Neurogenic Bowel Dysfunction Treatment & Management
- Author: Juan L Poggio, MD, MS, FACS, FASCRS; Chief Editor: Elizabeth A Moberg-Wolff, MD more...
Treatment of neurogenic bowel dysfunction (NBD) is initially conservative. Patients with suspected bowel rupture or perforation should be transferred to surgical care, as should any patients with rectal prolapse; these conditions are associated with a high morbidity and are best managed surgically.
Consultation with a gastroenterologist, a surgeon, or both should be considered in recalcitrant cases or in cases where complications are suggested or have been observed.
It is important to remain alert for possible complications. Failure to identify bowel impaction could lead to bowel perforation. Failure to identify fecal impaction because of the presence of diarrhea may lead to missing the diagnosis of intestinal obstruction.
A bowel management program, personalized for the patient, should be established that involves adjustment of dietary fiber and fluid intake, modulation of stool consistency, promotion of stool transit through the bowel, and effective reflex or mechanical evacuation of stool from the rectum. Scheduled bowel emptying should be recommended to avoid incontinence and reduce impaction.
Pharmacologic options include the following:
Colonic stimulants (eg, bisacodyl) - Polyethylene glycol–based bisacodyl suppositories may take effect more quickly than vegetable oil–based bisacodyl suppositories in patients with NBD after spinal cord injury (SCI) 
Hyperosmolar agents (eg, sodium bisphosphonate)
Bulking agents (eg, psyllium)
Stool softeners (eg, docusate sodium)
Between scheduled bowel-care efforts, most patients should make use of stool softeners, ideally with fiber to increase the bulk of the stools and thereby enhance defecatory response. Patients with reflex bowel function should aim to have soft formed stools. Patients with flaccid bowel function should aim for firmer stools to reduce the likelihood of fecal incontinence.
Other means of triggering the defecation reflex include the following:
Abdominal massage - This is performed before or during defecation by applying gentle pressure along the colon in a clockwise manner
Digital stimulation - This is performed by inserting a finger into the anal canal and applying pressure along the circumference of the canal until relaxation of the external canal is felt 
Placement of rectal stimulant suppositories
Enemas (see the image below)
Various combinations of these techniques
The Malone antegrade continence enema (MACE) is an approach that makes use of a surgically created entry into the large intestine for irrigation. The appendix serves as a conduit between the skin and the cecum, forming an appendicocecostomy. Enema fluid can be introduced through the stoma via a catheter. This procedure can be employed in patients with chronic refractory NBD, who typically do not have enough rectal tone to allow the use of rectal enemas. The appendicocecostomy is used most often in children with spina bifida.
The sacral anterior root stimulator was developed for spinal cord injury (SCI) patients with neurogenic bladder, but it is also effective for patients with constipation. The implant is placed during a laminectomy of L2 to L4. The stimulator is triggered by an external device that causes peristalsis of distal colon and rectum.
Sacral nerve stimulation with an electrode placed through the sacral foramen between S2 and S4 is effective for incomplete cauda equina and spinal lesions.[28, 29] Before implantation, a 3-week percutaneous nerve evaluation test is done with a temporary electrode and external battery. Once improvement in fecal incontinence is confirmed, the permanent pulse generator and electrode are placed. The implant provides continuous low-level electrical impulses to the sacral plexus, influencing the anal canal, the colon, and the pelvic floor.
A colostomy or ileostomy is considered in highly refractory cases or when stool incontinence complicates other problems, such as pressure sore management.
Bowel perforation is a surgical emergency resulting from fecal impaction. If clinical and radiologic findings suggest bowel rupture, the patient must be immediately referred for surgical intervention.
Biofeedback and behavioral training are beneficial for improving sensory and motor awareness in patients with incomplete neurogenic bowel lesions, especially children.[30, 31]
Another option is transanal irrigation, which assists in the evacuation of stool by introducing water into the colon and rectum through a catheter in the anus. This may be done daily or every other day. It has been shown to decrease constipation and increase quality of life in patients with SCI.
