Effectiveness and safety of digital rectal stimulation and abdominal massage for neurogenic bowel dysfunction in stroke patients: a randomized controlled trial protocol.

BACKGROUND: Neurogenic bowel dysfunction (NBD) is a prevalent complication among stroke patients, significantly affecting their quality of life, duration of hospitalization, medical expenses, and even mortality. Although current guidelines suggest a conservative strategy for addressing bowel dysfunction, which includes techniques such as digital rectal stimulation (DRS) and abdominal massage, the availability of interventions remains limited in healthcare facilities. METHODS: This study follows a prospective randomized controlled parallel-group clinical trial design. The control group will receive standard care, while the intervention group will undergo a program that combines DRS and abdominal massage in addition to standard care. The duration of the intervention for both groups will be 6 weeks. The primary outcome measures will be the Wexner score. Furthermore, secondary outcomes measure will be assessed, including Bristol score, Patient Assessment of Constipation-Quality of Life (PAC-QoL), and Fecal Incontinence Quality of Life (FI-QoL). DISCUSSION: This study aims to evaluate the effectiveness and safety of a bowel rehabilitation program for stroke patients with NBD. The findings will provide information that can contribute to the formulation of bowel management strategies. TRIAL REGISTRATION: The study has been registered in the Chinese Clinical Registry under the number ChiCTR2300071709. This registration was completed on May 23, 2023. All items from the World Health Organization Trial Registration Data set are described in this manuscript.

The impact of antegrade continence enemas on bladder function in patients with neurogenic bladder and bowel.

INTRODUCTION: In neurologically intact children with constipation and lower urinary tract symptoms, treatment of constipation frequently results in improved or resolved lower urinary tract symptoms. The impact of treatment of constipation on bladder function in children with a neurogenic bowel and bladder is not well studied. The objective of this study was to evaluate the impact of antegrade continence enemas (ACE) via Chait tube on urodynamic study (UDS) parameters and urinary continence in patients with neurogenic bowel and bladder (NGB). We hypothesized that following ACE some patients would demonstrate improved UDS parameters and improved urinary continence. MATERIALS AND METHODS: A review of patients with NGB who underwent a cecostomy was performed. Inclusion criteria required UDS within 12 months before and after Chait tube placement and no change in clean intermittent catheterization or anticholinergic medications. UDS parameters assessed included bladder capacity, bladder compliance, and bladder stability. In addition, the frequency of antegrade continence enemas and encopresis were reviewed as was the frequency of UTIs before and after the surgery. RESULTS: 8 children met inclusion criteria, including 5 girls and 3 boys, with a mean (range) age of 8.5 years (5-13). All children were on clean intermittent catheterization and 7 were on anticholinergic medications. The patients demonstrated a significant improvement in constipation and encopresis (p < 0.05). All but 1 patient had resolution of encopresis, and 6 of 7 patients who had constipation before ACE management had a resolution of constipation. 2 patients (25%) developed urinary continence (i.e., dry between CIC), and 2 others had improvement in continence. 3, 2, and 2 patients had urodynamic improvement in bladder capacity, compliance, or stability, respectively. However, no significant improvement in urinary incontinence or UDS parameters was demonstrated for the group overall. DISCUSSION: Our data demonstrate that some children with neurogenic bowel and bladder will have improvement in continence and UDS parameters following the initiation of ACE. Despite significant improvement in constipation and encopresis, the frequency of bladder improvement in this population appears less than that reported in neurologically intact children following treatment of constipation. Confirmatory studies with a larger number of children are needed. However, since constipation appears to negatively impact bladder function in some children with neurogenic bowel and bladder, it is reasonable to try to eliminate significant constipation in these patients before increasing pharmaceutical management of their neurogenic bladder.

Transanal irrigation to manage neurogenic bowel in the pediatric population with spina bifida: a scoping review.

