8. Annual Assessment of Neurogenic Bowel

Actionable Nuggets for SCI (3rd ed., 2016)

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

The Problem:

Evidence-based Best Practice:

Neurogenic bowel dysfunction affects 95% of individuals with spinal cord injury (SCI). Ongoing monitoring of bowel function in primary care is required to ensure safety, effectiveness, and predictability, as well as to meet the goals of the individual with a SCI – continence, reasonable evacuation time, regularity.

There are two types of bowel dysfunction associated with SCI:

• 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 #13);
• 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.

Annual assessment of neurogenic bowel in primary care is essential to detect changes in bowel functioning and bowel management. The assessment should include abdominal palpation, rectal exam, assessment of anal sphincter tone, and inspection for perianal lesions. For patients over 50 years of age, fecal occult blood testing should be conducted to screen for colon cancer bi-annually (see Nugget #11). 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.

Both conditions result in constipation, difficulty with evacuation and fecal incontinence.

Key Reference:

    Pan, Y., Liu, B., Li, R., Zhang, Z., & Lu, L. (2014). Bowel Dysfunction in Spinal Cord Injury: Current Perspectives. Cell Biochemistry and Biophysics, 69(3), 385–388. http://doi.org/10.1007/s12013-014-9842-6

Additional References (chronological listing):

    Craven, B. C. (2015). Phenomenological study of neurogenic bowel from the perspective of individuals living with spinal cord injury. Archives of Physical Medicine and Rehabilitation, 96(1), 49–55. http://doi.org/10.1016/j.apmr.2014.07.417
    Park, H. J., Noh, S. E., Kim, G. D., & Joo, M. C. (2013). Plain abdominal radiograph as an evaluation method of bowel dysfunction in patients with spinal cord injury. Annals of Rehabilitation Medicine, 37(4), 547–555. http://doi.org/10.5535/arm.2013.37.4.547
    Krassioukov, A., Eng, J.J., & Venables, B. (2012). Neurogenic bowel following spinal cord injury. In Eng, J.J., Teasell, R.W., Miller, W.C., Wolfe, D.L., Townson, A.F., Hseich, J.T.C., et al. editors. Spinal Cord Injury Rehabilitation Evidence. Version 4.0. Vancouver, p 1-39.
    Pardee, C., Bricker, D., Rundquist, J., MacRae, C., & Tebben, C. (2012). Characteristics of neurogenic bowel in spinal cord injury and perceived quality of life. Rehabilitation Nursing, 37(3), 128–135. http://doi.org/10.1002/RNJ.00024
    Coggrave, M., & Norton, C. (2010). The need for manual evacuation and oral laxatives in the management of neurogenic bowel dysfunction after spinal cord injury: a randomized controlled trial of a stepwise protocol. Spinal Cord, 48, 504-510.
    Coggrave, M., Norton, C., & Wilson-Barnett, J. (2009). Management of neurogenic bowel dysfunction in the community after spinal cord injury: a postal survey in the United Kingdom. Spinal Cord, 47(4), 323-30.http://dx.doi.org/10.1038/sc.2008.137
    Krogh, K., & Christensen, P. (2009). Neurogenic colorectal and pelvic floor dysfunction. Best Practice & Research Clinical Gastroenterology, 23, 531-43.
    Preziosi, G., & Emmanuel, A. (2009). Neurogenic bowel dysfunction: pathophysiology, clinical manifestations and treatment. Expert Review of Gastroenterology & Hepatology, 3(4), 417.
    Faaborg, P.M., et al. (2008). The pattern of colorectal dysfunction changes with time since spinal cord injury. Spinal Cord, 46(3), 234-8. http://dx.doi.org/10.1038/sj.sc.3102121
    Singal AK, Rosman AS, Bauman WA, & Korsten M.A. (2006). Recent concepts in the management of bowel problems after spinal cord injury. Advanced Medical Science, 51, 15-22.
    Goetz, L.L., Nelson, A.L., Guihan, M., Bosshart, H.T., Harrow, J., Gerhart, K.D., Krasnicka, B., et al. (2005). Provider adherence to implementation of clinical practice guidelines for neurogenic bowel in adults with spinal cord injury. The Journal of Spinal Cord Medicine, 28(5), 394-406.
    Ng, C., et al. (2005). Gastrointestinal symptoms in spinal cord injury: relationships with level of injury and psychological factors. Diseases of the Colon & Rectum, 48(8), 1562-8. http://dx.doi.org/10.1007/s10350-005-0061-5
    Lynch, A.C., et al. (2000). Bowel dysfunction following spinal cord injury: A description of bowel function in a spinal cord-injured population and comparison with age and gender matched controls. Spinal Cord, 38(12), 717-23. http://dx.doi.org/10.1038/sj.sc.3101058
    Consortium for Spinal Cord Medicine (1998). Clinical practice guidelines: Neurogenic bowel management in adults with spinal cord injury. Journal of Spinal Cord Medicine, 21(3), 248-93. http://www.pva.org/site/News2?page=NewsArticle&id=7651
    Han, T.R., Kim, J.H., & Kwon, B.S. (1998). Chronic gastrointestinal problems and bowel dysfunction in patients with spinal cord injury. Spinal Cord, 36(7), 485-90. http://dx.doi.org/10.1038/sj.sc.3100616
    Glickman, S., & Kamm, M.A. (1996). Bowel dysfunction in spinal-cord-injury patients. Lancet, 347(9016), 1651-3. http://dx.doi.org/10.1016/S0140-6736(96)91487-7
    Stone, J.M., et al. (1990). Chronic gastrointestinal problems in spinal cord injury patients: A prospective analysis. American Journal of Gastroenterology, 85(9), 1114-9. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=2389723
    Gore, R.M., Mintzer, R.A., & Calenoff, L. (1981). Gastrointestinal complications of spinal cord injury. Spine (Phila Pa 1976), 6(6), 538-44. http://dx.doi.org/10.1097/00007632-198111000-00002