Physical therapy can be helpful. In general, any improvement in mobility and activity levels that can be achieved in an affected individual increases the potential for lessening constipation and fecal impaction.
Occupational therapists work hand in hand with nurses to improve toileting and transfer techniques, with the goal of improving independence and thereby potentially lessening fecal incontinence.
Recommendations for monitoring and follow-up include the following:
Annual follow-up visits for patients with SCI or spina bifida; even more frequent follow-up may be necessary for some patients
Thorough physical examination, including rectal examination, as part of regular follow-up
In patients older than 50 years, stool testing for occult blood to rule out colorectal cancer
Evaluation of device use in patients with SCI
Monitoring to confirm use of appropriate medications
Advice to ensure that patients’ daily diet contains 15-30 mg of fiber
Additional diagnostic workup (eg, radiologic evaluation) when necessary (eg, in cases of fecal impaction or potential perforation)
Coggrave M, Norton C. Neurogenic bowel. Handb Clin Neurol. 2013. 110:221-8. [Medline].
Gor RA, Katorski JR, Elliott SP. Medical and surgical management of neurogenic bowel. Curr Opin Urol. 2016 May 5. [Medline].
Ash D. Sustaining safe and acceptable bowel care in spinal cord injured patients. Nurs Stand. 2005 Nov 2-8. 20 (8):55-64, quiz 66. [Medline].
Gurjar SV, Jones OM. Physiology: evacuation, pelvic floor and continence mechanisms. Surgery. 2011 Aug. 29 (8):358-61.
Brading A, Ramalingham T. Mechanisms controlling normal defaecation and the potential effects of spinal cord injury. Weaver LC, Polosa C (eds). Progress in Brain Research. Philadelphia: Elsevier; 2006. 345-58.
Krogh K, Christensen P. Neurogenic colorectal and pelvic floor dysfunction. Best Pract Res Clin Gastroenterol. 2009. 23 (4):531-43. [Medline].
Coggrave M. Management of neurogenic bowel. Br J Neurosci Nurs. 2005. 1:6-13.
Pellat GC. Neurogenic continence. Part 1: pathophysiology and quality of ilfe. Br J Nurs. 2008 Jul 10-23. 17 (13):836-41. [Medline].
Wiesel P, Bell S. Bowel dysfunction: assessment and management in the neurological patient. Bowel Continence Nursing. 2004. 181-203.
Johanson JF, Lafferty J. Epidemiology of fecal incontinence: the silent affliction. Am J Gastroenterol. 1996 Jan. 91 (1):33-6. [Medline].
Nelson RL. Epidemiology of fecal incontinence. Gastroenterology. 2004 Jan. 126 (1 Suppl 1):S3-7. [Medline].
Higgins PD, Johanson JF. Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol. 2004 Apr. 99 (4):750-9. [Medline].
Krogh K, Nielsen J, Djurhuus JC, Mosdal C, Sabroe S, Laurberg S. Colorectal function in patients with spinal cord lesions. Dis Colon Rectum. 1997 Oct. 40 (10):1233-9. [Medline].
Glickman S, Kamm MA. Bowel dysfunction in spinal-cord-injury patients. Lancet. 1996 Jun 15. 347 (9016):1651-3. [Medline].
Hinds JP, Eidelman BH, Wald A. Prevalence of bowel dysfunction in multiple sclerosis. A population survey. Gastroenterology. 1990 Jun. 98 (6):1538-42. [Medline].
Coggrave M, Norton C, Cody JD. Management of faecal incontinence and constipation in adults with central neurological diseases. Cochrane Database Syst Rev. 2014 Jan 13. 1:CD002115. [Medline].
Krogh K, Ostergaard K, Sabroe S, Laurberg S. Clinical aspects of bowel symptoms in Parkinson's disease. Acta Neurol Scand. 2008 Jan. 117 (1):60-4. [Medline].
