Neurogenic Bowel Dysfunction in Patients with Spinal Cord Injury and Multiple Sclerosis—An Updated and Simplified Treatment Algorithm

Abstract

Neurogenic bowel dysfunction (NBD) is a common condition in individuals with spinal cord injury (SCI) or multiple sclerosis (MS). It usually entails constipation, difficult evacuation of the rectum, and fecal incontinence (FI); often in combination. It is highly burdensome for affected patients and is correlated with poor quality of life. The current treatment algorithm, or treatment pyramid, does not completely correspond to actual clinical practice, and the known and classical pyramid contains both treatments still in their experimental stage as well as several treatments which are not available at all treatment centers. Thus, an updated treatment algorithm is called upon, and the authors of this paper therefore propose a simplified version of the treatment pyramid, aiming to guide clinicians in treating NBD.

The Functional Implications of Transanal Irrigation: Insights from Pathophysiology and Clinical Studies of Neurogenic Bowel Dysfunction

“…TAI is a second-line intervention for patients with NBD and is often recommended after patients experience insufficient results with standard or conservative care [ 12 , 14 , 15 , 20 ]. This review article focuses on the system with a rectal catheter with a balloon.…”

“…With the participation of several multi-disciplinary experts, bowel physiology was identified as a top priority to elucidate the effects and interventions on bowel function. Since this meeting, the Consortium of Spinal Cord Medicine Clinical Practice Guidelines on the Management of Neurogenic Bowel Dysfunction in Adults after SCI have been updated and several consensus statements have been developed inclusive of patients’ input [ 11 , 12 , 13 , 14 , 15 ]. More recently, Dietz et al identified that meticulous attention to the patient is required during the first five years postinjury to achieve a successful bowel management plan that is sustained for 25 years [ 16 ].…”

“…Bowel programs for patients with NBD are individualized and comprehensive, with a goal to achieve effective bowel evacuation and prevent incontinence. Individualization is based on medical history, including GI symptoms, level and severity of neurological impairment based on the International Standard for Neurological Classification of Spinal Cord Injury and Autonomic Function following SCI, physical examination, images documenting fecal loading, and input from the patient and caregiver [ 12 , 13 , 14 , 15 , 17 , 18 ]. Comprehensive bowel care aims to achieve regular bowel movements with improved colonic transit and rectal evacuation, predictable defecation, completion of bowel care within 30–60 min, and increased independence.…”

“…Several guidelines and consensus publications endorse a stepwise approach to bowel care, tailored to the individual [ 12 , 14 , 15 , 19 , 20 ]. Conservative treatment (also referred to as basic treatment or standard of care) includes diet and/or lifestyle modifications, oral laxatives, and rectal laxatives, possibly in combination with additional rectal evacuation assistance (i.e., digital anorectal stimulation).…”

“…In the Consortium of Spinal Cord Medicine Clinical Practice Guidelines on the Management of Neurogenic Bowel Dysfunction in Adults after SCI, TAI is recommended in individuals with NBD who have insufficient results with conservative measures [ 15 ]. More recently, Magnuson et al proposed an updated and simplified treatment algorithm for effective bowel care, reflecting clinical practice and commonly available treatment modalities, with TAI as a second-line step in treatment progression, especially for those who have insufficient response to conservative measures such as enema [ 14 ].…”