Summary

Neurogenic bowel dysfunction and associated morbidity is very common after SCI and can severely affect the quality of life of an individual with SCI. In addition, neurogenic bowel dysfunction complications can lead to increased use of health care resources, and while rarely fatal, contributes to a decrease in quality of life. For individuals with SCI neurogenic bowel dysfunction is of huge importance and yet research in this area of care is sadly lacking. Studies available frequently include small samples, are methodologically unsound and poorly reported. There is no evidence for the use of oral laxatives, little for rectal stimulants and few studies determine the best way to structure a bowel program. Developing an effective and acceptable bowel management program still relies largely upon trial and error and the experience of the healthcare professional supporting the patient. Further research is required in all areas of this field.

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.

There is level 4 evidence (from one case series; N=11) (Cameron et al. 1996) that indicates high fibre diets may lengthen colonic transit time in individuals with SCI. There is level 4 evidence (from one pre-post study; N=6) (Korsten et al. 2007) that digital rectal stimulation increases motility in the left colon.

There is level 4 evidence (from one pre-post study; N=24) (Ayas et al. 2006) that abdominal massage is ineffective for treating the neurogenic bowel.

There is conflicting level 4 evidence (from one pre-post study; N=20) (Hu et al. 2013) that abdominal massage is effective in reducing bowel movement time as well as dosage of glycerine enemas.

There is level 1b evidence (from one RCT: Korsten et al. 2004) that electrical stimulation of the abdominal wall muscles can improve bowel management for individuals with tetraplegia.

There is level 2 evidence (from one prospective controlled trial: Binnie et al. 1991) that supports the use of sacral anterior root stimulation to reduce severe constipation in complete SCI.

There is level 4 evidence (from three pre-post studies: Tsai et al. 2009; Lin et al. 2001, 2002) that functional magnetic stimulation may reduce colonic transit time in individuals with SCI.

There is level 4 evidence (from one pre-post study with two subjects: Mentes et al. 2007) that posterior tibial nerve stimulation improves bowel management for those with incomplete SCI. There is level 4 evidence (from one pre-post study with two subjects: Johnston et al. 2005) that the Praxis FES system increases the frequency of defecation and decreases time required for bowel care in individuals with SCI.

There is level 4 evidence (from one case series: Puet et al. 1997) that supports using pulsed water irrigation (intermittent rapid pulses) to remove stool in individuals with SCI.

There is level 1b evidence (from one RCT: Christensen et al. 2006) that supports the use of transanal irrigation (Peristeen Anal Irrigation system) over conservative bowel treatment (as outlined by the Paralyzed Veterans of America clinical practice guidelines) in individuals with chronic SCI and bowel management problems.

There is level 4 evidence (from one case series, one cross-sectional, and three non-randomized cohort studies: Del Popolo et al. 2008; Christensen et al. 2008; Faaborg et al. 2009; Kim et al. 2013) that supports the use of transanal irrigation to manage neurogenic bowel dysfunction.

There is level 4 evidence (from four retrospective reviews: Teichman et al. 1998; Christensen et al. 2000; Teichman et al. 2003; Worsøe et al. 2008) that the Malone Antegrade Continence Enema successfully treats neurogenic bowel dysfunction.

There is level 4 evidence (from one retrospective review: Christensen et al. 2000) that the enema continence catheter can be used to treat neurogenic bowel dysfunction.

Prucalopride: There is level 1b evidence (from one RCT: Krogh et al. 2002) that prucalopride increases stool frequency, improves stool consistency and decreases gastrointestinal GI transit time; higher doses (2mg/day) were associated with moderate/severe abdominal pain.

Metoclopramide: There is level 2 evidence (from one prospective controlled trial; N=20) (Segal et al. 1987) that intravenous administration of metoclopramide decreases time of gastric emptying.

Neostigmine: There is level 1b evidence (from one RCT: Korsten et al. 2005) that neostigmine, administered with or without glycopyrrolate, leads to a greater expulsion of stool. There is level 1 evidence that neostigmine with glycopyrrolate decreases total bowel evacuation times and improves bowel evacuation.

Fampridine: There is level 1b evidence (from one RCT: Cardenas et al. 2007) that fampridine can increase the number of days with bowel movements.

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.

There is level 4 evidence (from six studies: Frisbie et al. 1986; Stone et al. 1990; Kelly et al. 1999; Rosito et al. 2002; Branagan et al. 2003; Munck et al. 2008) that colostomy reduces the number of hours spent on bowel care.

There is level 4 evidence (from one retrospective pre-post study: Frisbie et al. 1986) that colostomy greatly simplifies bowel care routines.

There is level 4 evidence (from one case study: Rosito et al. 2002) that colostomy reduces the number of hospitalizations caused by gastrointestinal problems and improves physical health, psychosocial adjustment and self-efficacy areas within quality of life.

There is level 4 evidence (from one cross-sectional study: Coggrave et al. 2012) that colostomy reduces need for laxative use and dietary manipulation to assist bowel care. There is level 5 evidence (from one case report with one subject: Hoenig et al. 2001) that a standing table alleviates constipation in an individual with SCI.

There is level 4 evidence (from one cross-sectional study: Uchikawa et al. 2007) that a newly developed washing toilet seat with a CCD camera monitor for visual feedback reduces time spent on bowel care.