OBJECTIVE: To map available scientific evidence about the pediatric population with spina bifida submitted to transanal irrigation to manage signs and symptoms of neurogenic bowel. SOURCE OF DATA: This research was developed according to recommendations from the Joanna Briggs Institute Reviewers' Manual and the PRISMA Extension for Scoping Reviews. Searches were carried out in the databases: CINAHL, Medline/Pubmed, Scielo, Scopus, Web of Science, Embase, LILACS, Proquest, and the CAPES catalog of theses and dissertations. Quantitative and qualitative studies on the topic were included, as long as they dealt with this population. There was no predetermined time frame. SUMMARY OF THE FINDINGS: The authors found 1.020 studies, selected 130 for close reading, and included 23 in the review, all of which had been published from 1989 to 2021. The authors mapped the characteristics of the studies, including their definitions of concepts and use of scales, criteria for the indication of transanal irrigation, training to carry out the procedure, devices and solutions used, number and frequency of transanal irrigations, health care actions, time spent, associated complications, complementary exams, adherence rate, follow-up, and outcomes, focusing on the benefits for bowel management. CONCLUSIONS: Despite the variability of evaluation parameters and term definitions, evidence suggests that transanal irrigation is a safe and effective method to manage fecal incontinence. Studies in the field are likely to grow, using standardized scales and longitudinal follow-ups. The authors suggest further research on transanal irrigation in the pediatric population with spina bifida in the Latin American context.

Transanal Irrigation for People With Neurogenic Bowel Dysfunction: An Integrative Literature Review.

Transanal irrigation has been introduced as a complement to standard bowel care for people with neurogenic bowel dysfunction. There is no contemporary integrative review of the effectiveness and feasibility of transanal irrigation from a holistic nursing perspective, only fragments of evidence to date. The aim was to investigate the effectiveness and feasibility of transanal irrigation for people with neurogenic bowel dysfunction. An integrative literature review was conducted. Nineteen studies were included. According to the results, transanal irrigation can reduce difficulties associated with defecation, episodes of incontinence, and the time needed for evacuation and bowel care. Transanal irrigation can increase general satisfaction with bowel habits and quality of life and decrease level of dependency. However, there are practical problems to overcome and adverse effects to manage. Discontinuation is relatively common. The results support the effectiveness of transanal irrigation, but feasibility is inconclusive. Users, including caregivers, report practical problems, and compliance was not always easy to achieve. It is important that users, including caregivers, are well informed and supported during transanal irrigation treatment, especially during introduction. The quality of the studies found was generally weak; therefore, high-quality quantitative and qualitative studies are needed on the topic.

The Malone antegrade continence enema adapting a transanal irrigation system in patients with neurogenic bowel dysfunction.

INTRODUCTION: Patients with severe neurogenic bowel dysfunction (NBD) may undergo the Malone antegrade continence enema (MACE) surgery to perform antegrade bowel irrigation (ABI). The standard approach may be prevented by a previous appendectomy or complicated by appendicular stenoses and/or stomal leakages. We present the experience by our tertiary referral center for NBD, adopting a modified surgical technique, based on a neoappendix with the terminal ileum to preserve the natural anti-reflux mechanism of the ileocecal valve and avoid stool leakage, and a largely available transanal irrigation (TAI) system to catheterize the neoappendix and perform ABI. CASE PRESENTATION: Three individuals with NBD successfully underwent our modified MACE program. Case 1 had cauda equina syndrome. He underwent surgery at 40. Case 2 was a man who suffered from spinal cord dysfunction due to acute disseminated encephalomyelitis, functionally T12 AIS B, at 57. Case 3 was a man with traumatic L1 AIS B paraplegia. At 60 he underwent surgery after 29 years since the injury. He needed a surgical revision due to a postoperative subcutaneous infection. After 121, 84 and 14 months from surgery, the three individuals performed ABI every 2 days, presented functional stomas, had no fecal incontinence, and reported an NBD score of 6, compared to 40, 33 and 35 pre-operatively. DISCUSSION: To our knowledge, this is the first report of MACE combining a tapered terminal ileum conduit and an adapted TAI system. Our approach proved to be a safe and effective strategy for severe NBD avoiding a colostomy.

Neurogenic bowel treatments and continence outcomes in children and adults with myelomeningocele.

