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Neurogenic Bowel Dysfunction Workup

  • Author: Juan L Poggio, MD, MS, FACS, FASCRS; Chief Editor: Elizabeth A Moberg-Wolff, MD  more...
Updated: May 26, 2016

Basic Studies

Patients older than 50 years should undergo annual stool testing for occult blood. In patients with diarrhea of unknown etiology, stool examination for fecal leukocytes, Clostridium difficile toxin, and ova and parasites should be performed.

An abdominal radiograph is useful for evaluating megacolon and distribution of feces.


Studies to Assess Structure and Function

Incontinence and evacuation can be investigated by tests that assess sphincter structure and function, such as anorectal manometry and endoanal ultrasonography. Anorectal and pelvic floor function can be assessed by means of defecating proctography and nerve conduction studies. Luminal integrity and colonic function can be evaluated by means of endoscopy and transit studies.[5]

Anorectal manometry

Anal manometry is performed by placing a water-based catheter balloon system into the distal rectum and withdrawing it through the anal canal in a stepwise manner or using a solid-state device containing microtransducers to measure anal canal pressure at various points along the catheter. This study can be employed to determine the resting and voluntary squeeze pressures of the anal canal, the length of the canal, the Valsalva reflex, and the presence of the rectoanal inhibitory reflex.[10]

Endoanal ultrasonography

Endoanal ultrasonography evaluates sphincter integrity by using an internal rotating microtransducer. Normally, the external sphincter is a hyperechoic circumferential structure, and the internal sphincter is hypoechoic. Defects and scarring appear as incomplete rings.[5]

Defecating proctography

Video fluoroscopy provides structural and functional information during defecation. An oral contrast agent is given to delineate the small bowel, and barium is placed into the rectum. X-rays are taken while the patient attempts to defecate.


Needle electrodes are placed into the puborectalis or external anal sphincter to assess the state of the muscle and innervating nerve as a function of electrical activity during the resting and contractile phases.

Sensory testing

Rectal sensory function is evaluated by means of rectal balloon insufflation. The balloon is progressively distended until particular sensations are perceived by the patient. The volumes at which these sensations are perceived are recorded. The following three sensory thresholds are usually defined[22] :

  • Constant sensation of fullness
  • Urge to defecate
  • Maximum tolerated volume


Endoscopic studies, such as rectosigmoidoscopy, anoscopy, and colonoscopy, can be used to visualize anatomic abnormalities or lesions; however, they cannot assess the function of the gastrointestinal tract.

Contributor Information and Disclosures

Juan L Poggio, MD, MS, FACS, FASCRS Associate Professor of Surgery, Director of Robotic Colon and Rectal Surgery, Division of Colorectal Surgery, Department of Surgery, Drexel University College of Medicine

Juan L Poggio, MD, MS, FACS, FASCRS is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons

Disclosure: Nothing to disclose.


Julie G Grossman, MD Resident Physician in General Surgery, Drexel University College of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Richard Salcido, MD Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine

Richard Salcido, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Association for Physician Leadership, American Medical Association, Academy of Spinal Cord Injury Professionals

Disclosure: Nothing to disclose.

Chief Editor

Elizabeth A Moberg-Wolff, MD Medical Director, Pediatric Rehabilitation Medicine Associates

Elizabeth A Moberg-Wolff, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Additional Contributors

Teresa L Massagli, MD Professor of Rehabilitation Medicine, Adjunct Professor of Pediatrics, University of Washington School of Medicine

Teresa L Massagli, MD is a member of the following medical societies: Academy of Spinal Cord Injury Professionals, American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists

Disclosure: Nothing to disclose.


Medscape Reference thanks Dawn Sears, MD, Associate Professor of Internal Medicine, Division of Gastroenterology and Hepatology, Scott and White Memorial Hospital; and Dan C Cohen, MD, Fellow in Gastroenterology, Scott and White Hospital, Texas A&M Health Science Center College of Medicine, for assistance with the video contribution to this article.

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Administration of an enema.
Illustration of neural control of gut wall by sympathetic, parasympathetic and enteric nervous system. Courtesy of Wikimedia Commons.
Colonoscopy reveals diverticulosis (pockets within colon that can bleed or become infected). Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
Abdominal X-ray showing fecal impaction extending from pelvis upward to left subphrenic space and from left toward right flank, measuring over 40 cm in length and 33 cm in width. Image courtesy of Wikimedia Commons
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