‘Neurogenic bowel management is the regular delivery of a programme of planned interventions designed to pre-emptively achieve effective bowel evacuation’ ... in the context of disability, Finding the evidence, Can wi provide evidence based bowel management?, Choices for bowel management, Bowel management in practice, Multi-faceted programmes, establish a routine, Diet, Abdominal massage, Gastrocolic reflex, Stimulation of anorectal reflexes for evacuation, Digital or manual removal of stool, Oral laxatives/motility stimulants, Transanal irrigation, Antegrade Continence Enema, Sacral Nerve Stimulation, Colostomy, Conclusion

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Dr Maureen Coggrave PhD MSc RN
National Spinal Injuries Centre
Stoke Mandeville Hospital UK
Buckinghamshire New University
King’s College, London
‘Neurogenic bowel management is the regular
delivery of a programme of planned
interventions designed to pre-emptively
achieve effective bowel evacuation’

2. 02.04.2014
2
Physical
Reduced mobility – paralysis, fatigue, weakness,
spasticity
Impaired balance and flexibility
Reduced/absent manual dexterity
Accessibility issues
Dependency and aging
Psychological/emotional
Fear, anxiety and shame
Depression/lack of engagement
Cognitive ability
Lack of / readiness for knowledge
Much bowel management takes place in non
specialist settings
Most bowel management takes place in the
home – relies upon self management
Not just about the bowel dysfunction
rehabilitation
lifestyle issues
personal preferences
local availability of interventions
costs

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Systematic reviews
Cochrane – RCT and quasi randomised studies
SCIRE – all intervention studies
Guidelines –
Guideline for neurogenic bowel management in
adults with spinal cord injury 1998, USA
MASCIP Guidelines 2012, UK
‘the conscientious, explicit, and judicious use of
current best evidence in making decisions
about the care of individual patients’
Sackett et al(1996)

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Stoma
SARS/Sacral nerve stimulation/PTNS?
Antegrade colonic irrigation?
Transanal irrigation
Rectal interventions – digital stimulation, digital evacuation,
suppositories, enema
Medications:
Stimulant &
other laxatives?
Prucalopride?
Gentamycin?
Neostigmine?
Capromorelin?
Adapted from Christensen 2006
Routine, diet and fluids, lifestyle alteration,laxatives, constipating medication
Assess needs for bowel management
Residual bowel function
Medical history, pre injury bowel function
Transit studies, anorectal manometry
Medications
Diet and fluid intake
Level of activity
Level of independence – transfer ability/moving and
handling issues, hand function
Psychological and emotional factors
Home and care circumstances

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No systematic evidence for what should be
included in assessments
No evidence to support utility of invasive
assessment
Relies largely on clinical experience and
expertise – expert agreement
Little research evidence for ‘programmes’ – but
clinically all management is based on such
programmes
Conflicting evidence from SCI 4 trials (1 RCT)
regarding impact of systematic programmes
(Coggrave 2006, 2009, Correa and Rotter 2000,
Badiali 1997)
No evidence to support combinations of
interventions

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Regarded as fundamental to effective control of
the bowel
Expert consensus
Advise the patient regarding their diet – at
least 2 portions of whole grains, ‘5 a day’ of
fruits and vegetables, aim for moderate fibre
intake (around 18gms)
1 case series (11 individuals) indicated that a
high fibre diet may lengthen colonic transit
time (Cameron 1996)

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Used widely, independently and carer-
delivered
Reported by 20-30% of SCI individuals
Recommended at several stages of the bowel
management programme
1 pre-post study concluded ineffective for
neurogenic bowel dysfunction (Ayas 2006)
RCT in MS (30 participants) demonstrated
benefit – McClurg et al 2012
Take food or drink 15-30 minutes prior to
commencing bowel evacuation
Widely recommended for reflex and areflexic
bowel dysfunction
Contradictory evidence – Aaronson 1985, Glick
et al 1984, Menardo 1987
Is a drink as effective as food?

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For individuals with reflex bowel dysfunction
Digital rectal stimulation – reported by 35-50% of
SCI individuals– associated with longer duration of
care
Rectal stimulants – used by up to 70%
Suppositories – glycerin, bisacodyl, Lecicarbon E
Mini enemas – citric acid, docusate
(Coggrave 2009, Correa and Rotter 2000, Kirk 1997))
1 pre-post study (6 participants) demonstrated that
digital rectal stimulation increases motility in the
left colon in SCI individuals (Korsten 2007)
1 RCT Bisacodyl in PEG suppositories (9
participants) can stimulate effective bowel
evacuation (House and Stiens 1997) significantly
reducing time and assistance required
Micro enemas safe and more effective than
glycerin or bisacodyl suppositories (Dunn and
Galka 1994)
No data on long term use