PURPOSE: Neurogenic bowel dysfunction (NBD) is a common comorbidity of myelomeningocele (MMC), the most common and severe form of spina bifida. The National Spina Bifida Patient Registry (NSBPR) is a research collaboration between the CDC and Spina Bifida Clinics. Fecal continence (continence) outcomes for common treatment modalities for NBD have not been described in a large sample of individuals with MMC. NSBPR patients with MMC and NBD were studied to determine variation in continence status and their ability to perform their treatment independently according to treatment modality and individual characteristics. METHODS: Continence was defined as < 1 episode of incontinence per month. Eleven common treatments were evaluated. Inclusion criteria were established diagnoses of both MMC and NBD, as well as age ⩾ 5 years (n= 3670). Chi-square or exact statistical tests were used for bivariate analyses. Logistic regression models were used to estimate the odds of continence outcomes by age, sex, race/ethnicity, level of motor function, and insurance status. RESULTS: At total of 3670 members of the NSBPR met inclusion criteria between November 2013 and December 2017. Overall prevalence of continence was 45%. Prevalence ranged from 40-69% across different treatments. Among continent individuals, 60% achieved continence without surgery. Antegrade enemas were the most commonly used treatment and had the highest associated continence rate. Ability to carry out a treatment independently increased with age. Multivariable logistic regression showed significantly higher odds of continence among individuals aged ⩾ 12 years, female, non-Hispanic white, and with private insurance.

Efficacy of Peristeen® transanal irrigation system for neurogenic bowel in the pediatric population.

This study demonstrates significantly improved bowel symptoms and satisfaction with Peristeen® use in pediatric patients with neurogenic bowel. The longer patients used Peristeen®, the greater the reduction in severity of their Neurogenic bowel and the greater the satisfaction with their bowel management.

Malone Antegrade Continence Enemas vs. Cecostomy vs. Transanal Irrigation-What Is New and How Do We Counsel Our Patients?

PURPOSE OF REVIEW: No gold standard exists for managing neurogenic bowel dysfunction, specifically in individuals with spina bifida. Since the International Children's Continence Society published its consensus document on neurogenic bowel treatment in 2012, an increased focus on why we must manage bowels and how to improve our management has occurred. This review provides updated information for clinicians. RECENT FINDINGS: A surge in research, mostly retrospective, has been conducted on the success and satisfaction of three types of management for neurogenic bowel. All three management techniques have relatively high success rates for fecal continence and satisfaction rates. Selection of which treatment to carry out still is debated among clinicians. Transanal irrigation is a safe and effective management option for neurogenic bowel that does not require surgery. Antegrade enemas can be carried out via cecostomy tube or Malone antegrade continence enema with similar fecal continence outcomes.

Bowel management program in patients with spina bifida.

PURPOSE: Our center has been successfully implementing a bowel management program (BMP) for fecal incontinence consecutive to anorectal malformation and Hirschsprung disease. Recently, the number of patients with spina bifida requiring management for fecal incontinence has increased. The purpose of this study was to review the results of bowel management in patients with spina bifida and the challenges unique to this population. METHODS: A retrospective chart review was performed including all patients with spina bifida who attended our BMP from February 2016 until April 2018. Data collection included: prenatal intervention, gender, age, characteristics of contrast enema, success rateand challenges faced. RESULTS: Twenty-two patients met inclusion criteria 13 of which were females. Three patients had their myelomeningocele repaired prenatally, the remaining were repaired postnatally. Patient ages ranged from 2 to 24 years. Only nine patients were referred to BMP at proper toilet training age. Three patients came to BMP status post an antegrade enema procedure with reported "accidents" on their current regimen. The colon in the contrast enema was non-dilated in all patients and two behaved as hypermotile requiring loperamide. Seventeen patients (77%) were clean of stool and considered successful. Solution leakage during enema administration was the most common challenge and was corrected by increasing the Foley balloon fill volume. CONCLUSIONS: Our bowel management program with enemas is effective for patients with a history of spina bifida. The data support specific considerations for this population including frequent adjustments, close follow-up and specific administration techniques.

Abdominal massage plus advice, compared with advice only, for neurogenic bowel dysfunction in MS: a RCT.

