompressive nucleus pulposus extrusion (ANNPE).

Hypotheses/Objectives

To investigate clinical, diagnostic, and therapeutic predictors of UI and FI in dogs with ANNPE affecting the T3‐L3 spinal cord segments.

Animals

Hundred and eighty‐seven dogs with T3‐L3 ANNPE diagnosed based on clinical and MRI findings.

Methods

Multicenter retrospective study. Data were obtained from medical records and telephone questionnaires and analyzed by logistic regression.

Results

UI and FI were reported in 17 (9.1%) and 44 (23.5%) dogs, respectively. Paraplegic dogs were 3 times (95% CI = 1.25, 10.87) more likely to develop UI (P = .018) and 4 times (95% CI = 1.94, 12.56) more likely to develop FI (P = .001) compared to nonparaplegic dogs. Dogs with an intramedullary hyperintensity greater than 40% of the cross‐sectional area of the spinal cord at the same level on transverse T2‐weighted MRI images were 4 times more likely to develop UI (95% CI = 1.04, 21.72; P = .045) and FI (95% CI = 1.56, 10.39; P = .004) compared to dogs with smaller lesions. FI was 3 times (95% CI = 1.41, 7.93) more likely in dogs that were not treated with nonsteroidal anti‐inflammatory drugs (NSAIDs) after diagnosis compared to dogs administered NSAIDs (P = .006) and 2 times (95% CI = 1.12, 5.98) more likely in dogs presented with clinical signs compatible with spinal shock compared to dogs without (P = .026).

Conclusion and Clinical Importance

The identification of clinical, diagnostic, and therapeutic predictors of UI and FI in dogs with T3‐L3 ANNPE can help to approach these autonomic dysfunctions occurring after spinal cord injury.

[Anorectal disorders in patients with multiple sclerosis: Physiopathology, prevalence, impact, and management]

OBJECTIVE

Neurogenic bowel disorders (NBD) are frequently observed in patients with multiple sclerosis (MS); the prevalence of constipation is estimated to be 35-54 % and fecal incontinence between 29 and 51 % (LE 4). They contribute to the deterioration of patients' quality of life (LE 4). The aim of this article is to review the literature on the physiopathology, prevalence, impact, and management of bowel disorders in patients with MS in order to educate caregivers about their existence and thus help them to optimize therapeutic choices.

MATERIALS AND METHODS

A bibliographic search was conducted between 2000 and 2019 and 31 relevant scientific articles were selected. Relevant references were subsequently added, bringing the total to 50 articles. A level of scientific evidence (LE) was assigned to each article, except for literature reviews.

RESULTS

The origin of NBD is multifactorial and includes impairment of neurological pathways, polypharmacy, behavioural disorders, and loss of autonomy (LE 4). Patients with MS should be questioned about their bowel habits and, in cases of proven NBD, specific management options should be offered. The first step concerns the dietary and lifestyle rules associated with the use of laxatives, suppositories, and/or enemas (LE 4). In the event of failure, therapies such as abdominal massages (LE 1 and 2), biofeedback and transanal irrigation can be proposed (LE 4). Anterograde colonic irrigation may also be an option (LE 4). The efficacy of stimulating the posterior tibial nerve needs to be proven (LE 4). The implantation of a sacral neuromodulation device is, for the moment, difficult due to the impossibility of performing a spinal magnetic resonance imaging during follow-up. A stoma improves the quality of life of patients and should not be proposed too late.

CONCLUSION

Effective treatment of NBD improves the quality of life of patients and reduces the incidence of bladder disorders (LE 4).

Reduced colonic smooth muscle cholinergic responsiveness is associated with impaired bowel motility after chronic experimental high-level spinal cord injury

The mechanisms underlying bowel dysfunction after high-level spinal cord injury (SCI) are poorly understood. However, impaired supraspinal sympathetic and parasympathetic control is likely a major contributing factor. Disruption of the descending autonomic pathways traversing the spinal cord was achieved by a T3 complete spinal cord transection, and colonic function was examined in vivo and ex vivo four weeks post-injury. Total gastrointestinal transit time (TGTT) was reduced and contractility of the proximal and distal colon was impaired due to reduced M₃ receptor sensitivity. These data describe a clinically relevant model of bowel dysfunction after SCI.

Neurogenic bowel management for the adult spinal cord injury patient

BACKGROUND

Bowel function can be markedly changed after a spinal cord injury (SCI). These changes, and the care associated with managing the changes, can greatly impact a person's quality of life over a lifetime.

PURPOSE

The purpose of the SIU-ICUD workgroup was to identify, assess, and summarize evidence and expert opinion-based themes and recommendations regarding bowel function and management in SCI populations.

METHODS

As part of the SIU-ICUD joint consultation of Urologic Management of the Spinal Cord Injury, a workgroup was formed and comprehensive literature search of English language manuscripts regarding bowel physiology and management plans for the SCI patient. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for levels of evidence (LOEs) and grades of recommendation (GORs).

RESULTS

Neurogenic bowel symptoms are highly prevalent in the SCI population. Patients with injuries above the conus medullaris have increased bowel motility and poor anorectal sphincter relaxation. Patients with injuries below the conus are more likely to have an areflexic colon and low sphincter tone. Conservative management strategies include diet modification and anorectal stimulation. There are few evidence-based pharmacologic interventions, which improve fecal transit time. Intestinal ostomy can be an effective treatment for reducing hours spent per week on bowel management and colostomy may be easier to manage than ileostomy due to solid vs liquid stool.

CONCLUSIONS

By understanding physiology and treatment options, patients and care teams can work together to achieve goals and maximize quality of life after injury.