Doshi VS, Say JH, Young SH, Doraisamy P. Complications in stroke patients: a study carried out at the Rehabilitation Medicine Service, Changi General Hospital. Singapore Med J. 2003 Dec. 44 (12):643-52. [Medline]. [Full Text].
Sonnenberg A, Tsou VT, Müller AD. The "institutional colon": a frequent colonic dysmotility in psychiatric and neurologic disease. Am J Gastroenterol. 1994 Jan. 89 (1):62-6. [Medline].
Ozisler Z, Koklu K, Ozel S, Unsal-Delialioglu S. Outcomes of bowel program in spinal cord injury patients with neurogenic bowel dysfunction. Neural Regen Res. 2015 Jul. 10 (7):1153-8. [Medline]. [Full Text].
Caruana BJ, Wald A, Hinds JP, Eidelman BH. Anorectal sensory and motor function in neurogenic fecal incontinence. Comparison between multiple sclerosis and diabetes mellitus. Gastroenterology. 1991 Feb. 100 (2):465-70. [Medline].
Yi Z, Jie C, Wenyi Z, Bin X, Hongzhu J. Comparison of efficacies of vegetable oil based and polyethylene glycol based bisacodyl suppositories in treating patients with neurogenic bowel dysfunction after spinal cord injury: a meta-analysis. Turk J Gastroenterol. 2014 Oct. 25 (5):488-92. [Medline]. [Full Text].
Gordon M, Naidoo K, Akobeng AK, Thomas AG. Cochrane Review: Osmotic and stimulant laxatives for the management of childhood constipation (Review). Evid Based Child Health. 2013 Jan. 8 (1):57-109. [Medline].
Coggrave M. Neurogenic continence. Part 3: Bowel management strategies. Br J Nurs. 2008 Aug 14-Sep 10. 17 (15):962-8. [Medline].
Hoy NY, Metcalfe P, Kiddoo DA. Outcomes following fecal continence procedures in patients with neurogenic bowel dysfunction. J Urol. 2013 Jun. 189 (6):2293-7. [Medline].
Gstaltner K, Rosen H, Hufgard J, Märk R, Schrei K. Sacral nerve stimulation as an option for the treatment of faecal incontinence in patients suffering from cauda equina syndrome. Spinal Cord. 2008 Sep. 46 (9):644-7. [Medline]. [Full Text].
Lombardi G, Del Popolo G, Cecconi F, Surrenti E, Macchiarella A. Clinical outcome of sacral neuromodulation in incomplete spinal cord-injured patients suffering from neurogenic bowel dysfunctions. Spinal Cord. 2010 Feb. 48 (2):154-9. [Medline]. [Full Text].
Rasmussen MM, Kutzenberger J, Krogh K, Zepke F, Bodin C, Domurath B, et al. Sacral anterior root stimulation improves bowel function in subjects with spinal cord injury. Spinal Cord. 2015 Apr. 53 (4):297-301. [Medline].
Levitt M, Peña A. Update on pediatric faecal incontinence. Eur J Pediatr Surg. 2009 Feb. 19 (1):1-9. [Medline].
Griffin SJ, Parkinson EJ, Malone PS. Bowel management for paediatric patients with faecal incontinence. J Pediatr Urol. 2008 Oct. 4 (5):387-92. [Medline].
Christensen P, Andreasen J, Ehlers L. Cost-effectiveness of transanal irrigation versus conservative bowel management for spinal cord injury patients. Spinal Cord. 2009 Feb. 47 (2):138-43. [Medline].
[Guideline] Duncan PW, Zorowitz R, Bates B, Choi JY, Glasberg JJ, Graham GD, et al. Management of Adult Stroke Rehabilitation Care: a clinical practice guideline. Stroke. 2005 Sep. 36 (9):e100-43. [Medline]. [Full Text].