Multifaceted Bowel Management Programs

Discussion

A combination of interventions, as components of a comprehensive bowel routine, is recommended for the management of neurogenic bowel following SCI. These include dietary manipulation, anorectal stimulation and manual evacuation, timing the performance of the bowel routine to follow food intake (thus taking advantage of gastro-colic and recto-colonic reflexes), and a variety of pharmacological agents, oral and rectal. Unfortunately, only a limited number of studies evaluated the effects of different protocols on bowel function following SCI. From the results of three pre-post studies and one RCT, it is apparent that response to the protocols is highly individualized. However, the Badiali et al. (1997) multifaceted bowel management program effectively reduced gastrointestinal transit time while Correa and Rotter’s (2000) program reduced the incidence of difficult evacuation. Coggrave et al. (2006) modified the bowel management program originally proposed by Badiali et al. (1997) by including an additional step of manual evacuation and found a significant decrease in the number of bowel movement episodes requiring laxatives (from 62.8% to 23.1%). These authors also reported a significant decrease in the mean duration of bowel management episodes with introduction of this protocol (Coggrave et al. 2006). As these three studies incorporated several factors into the bowel management programs including diet, fluid consumption, and routine bowel practice, it is not possible to determine the key factor. Using the same management program in their 2006 pre-post study (Coggrave et al. 2006), Coggrave and Norton (2010) more recently conducted a 6-week RCT in which the management program was compared to the control group’s usual bowel care consisting of each subject’s usual type, number and order of interventions to achieve evacuation. The authors wanted to examine whether systematic use of less invasive interventions (i.e. the first few steps in the management program: simulation of gastro-colic reflex 20 min before starting bowel care, abdominal massage, perianal digitation, anorectal digitation and glycerin suppositories), could reduce the need for oral laxatives or more invasive interventions such as rectal stimulants and manual evacuation.Findings revealed that bowel care took longer in the experimental group, fecal incontinence was more frequent (p=0.04), and the need for oral laxatives and invasive interventions was not reduced (p=0.4). The findings in this RCT (Coggrave & Norton 2010) are in contrast with other published findings in which the use of a multifaceted program reduced the level of intervention needed for evacuation and duration of bowel management (Coggrave et al. 2006; Badiali et al. 1997). The samples in the earlier studies, however, were younger and injured for a shorter period of time, and both factors are associated with less frequent use of medicated rectal stimulants, manual evacuation, and oral laxatives (Coggrave et al. 2009).

Conclusion

There is level 1b evidence (from one RCT; N=68)(Coggrave & Norton 2010) that systematic use of less invasive interventions does not reduce the need for oral laxatives or more invasive interventions such as rectal stimulants and manual evacuation.

There is also level 1b evidence (Coggrave & Norton 2010) that use of a multifaceted bowel management program may increase the duration of bowel management. This is in contrast with level 4 evidence (from three pre-post studies; aggregate N=65) (Coggrave et al. 2006; Correa & Rotter 2000; Badiali et al. 1997) that multifaceted bowel management programs may reduce GI transit time, incidences of difficult evacuations, and duration of time required for bowel management.