Pharmacological Rectal Stimulants
Pharmacological rectal stimulants (suppositories and enemas) are a common component of a successful bowel management program, used by up to 60% of individuals with UMN bowel dysfunction (Coggrave et al. 2009). The two most commonly used are the glycerin suppository, which provides a mild local stimulus and lubrication, and the bisacodyl (dulcolax) suppository, which provides a dose of stimulant laxative directly to the colonic mucosa producing peristalsis throughout the colon. Other options include sodium hydrogen carbonate suppositories, sodium citrate and glycerol micro-enema and docusate sodium micro-enema.
Discussion
Pharmacological rectal agents (suppositories or enemas) are commonly used by individuals with SCI to stimulate reflex evacuation at the time chosen for bowel care. They are an essential element of a bowel program for many individuals with upper motor neuron bowel though there is little evidence to support most of the suppositories and enemas used. However, the effectiveness of the hydrogenated vegetable oil-based bisacodyl suppositories compared to the polyethylene glycol-based suppositories has been examined. The total bowel care time with the polyethylene glycol-based suppository is significantly less (Stiens et al. 1998; Frisbie 1997; Dunn & Galka 1994) compared to hydrogenated vegetable oil based suppository. House and Stiens (1997) compared the effectiveness of hydrogenated vegetable-based, polyethylene glycol-based and docusate glycerin (mini-enema) in subjects with upper motor neuron lesions. Results showed a significant decrease in bowel care time using the polyethylene glycol-based suppository and the mini-enema as compared with the hydrogenated vegetable oil-based suppositories. Amir et al. (1998) found in a cohort of seven individuals with SCI that docusate sodium mini enema scored best in neurogenic bowel symptom reduction followed by, in descending order of efficacy, mineral oil enema, bisacodyl suppositories and glycerin suppositories.
Conclusion
There is level 1b evidence (from 1 RCT: House & Stiens 1997) to support polyethylene glycol-based suppositories for bowel management. There is a clinically significant decrease in the amount of nursing time for persons requiring assistance and less time performing bowel care for the independent individual.
Author Year; Country
Score Research Design Total Sample Size |
Methods | Outcome |
House & Stiens 1997; USA
RCT PEDro = 7 N=15 |
Population: 9 participants with cervical injuries, 6 with thoracic injuries (11 complete, 4 incomplete); Age range: 26-61; Duration of injury: 3 months to 45 yrs
Treatment: At each regularly scheduled bowel care session, insertion of either a 10 mg hydrogenated vegetable-oil base (HVB) or 10 mg polyethylene glycol base (PGB) suppository. Additionally, 10 participants received 3 TVC (polyethylene glycol-based, glycerine, docusate sodium mini-enemas). Outcome Measures: time to flatus, flatus to stool flow, defecation period, time to transfer cystometrogram, intracolonic pressure, colonic motor and myoelectrical activity |
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Amir et al. 1998;
USA Prospective Cohort N=7 |
Population: Level of injury: C4-T12, 6 participants with tetraplegia, 1 subject with paraplegia; Age range: 21-76yrs; Duration of injury range: 2-25yrs
Treatment: Each subject was studied after receiving one week of therapy with one of the following four modalities: 1) two bisacodyl suppositories, 2) two glycerin suppositories, 3) one mineral oil enema and 4) one docusate sodium mini enema (Theravac SB) daily. Outcome Measures: total colonic and segmental colonic transit times |
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Stiens et al. 1998;
USA Prospective controlled trial N=14 |
Population: Level of injury: C3-L1 (4 incomplete, 10 with complete); All males; Age: mean 53.4yrs: Duration of injury: mean 18.3yrs
Treatment: PGB vs. HVB bisacodyl suppositories at initiation of side-lying bowel care Outcome Measures: Time to flatus, flatus to stool flow, defecation period, clean up, total bowel care time |
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Frisbie 1997;
USA Prospective controlled trial N=19 |
Population: Level of injury: T1-7 (15 cervical, 4 thoracic); Age: mean (range) 64 (41-81)yrs; Duration of injury: mean (range) 19 (3-51)yrs.
Treatment: A PGB vs HVB bisacodyl suppository Outcome Measures: Average time for complete bowel evacuation |
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Dunn & Galka 1994; USA
Case Series N=14 |
Population: Level of injury: C5-L1, (5 tetraplegics, 9 paraplegics); Age: range 27-67yrs; Duration of injury: range 2-38yrs
Treatment: Phase 1: bisacodyl suppositories for five bowel programs for baseline data. Phase 2: docusate sodium mini enema (Theravac SB) for the next five bowel programs. Phase 3: bisacodyl for five more bowel programs Outcome Measures: Self-reported diary including time of insertion of the rectal medication; time of first evacuation; time required to complete the first evacuation; other interventions used; bowel problems between bowel programs |
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