8. Annual Assessment of Neurogenic Bowel

Conduct an annual assessment of bowel function in patients with SCI.

The Problem

Neurogenic bowel dysfunction is rated as one of the most significant factors affecting quality of life for people with SCI. Bowel dysfunction affects 95% of people with spinal cord injuries, and has profound effects on functional, psychological and social life. Bowel function typically deteriorates over time in the SCI population, resulting in increased evacuation time, constipation, and bowel incontinence.

Evidence-based Best Practice

There are two types of bowel dysfunction associated with SCI, both of which may result in constipation, difficulty with evacuation, and fecal incontinence.

  • An Upper Motor Neuron (UMN) lesion (above T12) typically produces a hyper-reflexive bowel; that is, spastic paralysis of the colonic wall and anal sphincters. It may also be associated with proximal impaction of stool and autonomic dysreflexia (see Nugget #4);
  • A Lower Motor Neuron (LMN) lesion (T12 and below) produces an areflexive bowel (flaccid paralysis of the external sphincter and levator ani), and impaction of stool in the rectum.

Ongoing monitoring of bowel function in primary care is required to ensure safety, effectiveness, and predictability. Annual assessment should include:

  • abdominal palpation;
  • inspection for perianal lesions;
  • medication review, for bowel-related side effects;
  • digital rectal exam, including anal sphincter tone, anal sensitivity and voluntary control. Be aware of potential to stimulate Autonomic Dysreflexia when performing exam (see Nugget #4).
  • For those with UMN lesions, the ano-cutaneous reflex should also be elicited by stroking of the skin around the anus. This test, sometimes referred to as the anal wink, ensures that reflex sphincter functioning remains intact.
  • For patients over 50 years of age, fecal occult blood testing should be conducted to screen for colon cancer bi-annually (see Nugget #11).
  • Alarm symptoms include: worsening of existing bowel dysfunction; weight loss; blood loss.

Key Reference

Cotterill, N., Madersbacher, H., Wyndaele, J. J., Apostolidis, A., Drake, M. J., Gajewski, J., … & Sievert, K. D. (2018). Neurogenic bowel dysfunction: Clinical management recommendations of the Neurologic Incontinence Committee of the Fifth International Consultation on Incontinence 2013. Neurourology and urodynamics, 37(1), 46-53.

Actionable Nuggets (4th ed., 2019)

Additional References (since 2016)

Kreydin, E., Welk, B., Chung, D., Clemens, Q., Yang, C., Danforth, T., . . . Ginsberg, D. A. (2018). Surveillance and management of urologic complications after spinal cord injury. World Journal of Urology, 36(10), 1545-1553. doi:10.1007/s00345-018-2345-0