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Reported by 56% of SCI individuals
Associated with shorter duration of bowel
evacuation
Essential in areflexic bowel dysfunction?
Unpopular with patients
Regarded with suspicion outside specialist
units
1 underpowered RCT (63 participants) Coggrave
2009
60% of SCI individuals reportedly use laxatives
of some kind (Coggrave et al 2009)
Stimulants – senna, bisacodyl
Stool softeners – dioctyl, bulkers, osmotics
Colonic motility agents – prucalopride

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No trial evidence for any commonly used laxative
medication in individuals with SCI
2RCTs –
IM Neostimine/glycopyrrolate (7 participants)
significantly reduces time to first flatus, first and last stool
(Rossman 2008)
IV neostigmine 2mgs (13 participants) better evacuation
than normal saline (Korsten 2005)
1 RCT prucalopride 1 or 2mg (22) decreased
constipation, increased frequency of defaecation
(Krogh 2002)
Capromorelin – animal studies only (Ferens et al
2011)
Next step from conservative management if
appropriate – increasing uptake
Uses water to evacuate the rectum and distal
colon
Selection criteria unclear – high attrition rate
Very small risk of bowel perforation (1/50,000)
Significantly improves evacuation parameters
in many individuals

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1 RCT (87 participants)showing very positive
outcomes and low rate of complications
(Christensen et al 2006)
Multiple non-randomised studies
Several reviews now available – Emmanuel 2010,
Christensen et al 2010, Emmanuel et al 2013
More products and variants have come to
market rapidly
Continent
catheterisable
stoma
formed from
the appendix
or caecum for
antegrade
irrigation –
uncommon
in adult
practice

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Small pre-post studies
May reduce the duration of bowel care and incidence
of faecal incontinence (Teichman et al 1998 & 2003, Gerharz et al
1997, Christensen et al 2000, Bruce et al 1999)
Autonomic dysreflexia was eradicated in one case
study (Teichman 1998)
Common in children with spina bifida but few ACEs
reported in adults with neurogenic bowel dysfunction
Failure rate in some studies is high (Gerharz et al 1997).
Continuous stimulation of
the sacral nerves
Improves faecal
incontinence and
constipation
Requires intact pathways
between sacrum and bowel
Beneficial in incomplete
spinal cord injury
(Jarrett 2005, Kenefick 2004)
Posterior Tibial Nerve
Stimulation?

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Around 2.4% of SCI individuals have a stoma for bowel management in
the UK (Coggrave 2009)
Coggrave 2012 – retrospective postal survey-92 respondents (62%)
response
Reasons for colostomy: 68% cite prolonged bowel care, 53% FI, 29%
constipation
15% cite carer difficulties
Significant reduction in AD, duration of care, dependency, laxative
use, dietary manipulation but 31% still use laxatives
Significant increase in satisfaction (p=<.001), ability to live with bowel
care and reduced impact on daily life
53% felt their stoma was not formed at the right time
11% of these would have preferred surgery a year earlier, 28% up to 5
years, 30% up to 10 years, 32% earlier still
(Frisbie 1986, Stone 1990, Safadi 2003, Branagan 2003, Saltzstein 1990, Craven 1998, Randall 2001)
Updated Cochrane review
– 20 RCT or quasi RCTs
found world wide
Coggrave et al 2014
“while a range of medical
and surgical treatments
are available, there is
little evidence for their
effectiveness..” Paris et al
2011
“more intervention
trials are needed to
assess management
programmes…especi
ally multicentre
trials” Krassiokov et
al 2010
70 years of
clinical
experience in
managing
bowel
dysfunction

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Not life
threatening so
not important?
Complex to
study, difficult to
recruit to?
Sensitive
area of
research
Lee and Renzetti 1993
Costs for
researchers –
‘dirty work’
Lawler 1991, Wolf 1996
Costs for
participants -
Funding
issues?
Bowel
management
research
Collaboration
- with patients
- with other centres
- with other disciplines
- with business
-with other patient groups
Guidelines for management of
neurogenic bowel dysfunction
MASCIP 2009, 2012
•To improve quality of care
•Empower patients
•Influence public policy
•Benefits for healthcare staff –
•Direct the work of researchers
•Raise profile
•Variations in practice in specialist areas
•Low level of knowledge outside
specialist areas and reluctance to deliver
bowel care
•Limited evidence base
•Need to bring together what is known –
research and good clinical practice

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Evidence base is scanty
Bowel management is high on the SCI person’s
agenda (Anderson 2004)
Needs to be a high priority for research
Promote and share our clinical experience and
skills to support people with SCI – in our
wards and their homes
MASCIP Guidelines
www.mascip.co.uk/guidelines.aspx
Cochrane review
www.thecochranelibrary.com