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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.

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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.

Electromyography

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

Endoscopy

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.

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Contributor Information and Disclosures
Author

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.

Coauthor(s)

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.

Acknowledgements

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.

References
  1. Coggrave M, Norton C. Neurogenic bowel. Handb Clin Neurol. 2013. 110:221-8. [Medline].

  2. Gor RA, Katorski JR, Elliott SP. Medical and surgical management of neurogenic bowel. Curr Opin Urol. 2016 May 5. [Medline].

  3. 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].

  4. Benevento BT, Sipski ML. Neurogenic bladder, neurogenic bowel, and sexual dysfunction in people with spinal cord injury. Phys Ther. 2002 Jun. 82 (6):601-12. [Medline]. [Full Text].

  5. Gurjar SV, Jones OM. Physiology: evacuation, pelvic floor and continence mechanisms. Surgery. 2011 Aug. 29 (8):358-61.

  6. 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.

  7. Krogh K, Christensen P. Neurogenic colorectal and pelvic floor dysfunction. Best Pract Res Clin Gastroenterol. 2009. 23 (4):531-43. [Medline].

  8. Coggrave M. Management of neurogenic bowel. Br J Neurosci Nurs. 2005. 1:6-13.

  9. Pellat GC. Neurogenic continence. Part 1: pathophysiology and quality of ilfe. Br J Nurs. 2008 Jul 10-23. 17 (13):836-41. [Medline].

  10. Wiesel P, Bell S. Bowel dysfunction: assessment and management in the neurological patient. Bowel Continence Nursing. 2004. 181-203.

  11. Johanson JF, Lafferty J. Epidemiology of fecal incontinence: the silent affliction. Am J Gastroenterol. 1996 Jan. 91 (1):33-6. [Medline].

  12. Nelson RL. Epidemiology of fecal incontinence. Gastroenterology. 2004 Jan. 126 (1 Suppl 1):S3-7. [Medline].

  13. Higgins PD, Johanson JF. Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol. 2004 Apr. 99 (4):750-9. [Medline].

  14. 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].

  15. Glickman S, Kamm MA. Bowel dysfunction in spinal-cord-injury patients. Lancet. 1996 Jun 15. 347 (9016):1651-3. [Medline].

  16. Hinds JP, Eidelman BH, Wald A. Prevalence of bowel dysfunction in multiple sclerosis. A population survey. Gastroenterology. 1990 Jun. 98 (6):1538-42. [Medline].

  17. 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].

  18. 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].

  19. 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].

  20. 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].

  21. 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].

  22. 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].

  23. 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].

  24. 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].

  25. Coggrave M. Neurogenic continence. Part 3: Bowel management strategies. Br J Nurs. 2008 Aug 14-Sep 10. 17 (15):962-8. [Medline].

  26. 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].

  27. 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].

  28. 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].

  29. 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].

  30. Levitt M, Peña A. Update on pediatric faecal incontinence. Eur J Pediatr Surg. 2009 Feb. 19 (1):1-9. [Medline].

  31. Griffin SJ, Parkinson EJ, Malone PS. Bowel management for paediatric patients with faecal incontinence. J Pediatr Urol. 2008 Oct. 4 (5):387-92. [Medline].

  32. Emmanuel A. Review of the efficacy and safety of transanal irrigation for neurogenic bowel dysfunction. Spinal Cord. 2010 Sep. 48 (9):664-73. [Medline]. [Full Text].

  33. 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].

  34. [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].

 
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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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