BACKGROUND: Between 50% and 80% of people with multiple sclerosis (PwMS) experience neurogenic bowel dysfunction (NBD) (i.e. constipation and faecal incontinence) that affects quality of life and can lead to hospitalisation. OBJECTIVES: To determine the clinical effectiveness and cost-effectiveness of abdominal massage plus advice on bowel symptoms on PwMS compared with advice only. A process evaluation investigated the factors that affected the clinical effectiveness and possible implementation of the different treatments. DESIGN: A randomised controlled trial with process evaluation and health economic components. Outcome analysis was undertaken blind. SETTING: The trial took place in 12 UK hospitals. PARTICIPANTS: PwMS who had 'bothersome' NBD. INTERVENTION: Following individualised training, abdominal massage was undertaken daily for 6 weeks (intervention group). Advice on good bowel management as per the Multiple Sclerosis Society advice booklet was provided to both groups. All participants received weekly telephone calls from the research nurse. MAIN OUTCOME MEASURES: The primary outcome was the difference between the intervention and control groups in change in the NBD score from baseline to week 24. Secondary outcomes were measured via a bowel diary, adherence diary, the Constipation Scoring System, patient resource questionnaire and the EuroQol-5 Dimensions, five-level version (EQ-5D-5L). RESULTS: A total of 191 participants were finalised, 189 of whom were randomised (two participants were finalised in error) (control group, n = 99; intervention group, n = 90) and an intention-to-treat analysis was performed. The mean age was 52 years (standard deviation 10.83 years), 81% (n = 154) were female and 11% (n = 21) were wheelchair dependent. Fifteen participants from the intervention group and five from the control group were lost to follow-up. The change in NBD score by week 24 demonstrated no significant difference between groups [mean difference total score -1.64, 95% confidence interval (CI) -3.32 to 0.04; p = 0.0558]; there was a significant difference between groups in the change in the frequency of stool evacuation per week (mean difference 0.62, 95% CI 0.03 to 1.21; p = 0.039) and in the number of times per week that participants felt that they emptied their bowels completely (mean difference 1.08, 95% CI 0.41 to 1.76; p = 0.002), in favour of the intervention group. Of participant interviewees, 75% reported benefits, for example less difficulty passing stool, more complete evacuations, less bloated, improved appetite, and 85% continued with the massage. A cost-utility analysis conducted from a NHS and patient cost perspective found in the imputed sample with bootstrapping a mean incremental outcome effect of the intervention relative to usual care of -0.002 quality-adjusted life-years (QALYs) (95% CI -0.029 to 0.027 QALYs). In the same imputed sample with bootstrapping, the mean incremental cost effect of the intervention relative to usual care was £56.50 (95% CI -£372.62 to £415.68). No adverse events were reported. Limitations include unequal randomisation, dropout and the possibility of ineffective massage technique. CONCLUSION: The increment in the primary outcome favoured the intervention group, but it was small and not statistically significant. The economic analysis identified that the intervention was dominated by the control group. Given the small improvement in the primary outcome, but not in terms of QALYs, a low-cost version of the intervention might be considered worthwhile by some patients. FUTURE WORK: Research is required to establish possible mechanisms of action and modes of massage delivery. TRIAL REGISTRATION: Current Controlled Trials ISRCTN85007023 and NCT03166007. FUNDING: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 58. See the NIHR Journals Library website for further project information.

A systematic review of clinical studies on electrical stimulation therapy for patients with neurogenic bowel dysfunction after spinal cord injury.

BACKGROUND: This study aimed to perform a systematic literature review of the clinical trial evidence on electrical stimulation for the treatment of neurogenic bowel dysfunction (NBD) after spinal cord injury (SCI). METHODS: Systematic electronic searches were carried out in the PubMed/Medline, EMBASE, Cochrane Central Register of Controlled Trials, and China National Knowledge Infrastructure databases, along with the reference lists in the include studies. Studies were eligible for inclusion if they adopted a controlled clinical design based on human population, the patients suffered from spinal cord injury, the main outcomes were the disorders of bowel function and the intervention was electrical stimulation. Also, the language was limited to English and Chinese. RESULTS: Eleven studies were included in this systematic review, comprising transcutaneous electrical stimulation, transrectal bowel stimulation, sacral nerve stimulation, intravesical electrical stimulation, etc. Of the 11 studies, 3 were randomized controlled trials, 8 were controlled before-and-after trials. The quality of the included studies was moderate bias risk. Most studies revealed that the electrical stimulation was beneficial for the patient with NBD after SCI. CONCLUSIONS: Only 11 small clinical studies with 298 participants have evaluated the efficacy of electrical stimulation for NBD after SCI. Although some studies showed electrical stimulation was benefit for the patient with NBD after SCI, there was currently not enough evidence to support the use of electrical stimulation could improve the clinical symptoms of those patients. Thus, well-designed randomized controlled trials with larger patient population are warranted to establish its benefit in clinical practice in the future.

