Neurogenic bowel management after spinal cord injury: a systematic review of the evidence

Abstract

Study design: Randomized-controlled trials (RCTs), prospective cohort, case-control, pre-post studies, and case reports that assessed pharmacological and non-pharmacological intervention for the management of the neurogenic bowel after spinal cord injury (SCI) were included.

Objective: To systematically review the evidence for the management of neurogenic bowel in individuals with SCI.

Setting: Literature searches were conducted for relevant articles, as well as practice guidelines, using numerous electronic databases. Manual searches of retrieved articles from 1950 to July 2009 were also conducted to identify literature.

Methods: Two independent reviewers evaluated each study's quality, using Physiotherapy Evidence Database scale for RCTs and Downs and Black scale for all other studies. The results were tabulated and levels of evidence assigned.

Results: A total of 2956 studies were found as a result of the literature search. On review of the titles and abstracts, 57 studies met the inclusion criteria. Multifaceted programs are the first approach to neurogenic bowel and are supported by lower levels of evidence. Of the non-pharmacological (conservative and non-surgical) interventions, transanal irrigation is a promising treatment to reduce constipation and fecal incontinence. When conservative management is not effective, pharmacological interventions (for example prokinetic agents) are supported by strong evidence for the treatment of chronic constipation. When conservative and pharmacological treatments are not effective, surgical interventions may be considered and are supported by lower levels of evidence in reducing complications.

Conclusions: Often, more than one procedure is necessary to develop an effective bowel routine. Evidence is low for non-pharmacological approaches and high for pharmacological interventions.

Figure 1. Schematic diagram of the GI Tract

Parasympathetic innervation is provided by the Vagus (CNX) from the esophagus to the spleenic corner of the large intestine. Innervation of the GI tract after the spleenic corner is provided by the sacral part of the parasympathetic nervous system (S2 – S4). Sympathetic innervation to the upper GI tract is provided by the SPNs localized within the upper thoracic spinal segment (T1–T5); the small and a large intestine are controlled by SPNs localized within the T6–T12 spinal segments.

Figure 2. Schematic diagram of the Enema Continence Catheter

A catheter is inserted into the rectum and a balloon is inflated to hold the catheter in place during the administration of an enema. After installing the enema, the balloon is deflated, the catheter is removed, and the bowel content will empty.

Figure 3. Diagram of the Malone Anterograde Continence Enema (MACE)

The MACE procedure involves a surgical operation to bring out the appendix through the skin thereby forming an appendicostomy. An enema may be introduced through the abdominal wall stoma. The enema produces a wash-out effect and stimulates colon peristalsis, which then evacuates the contents in the colon.