9. Periodic Re-evaluation of Bowel Management Program

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

A step-wise approach to bowel management is recommended, with involvement of SCI specialists as needed.

The Problem:

The effectiveness of bowel management in patients with spinal cord injury (SCI) may be assessed in primary care in terms of constipation, incontinence or delayed evacuations, despite adherence to a consistent bowel care routine. If these problems persist, overall re-design of the bowel program may be required.

Evidence-based Best Practice:

A highly individualized, multi-faceted approach to bowel management is required to optimize continence, stool consistency and bowel emptying. A bowel management program is usually designed for an individual with SCI during rehabilitation, and differs depending on the details of bowel functioning and hand functioning. Bowel care may need to be modified periodically as bowel function changes with age and duration post-injury, or as personal circumstances change. Furthermore, new methods of bowel management have been shown to be effective for some patients, such as trans-anal irrigation and sacral nerve root stimulation.

A step-wise approach to bowel management in spinal cord injury includes the following:

  • First line treatment involves conservative management, such as diet and fluid management (see Nugget # 10), regular scheduling, manual techniques, suppositories, irrigation, and abdominal massage.
  • When conservative techniques are inadequately effective, pharmacological measures may be considered as second level treatments; e.g., over-the-counter medications (laxatives and stool-softeners) and prescription medications (prokinetic agents such as metoclopramide). Transanal irrigation may also be beneficial for many individuals.
  • Finally surgical intervention may be indicated, such as colostomy, anterograde catheterization, implanted electrical sacral nerve stimulation.

Key Reference:

    Adriaansen, J. J., Van Asbeck, F. W., Van Kuppevelt, D., Snoek, G. J., & Post, M. W. (2015). Outcomes of neurogenic bowel management in individuals living with a spinal cord injury for at least 10 years. Archives of Physical Medicine and Rehabilitation, 96(8), 1546-1547. http://doi.org/10.1016/j.apmr.2015.01.011

 Additional References (chronological listing):

    Rasmussen, M. M., Kutzenberger J., Krogh K., Zepke F., Bodin C., Domurath B., & Christensen, P. (2015). Sacral anterior root stimulation improves bowel function in subjects with spinal cord injury. Spinal Cord, 53(4), 297–301. http://doi.org/10.1038/sc.2015.2
    Ozisler, Z., Koklu, K., Ozel, S., & Unsal-Delialioglu, S. (2015). Outcomes of bowel program in spinal cord injury patients with neurogenic bowel dysfunction. Neural Regeneration Research, 10(7), 1153–1158. http://doi.org/10.4103/1673-5374.160112
    Hughes, M. (2014). Bowel management in spinal cord injury patients. Clinics in Colon and Rectal Surgery, 27(3), 113–115. http://doi.org/10.1055/s-0034-1383904
    Kwok, S., Harvey, L., Glinsky, J., Bowden, J. L., Coggrave, M., & Tussler, D. (2014). Does regular standing improve bowel function in people with spinal cord injury? A randomised crossover trial. Spinal Cord, 53, 36-41. http://doi.org/10.1038/sc.2014.189
    Kim, H. R., Lee, B. S., Lee, J. E., & Shin, H. I. (2013). Application of transanal irrigation for patients with spinal cord injury in South Korea: a 6-month follow-up study. Spinal Cord, 51(5), 389–394. http://doi.org/10.1038/sc.2012.171
    Solomons, J., & Woodward, S. (2013). Digital removal of faeces in the bowel management of patients with spinal cord injury: a review. British Journal of Neuroscience Nursing. http://doi.org/10.12968/bjnn.2013.9.5.216
    Ness, W. (2013). Digital removal of faeces. Nursing Times, 109(17/18), 18–20.
    Worsøe, J., Rasmussen, M., Christensen, P., & Krogh, K. (2013). Neurostimulation for neurogenic bowel dysfunction. Gastroenterology Research and Practice, 2013. http://doi.org/10.1155/2013/563294
    Fourtassi, M., Charvier, K., Hajjioui, A., Havé, L., & Rode, G. (2012). Transanal irrigation for bowel and anorectal management in spinal cord-injured patients. Progres en urologie: journal de l’Association francaise d’urologie et de la Societe francaise d’urologie, 22(8), 467-474.
    Loftus, C., Wallace, E., McCaughey, M., & Smith, E. (2012). Transanal irrigation in the management of neurogenic bowel dysfunction. Prog Urol., 22(8), 467–474.
    Maheronnaghsh, R., Yousefian, A., & Rahimi-Movaghar, V. (2012). Updated evidence-based bowel management among spinal cord injury patients. J Inj Violence Res, 4(3 Suppl 1), 6757010.
    Krassioukov, A., Eng, J.J., Claxton, G., Sakakibara, B.M., Shum, S., & SCIRE Research Team (2010). Neurogenic bowel management after spinal cord injury: A systematic review of the evidence. Spinal Cord, 48(10), 718-733.
    Lombardi, G., Del Popolo, G., Cecconi, F., Surrenti, E., & Macchiarella, A. (2010). Clinical outcome of sacral neuromodulation in incomplete spinal cord-injured patients suffering from neurogenic bowel dysfunctions. Spinal Cord, 48, 154-9.
    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 and Research: Clinical Gastroenterology, 23(24), 531-543.
    Christensen, P. et al. (2006). A randomized, controlled trial of transanal irrigation versus conservative bowel management in spinal cord-injured patients. Gastroenterology, 131(3), 738-747.
    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
    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
    De Looze, D., et al. (1998). Constipation and other chronic gastrointestinal problems in spinal cord injury patients. Spinal Cord, 36(1), 63-6. http://dx.doi.org/10.1038/sj.sc.3100531
    Cameron, K.J., et al. (1996). Assessment of the effect of increased dietary fibre intake on bowel function in patients with spinal cord injury. Spinal Cord, 34(5), 277-83. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=8963975
    Menardo, G., et al. (1987). Large-bowel transit in paraplegic patients. Diseases of the Colon & Rectum, 30(12), 924-8. http://dx.doi.org/10.1007/BF02554277