Abdominal massage for neurogenic bowel dysfunction in people with multiple sclerosis (AMBER - Abdominal Massage for Bowel Dysfunction Effectiveness Research): study protocol for a randomised controlled trial.

BACKGROUND: Multiple sclerosis (MS) is a life-long condition primarily affecting younger adults. Neurogenic bowel dysfunction (NBD) occurs in 50-80% of these patients and is the term used to describe constipation and faecal incontinence, which often co-exist. Data from a pilot study suggested feasibility of using abdominal massage for the relief of constipation, but the effectiveness remains uncertain. METHODS/DESIGN: This is a multi-centred patient randomised superiority trial comparing an experimental strategy of once daily abdominal massage for 6 weeks against a control strategy of no massage in people with MS who have stated that their constipation is bothersome. The primary outcome is the Neurogenic Bowel Dysfunction Score at 24 weeks. Both groups will receive optimised advice plus the MS Society booklet on bowel management in MS, and will continue to receive usual care. Participants and their clinicians will not be blinded to the allocated intervention. Outcome measures are primarily self-reported and submitted anonymously. Central trial staff who will manage and analyse the trial data will be unaware of participant allocations. Analysis will follow intention-to-treat principles. DISCUSSION: This pragmatic randomised controlled trial will demonstrate if abdominal massage is an effective, cost-effective and viable addition to the treatment of NBD in people with MS. TRIAL REGISTRATION: ClinicalTrials.gov, ISRCTN85007023 . Registered on 10 June 2014.

[The Effectiveness of Abdominal Massage on Neurogenic Bowel Dysfunction in Patients With Spinal Cord Injury: A Systematic Review].

BACKGROUND: Neurogenic bowel dysfunction is a common comorbidity in spinal cord injury patients that may result in fecal incontinence. Abdominal massage is one intestinal training method that is used to improve bowel movement and defecation. PURPOSE: To review the effectiveness of abdominal massage on neurogenic bowel dysfunction in patients with spinal cord injury. METHODS: A systematic review of Chinese and English-language articles was performed in six databases using the following key words: spinal cord injury, abdominal massage, neurogenic bowel dysfunction, and bowel training. Relevant studies published prior to June 2016 that met the inclusion and exclusion criteria were selected. The Downs and Black scale was used to appraise the quality of each of the included studies. Eight studies were included in the final analysis. RESULTS: Four of these studies indicated that abdominal massage significantly improved bowel functions and the regularity and frequency of bowel movements. Although two of the studies indicated that abdominal massage significantly reduced the use of glycerin and laxatives, the remaining six did not. The eight studies earned respective quality scores ranging between 13 and 25. CONCLUSIONS / IMPLICATIONS FOR PRACTICE: The current literature lacks consensus on the efficacy of abdominal massage in terms of improving bowel dysfunction in patients with spinal cord injuries. Future studies should use more stringent experimental designs such as randomized controlled studies to explore the correlations among massage time and frequency and bowel function improvements in order to provide guidelines for clinical care applications.

Long-Term Outcomes and Longitudinal Changes of Neurogenic Bowel Management in Adults With Pediatric-Onset Spinal Cord Injury.

OBJECTIVES: To describe long-term outcomes of neurogenic bowel dysfunction (NBD), determine changes over time in the type of bowel program, and determine changes in psychosocial outcomes associated with NBD-related factors in adults with pediatric-onset spinal cord injury (SCI). DESIGN: Longitudinal cohort survey. Follow-up occurred annually for a total of 466 interviews, with most participants (75%) contributing to at least 3 consecutive interviews. SETTING: Community. PARTICIPANTS: Adults (N=131) who had sustained an SCI before the age of 19 years (men, 64.1%; tetraplegia, 58.8%; mean age ± SD, 33.4±6.1y; mean time since injury ± SD, 19.5±7.0y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Type and evacuation time of bowel management programs; standardized measures assessing life satisfaction, health perception, depressive symptoms, and participation. Generalized estimating equations were formulated to determine odds of change in outcomes over time. RESULTS: At first interview, rectal suppository/enema use was most common (51%). Over time, the likelihood of using manual evacuation (odds ratio [OR]=1.077; 95% confidence interval [CI], 1.023-1.134; P=.005), oral laxatives (OR=1.052; 95% CI, 1.001-1.107; P=.047), and colostomy (OR=1.071; 95% CI, 1.001-1.147; P=.047) increased, whereas the odds of rectal suppository use decreased (OR=.933; 95% CI, .896-.973; P=.001). Bowel evacuation times were likely to decrease over time in participants using manual evacuation (OR=.499; 95% CI, .256-.974; P=.042) and digital rectal stimulation (OR=.490; 95% CI, .274-.881; P=.017), but increase for rectal suppository/enema use (OR=1.871; 95% CI, 1.264-2.771; P=.002). When the level of injury was controlled for, participants using manual evacuation and digital rectal stimulation were more likely to have increases in community participation scores (P<.05). CONCLUSIONS: Changes in type of bowel program over time may be associated with the time required to complete bowel evacuation in this relatively young adult SCI population.

