9. Periodic Re-evaluation of Bowel Management Program

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

Monitor bowel management annually, and if effectiveness has changed, refer to physiatry for redesign of bowel care routine.

The Problem:

In patients with spinal cord injury (SCI), the effectiveness of bowel management may be assessed in primary care in terms of constipation, incontinence or delayed evacuations, despite adherence to a consistent 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 whether the details of bowel innervations and functioning, as well as 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.

A step-wise approach to bowel management is recommended.

First line treatment involves conservative management, such as diet and fluid management, 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.

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 an SCI – continence, reasonable evacuation time, regularity.

Key reference:

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

Additional references:

b=PubMed&dopt=Citation&list_uids=8963975
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.
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): p. 63-6. http://dx.doi.org/10.1038/sj.sc.3100531
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.
Krogh, K., & Christensen, P. (2009). Neurogenic colorectal and pelvic floor dysfunction. Best Practice and Research: Clinical Gastroenterology (of Publication: August 2009), 23 (24): 531-543.
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.
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
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