8. Annual Assessment of Neurogenic Bowel

Actionable Nuggets for SCI (2nd ed., 2013)

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

The Problem:

Neurogenic bowel dysfunction has been repeatedly rated as the most significant factor affecting the quality of life for people with SCI. Bowel management is a huge factor in the daily routines of people with spinal cord injuries, and has profound effects of functional, social and psychological life. Bowel function typically deteriorates over time in the SCI population, resulting in increased time for evacuation, more constipation and more bowel incontinence.

Evidence-based Best Practice:

Neurogenic bowel dysfunction affects 95% of individuals with spinal cord injury (SCI). 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 colon and anal sphincters. It may also be associated with proximal colonic impaction 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 the rectum.

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

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 (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.

Key reference:

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.

Additional reference:

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; quiz 331-3. http://dx.doi.org/10.1038/sc.2008.137
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
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
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
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.
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
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): p. 485-90.
http://dx.doi.org/10.1038/sj.sc.3100616
Krogh, K., & Christensen, P. (2009). Neurogenic colorectal and pelvic floor dysfunction. Best Practice & Research Clinical Gastroenterology, 23: 531-43.
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
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
Preziosi, G., & Emmanuel, A. (2009). Neurogenic bowel dysfunction: pathophysiology, clinical manifestations and treatment. Expert Review of Gastroenterology & Hepatology 3.4: 417.
Singal AK, Rosman AS, Bauman WA, & Korsten MA. (2006). Recent concepts in the management of bowel problems after spinal cord injury. Advanced Medical Science, 51: 15-22.
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