Electroacupuncture at Zusanli (ST36) ameliorates colonic neuronal nitric oxide synthase upregulation in rats with neurogenic bowel dysfunction following spinal cord injury.

Study designExperimental study.ObjectiveTo determine the effects of electroacupuncture (EA) at Zusanli (ST36) on colonic motility and neuronal nitric oxide synthase (nNOS) expression in rats with neurogenic bowel dysfunction (NBD) after spinal cord injury (SCI).SettingSecond School of Clinical Medical, Nanjing University of Chinese Medicine, Jiangsu, China.MethodsWe divided 30 adult Sprague-Dawley rats into a sham group (10 rats), a model group (SCI alone, 10 rats) and a EA group (SCI+EA at ST36, 10 rats). Defecation time was recorded as the time from activated carbon administration (on day 15) to evacuation of the first black stool. Immunohistochemical, real-time PCR and western blot analyses were performed to assess changes in nNOS-immunoreactive cells, and nNOS messenger RNA (mRNA) and protein, respectively, after 14 experimental days.ResultsDefecation time was lower in the EA group than in the model group (P<0.01). On immunohistochemical analysis, nNOS was localized in the myenteric plexus of the colon. The number of nNOS-immunoreactive cells and the intensity of nNOS staining were greater in the model group than in the sham group and lesser in the EA group than in the model group. Consistent with the immunohistochemical findings, nNOS mRNA and protein expression was higher in the model group than in the sham group and lower in the EA group than in the model group (P<0.05 for both).ConclusionIncreased colonic nNOS expression can induce/aggravate NBD in SCI rats. EA at ST36 ameliorated NBD, possibly by downregulating colonic nNOS expression.

Medical and surgical management of neurogenic bowel.

PURPOSE OF REVIEW: Neurogenic bowel dysfunction (NBoD) commonly affects patients with spina bifida, cerebral palsy, and spinal cord injury among other neurologic insults. NBoD is a significant source of physical and psychosocial morbidity. Treating NBoD requires a diligent relationship between patient, caretaker, and provider in establishing and maintaining a successful bowel program. A well designed bowel program allows for regular, predictable bowel movements and prevents episodes of fecal incontinence. RECENT FINDINGS: Treatment options for NBoD span conservative lifestyle changes to fecal diversion depending on the nature of the dysfunction. Lifestyle changes and oral laxatives are effective for many patients. Patients requiring more advanced therapy progress to transanal irrigation devices and retrograde enemas. Those receiving enemas may opt for antegrade enema administration via a Malone antegrade continence enema or Chait cecostomy button, which are increasingly performed in a minimally invasive fashion. Select patients benefit from fecal diversion, which simplifies care in more severe cases. SUMMARY: Many medical and surgical options are available for patients with NBoD. Selecting the appropriate medical or surgical treatment involves a careful evaluation of each patient's physical, psychosocial, financial, and geographic variables in an effort to optimize bowel function.

Anorectal biofeedback for neurogenic bowel dysfunction in incomplete spinal cord injury.

