State of the Art Bowel Management for Pediatric Colorectal Problems: Spinal Anomalies

Abstract

Background: Patients with spinal abnormalities often struggle with fecal and/or urinary incontinence (up to 87 and 92%, respectively) and require a collaborative approach to bowel management in conjunction.

Methods: To define existing approaches and propose state-of-the-art bowel management, a literature search was performed using Medline/PubMed, Google Scholar, Cochrane, and EMBASE databases and focusing on the manuscripts published July 2013 and July 2023.

Results: Patients with spinal anomalies have impaired innervation of the rectum and anal canal, decreasing the success rate from laxatives and rectal enemas. Thus, transanal irrigations and antegrade flushes are widely utilized in this group of patients. Based on spinal MRI, the potential for bowel control in these children depends on age, type, and lesion level. On referral for bowel management, a contrast study is performed to assess colonic motility and evacuation of stool, followed by a series of abdominal X-rays to define colonic emptying and adjust the regimen. The options for management include laxatives, rectal enemas, transanal irrigations, antegrade flushes, and the creation of a stoma. Approximately 22-71% of patients achieve social continence dependent on the type and level of the lesion.

Conclusion: Patients with spinal anomalies require a thorough assessment for continence potential and stool burden prior to initiation of bowel management. The optimal treatment option is defined according to the patient's age, anatomy, and mobility. The likelihood of independent bowel regimen administration should be discussed with the patients and their caregivers.

Keywords: antegrade continence enema; bowel management; constipation; enema; fecal incontinence; meningocele; spina bifida; spinal anomaly; tethered cord; urinary incontinence.

Figure 1

Fecal and urinary continence in patients with spinal anomalies depending on the type of lesion and the patient’s age. Numbers in squares reflect the age-specific prevalence of continence (fecal or urinary) in myelomeningocele patients, while those in circles pertain to non-myelomeningocele patients. Reprinted from Alabi, N.B.; Thibadeau, J.; Wiener, J.S.; Conklin, M.J.; Dias, M.S.; Sawin, K.J.; Valdez, R. Surgeries and Health Outcomes Among Patients with Spina Bifida. Pediatrics 2018, 142, 20173730 [30].

Figure 2

Independence from the bowel regimen in patients with myelomeningocele. ACE—antegrade continence enema; MMC—myelomeningocele; TAI—transanal irrigation. Data demonstrated from Kelly, M.S.; Wiener, J.S.; Liu, T.; Patel, P.; Castillo, H.; Castillo, J.; Dicianno, B.E.; Jasien, J.; Peterson, P.; Routh, J.C.; et al. Neurogenic Bowel Treatments and Continence Outcomes in Children and Adults with Myelomeningocele. J. Pediatr. Rehabil. Med. 2020, 13, 685–693 [35].

Figure 3

A stepwise protocol for bowel management in patients with spina bifida. ACE—antegrade continence enema; H&P—history and physical examination.

Figure 4

Transanal irrigation system (A) with a cone tip (B) or a catheter with a balloon (C).

Figure 5

Age-related bowel management and topics for discussion with the families of patients with spinal anomalies. ACE—antegrade continence enema; BM—bowel movement; FI—fecal incontinence; OBGYN—obstetrics and gynecology; TAI—transanal irrigation; UTI—urinary tract infection. The scheme is based on the algorithms recommended by the Spina Bifida Association [75] and Stevens et al. [6].

Figure 6

Fecal continence in patients with myelomeningocele based on their bowel regimen and age: young children (5–11 years), adolescents (12–19 years), and adults (20 years or older). Data from Kelly, M.S.; Wiener, J.S.; Liu, T.; Patel, P.; Castillo, H.; Castillo, J.; Dicianno, B.E.; Jasien, J.; Peterson, P.; Routh, J.C.; et al. Neurogenic Bowel Treatments and Continence Outcomes in Children and Adults with Myelomeningocele. J. Pediatr. Rehabil. Med. 2020, 13, 685–693 [35].