Approach Considerations
Treatment of neurogenic bowel dysfunction (NBD) is initially conservative. [2] 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.
Conservative Measures
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. [25] Scheduled bowel emptying should be recommended to avoid incontinence and reduce impaction.
Various pharmacologic treatments have been used, though there remains a need for further study in the literature. [27] Pharmacologic options include the following:
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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) [28]
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Hyperosmolar agents (eg, sodium bisphosphonate)
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Bulking agents (eg, psyllium)
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Stool softeners (eg, docusate sodium)
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Osmotic agents (eg, polyethylene glycol)
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. [29] 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:
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Abdominal massage - This is performed before or during defecation by applying gentle pressure along the colon in a clockwise manner
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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 [30]
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Placement of rectal stimulant suppositories
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Enemas (see the image below)
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Various combinations of these techniques
Other Nonoperative Treatments
Biofeedback and behavioral training can be beneficial for improving sensory and motor awareness in patients with incomplete neurogenic bowel lesions, especially children. [31, 32]
Another option is transanal irrigation (TAI), which assists in the evacuation of stool by introducing water into the colon and rectum through a catheter in the anus. [33, 34] This may be done daily or every other day. Small prospective trials showed significant improvements in pediatric patients with NBD in whom conservative measures have failed. [35] Other small prospective studies suggested that TAI may be more effective than conservative measures in select groups of patients. [36]
An international expert consensus recommended evaluating all of the previously described treatment methods before surgery is considered. [37]
Surgical Intervention
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. [38]
The sacral anterior root stimulator was developed for SCI patients with neurogenic bladder, but it is also effective for patients with constipation. The implant is placed during a laminectomy of L2-4. 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 [39] and spinal lesions. [40, 41] 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. [24]
A colostomy or ileostomy is considered in highly refractory cases or when stool incontinence complicates other problems, such as pressure injury 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.
Rehabilitation
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. [42]
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. [30]
Long-Term Monitoring
Recommendations for monitoring and follow-up include the following:
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Annual follow-up visits for patients with SCI or spina bifida; even more frequent follow-up may be necessary for some patients
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Thorough physical examination, including rectal examination, as part of regular follow-up
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In patients older than 50 years, stool testing for occult blood to rule out colorectal cancer,or colonoscopy
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Evaluation of device use in patients with SCI
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Monitoring to confirm use of appropriate medications
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Advice to ensure that patients’ daily diet contains 15-30 mg of fiber
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Additional diagnostic workup (eg, radiologic evaluation) when necessary (eg, in cases of fecal impaction or potential perforation)
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Administration of an enema.
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Illustration of neural control of gut wall by sympathetic, parasympathetic and enteric nervous system. Courtesy of Wikimedia Commons.
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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.
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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