STUDY DESIGN: A case-control study of prospectively collected data was performed. OBJECTIVES: To compare anorectal biofeedback (BF) outcomes in patients with incomplete motor spinal cord injury (SCI) and neurogenic bowel dysfunction (NBD) with a group of functional anorectal disorder-matched control patients. SETTING: Neurogastroenterology Unit affiliated with a Spinal Injury Unit in a tertiary referral centre in Sydney, Australia. METHODS: All consecutive patients with SCI and NBD referred for anorectal manometry and BF were matched in a 1:2 ratio with age, gender, parity and functional anorectal disorder-matched control patients. Instrumented BF was performed in six nurse-guided weekly visits. Outcomes included changes in anorectal physiology measures, symptom scores and quality-of-life measures. RESULTS: Twenty-one patients were included. These were matched with 42 patient controls. Following BF, symptom scores improved significantly in both groups, as did effect of bowel disorder on quality of life. Improvement in these measures did not differ between the groups. Patients with SCI and NBD showed improvement in their sensory and motor anorectal function, including lowering of first sensation threshold and more effective balloon expulsion. CONCLUSIONS: Patients with incomplete motor SCI responded as well to anorectal BF as functional anorectal disorder-matched controls. Spinal cord-injured patients also showed improvement in anorectal sensorimotor dysfunction and balloon expulsion. These novel findings indicate that clinicians should not be dissuaded from considering behaviour-based therapeutic interventions such as anorectal BF in selected spinal cord-injured patients.

Sacral anterior root stimulation improves bowel function in subjects with spinal cord injury.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To evaluate the long-term effect of the sacral anterior root stimulator (SARS) on neurogenic bowel dysfunction in a large, well defined spinal cord injury (SCI) cohort. SETTING: Department of Neuro-Urology, Bad Wildungen, Germany. METHODS: Subjects undergone surgery at for SARS-SDAF (sacral deafferentation) between September 1986 and July 2011 (n=587) answered a questionnaire. In total, 277 SARS subjects were available for the baseline (recall) and follow-up comparison. RESULTS: Median age was 49 years (range: 19-80), time from SCI to surgery was 10 years (range: 0-49) and from surgery to follow-up 13 (range: 1-25). Of the responders 73% used SARS for bowel emptying. On visual analog scale (VAS) ranging from 0-10 (best), satisfaction with SARS was 10. Baseline and follow-up comparison showed a decline in the median VAS score 0-10 (worst) for bowel symptoms from 6 (range: 4-8) to 4 (range: 2-6), P<0.0001; median neurogenic bowel dysfunction score from 17 (range: 11-2) to 11 (range: 9-15), P<0.0001; median St Marks score from 4 (range: 0-7) to 4 (range: 0-5), P=0.01; and median Cleveland constipation score from 7 (range: 6-10) to 6 (range: 4-8), P<0.0001. Use of suppositories, digital evacuation and mini enema and subjects totally dependent on assistance during defecation were significantly lower after SARS. CONCLUSIONS: The SARS has the potential to be one of the few treatment methods targeting multiple organ dysfunctions following SCI.

Independence does not come with the method--treatment of neurogenic bowel dysfunction in children with myelomeningocele.

AIM: The aim was to evaluate and compare different bowel regimes with regard to satisfaction, faecal incontinence and independence, and the relationship to quality of life among children with myelomeningocele (MMC). METHODS: A questionnaire, including the health-related quality of life instrument PedsQL 4.0™, was sent to all children aged seven to 16 years (n = 172) with MMC, treated at two centres in Sweden and one in Norway. The three centres cover a third of the population in the two countries. The response rate was 62%. RESULTS: Parents of children (30%) using antegrade colonic enemas (ACE) reported higher satisfaction (p = 0.01) than the parents of those (47%) using transanal irrigation (TAI). The children reported no significant difference. Children and parents in the ACE group reported more complete evacuation of the bowels than the TAI group. No significant difference was found in faecal incontinence or independent toileting. The children (40%) who emptied their bowels independently reported a higher quality of life. Children using TAI or ACE spent around one hour on the toilet at every bowel emptying. CONCLUSION: TAI and ACE are effective treatments, but time-consuming and difficult to perform independently. Higher parental satisfaction is obtained with ACE. Irrespective of method the children who can use the toilet independently report a higher quality of life, which makes efforts to support independence valuable.

Pudendal nerve stimulation: a potential tool for neurogenic bowel dysfunction!

Neurogenic bowel disease occurs after damage to the spinal cord, which affects the bowel's extrinsic innervation resulting in a lack of control of the colon with incontinence or constipation. To avoid more invasive procedures, sacral and pudendal nerve stimulation (PNS) have been recently considered as emerging treatment for patients with intractable constipation. In particular, PNS effects are thought to be secondary to interactions between the somatic and autonomic pathways within both the spinal cord and higher centers. Thus, PNS may be considered a potential tool in the treatment of neurogenic bowel dysfunction, even after a complete spinal cord damage.