Neurogenic Bowel Dysfunction in Patients with Neurogenic Bladder

Patients with primary neurologic conditions often experience urinary and bowel dysfunction due to loss of sensory and/or motor control. Neurogenic bowel dysfunction is frequently characterized by both constipation and fecal incontinence. In general, the management of neurogenic bowel dysfunction has been less well studied than bladder dysfunction despite their close association.. It is widely accepted that establishment of a multifaceted bowel regimen is the cornerstone of conservative management. Continuing assessment is necessary to determine need for more invasive interventions. In the clinical setting, the Urologist may be the principle provider addressing bowel concerns in addition to bladder dysfunction, and furthermore, treatment of one often impacts the other. Future directions should include development of follow up and management guidelines that address the comprehensive care of this patient population.

Bowel management in spinal cord injury patients

Spinal cord injuries are common in the United States, affecting approximately 12,000 people per year. Most of these patients lack normal bowel function. The pattern of dysfunction varies with the spinal level involved. Most patients use a bowel management program, and elements of successful programs are discussed. Surgical treatment, when indicated, could include sacral nerve stimulation, Malone antegrade continence enema, and colostomy.

A systematic review of the effectiveness of bowel management strategies for constipation in adults with stroke

OBJECTIVE

Constipation is one of the most common medical complications of acute stroke. Currently, management strategies to guide clinical practice are limited. This review aimed to examine the effectiveness of bowel management strategies for constipation in adults with stroke.

DESIGN

A systematic review of randomised controlled trials or other quantitative research designs in the absence of randomised controlled trials was undertaken.

DATA SOURCES

A comprehensive search of major electronic databases and all reference lists of relevant articles in the English language were performed from January 1990 up to March 2011.

REVIEW METHODS

Data were extracted and assessed by two independent reviewers. Due to differences in the study designs, the findings are presented in narrative form.

RESULTS

There were a total of three studies (two randomised controlled trials and one quasi-experimental study). One of the randomised controlled trials examined a single (once-only) structured nurse-led intervention and the other randomised controlled trial evaluated four bowel management programmes. Both studies yield improvements respectively in symptoms of bowel dysfunction and bowel training efficiency when the programme corresponded with the subjects' bowel patterns before the stroke onset. The quasi-experimental study compared the effectiveness of daily digital stimulation versus every other day and found higher bowel regularity with daily digital stimulation.

CONCLUSION

Constipation management strategies are limited. This review suggests that structured bowel programmes and nurse-led intervention in bowel care have a significant effect in improving bowel evacuations.

[Intestinal alterations in patients with a medullary lesion]

Loss of bowel control is distressing for persons with a medullary lesion and affects their quality of life. The present study aims to provide an updated review of the topic. Impaired neural control of continence and defecation after a medullary lesion provokes bowel dysfunction, with a high prevalence of two main symptoms: fecal incontinence and constipation. The physiopathology of these disorders is correlated with the neurological characteristics of the lesion, and various physiopathologic patterns have been established that correlate with the clinical manifestations. Evaluation of bowel dysfunction in these patients is normally exclusively clinical and complementary examinations are rarely used, although they seem promising. Treatment is based on establishing a program of evacuation. However, despite correct application, the results can be unsatisfactory and consequently other therapeutic alternatives should be developed.

Clinical utility of colonic and anorectal manometry in chronic constipation

Constipation is one of the most common digestive problems in North America with significant psychosocioeconomic implications. It is caused by either a primary disorder of colonic and anorectal function or by many secondary conditions such as constipating drugs, metabolic disorders and other colorectal problems. Given the heterogeneity of problems that cause constipation, defining the underlying pathophysiology is increasingly being recognized as a key step toward optimal management. Colonic manometry with sensation and tone assessment (barostat) and anorectal manometry with rectal sensation and compliance assessment and balloon expulsion test can provide a comprehensive evaluation of colonic and anorectal sensorimotor function and facilitate a diagnosis of slow transit constipation, dyssynergic defecation or irritable bowel syndrome, or an overlap of these disorders. This review provides a critical appraisal of the role of manometric techniques toward augmenting our understanding of colonic and anorectal physiology, both in health and constipation and discussing their clinical utility in the diagnosis and management of chronic constipation.

Neurogenic bowel management after spinal cord injury: a systematic review of the evidence

STUDY DESIGN

Randomized-controlled trials (RCTs), prospective cohort, case-control, pre-post studies, and case reports that assessed pharmacological and non-pharmacological intervention for the management of the neurogenic bowel after spinal cord injury (SCI) were included.

OBJECTIVE

To systematically review the evidence for the management of neurogenic bowel in individuals with SCI.

SETTING

Literature searches were conducted for relevant articles, as well as practice guidelines, using numerous electronic databases. Manual searches of retrieved articles from 1950 to July 2009 were also conducted to identify literature.

METHODS

Two independent reviewers evaluated each study's quality, using Physiotherapy Evidence Database scale for RCTs and Downs and Black scale for all other studies. The results were tabulated and levels of evidence assigned.

RESULTS

A total of 2956 studies were found as a result of the literature search. On review of the titles and abstracts, 57 studies met the inclusion criteria. Multifaceted programs are the first approach to neurogenic bowel and are supported by lower levels of evidence. Of the non-pharmacological (conservative and non-surgical) interventions, transanal irrigation is a promising treatment to reduce constipation and fecal incontinence. When conservative management is not effective, pharmacological interventions (for example prokinetic agents) are supported by strong evidence for the treatment of chronic constipation. When conservative and pharmacological treatments are not effective, surgical interventions may be considered and are supported by lower levels of evidence in reducing complications.

CONCLUSIONS

Often, more than one procedure is necessary to develop an effective bowel routine. Evidence is low for non-pharmacological approaches and high for pharmacological interventions.